Cholestasis is seen with many hepatobiliary disorders that produce extrahepatic biliary obstruction and/or intrahepatic biliary disruption. One particularly troublesome symptom associated with cholestasis is pruritus, which can range in severity from mild, to moderate in which sleep is disturbed, to extreme in which the lifestyle of the patient is completely disrupted.
This topic will review the pathogenesis, clinical manifestations, diagnosis, and management of cholestasis-associated pruritus. The disorders associated with cholestasis are discussed elsewhere. (See "Intrahepatic cholestasis of pregnancy" and "Clinical manifestations, diagnosis, and natural history of primary biliary cirrhosis" and "Primary sclerosing cholangitis in adults: Clinical manifestations and diagnosis" and "Drug-induced liver injury" and "Clinical manifestations and diagnosis of cholangiocarcinoma" and "Cirrhosis in adults: Etiologies, clinical manifestations, and diagnosis".)
The following discussion is consistent with 2009 guidelines from the American Association for the Study of Liver Diseases  and the European Association for the Study of the Liver  on the management of primary biliary cirrhosis and cholestatic liver disease, respectively.
Pruritus may develop in patients with cholestasis due to any cause. It may be seen with primary biliary cirrhosis, primary sclerosing cholangitis, intrahepatic cholestasis of pregnancy, biliary obstruction, chronic viral hepatitis, cirrhosis, prolonged drug-induced cholestasis, and inherited cholestasis syndromes (eg, progressive familial intrahepatic cholestasis and benign recurrent intrahepatic cholestasis ).
The frequency with which pruritus is seen in these conditions is variable :