Posters
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Resident
Discipline/Specialty (Author 1)
Internal Medicine
Academic Level (Author 2)
Resident
Discipline/Specialty (Author 2)
Internal Medicine
Academic Level (Author 3)
Resident
Discipline/Specialty (Author 3)
Internal Medicine
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Internal Medicine
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Internal Medicine
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Poster
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Patient Care
Abstract Type
Case Report
Abstract
Background: Oral contraceptives represent one of the most prevalently utilized pharmacological interventions for contraception, renowned for their safety and efficacy. However, their advantageous safety profile, these pharmaceuticals are intermittently correlated with infrequent yet significant hepatobiliary complications, including drug-induced cholestasis and hyperbilirubinemia1. The estrogenic constituents of oral contraceptives are recognized for their capacity to disrupt bile acid transport within the hepatic system, culminating in intrahepatic cholestasis2. This phenomenon is particularly alarming in individuals possessing inherent genetic susceptibilities, such as Dubin-Johnson Syndrome, wherein bilirubin metabolism and excretion are already adversely affected3. The identification and comprehension of these adverse effects are imperative for ensuring timely diagnosis and effective management.
Case Presentation: A 19-year-old Hispanic female patient with no significant prior medical history presented with generalized worsening jaundice, intense pruritus, generalized fatigue and passage of orange colored urine. These symptoms began about one month before the presentation. She denied fever, RUQ abdominal pain or changes in bowel habit. She is not on any routine medication except for oral contraceptive (ethinyl estradiol & levonorgestrel) pill commenced about 2 months before onset of symptoms. Vital signs at presentation were normal, examination was significant for generalized jaundice including the sclera.
Laboratory evaluations revealed isolated conjugated hyperbilirubinemia, with bilirubin level of 26.5mg/dl.
Test
D. Bil
ALT
AST
ALP
GGT
Hgb
PLT
WBC
INR
values
26.5mg/dl
33 U/L
46 U/L
321 U/L
24 U/L
12.9g/dl
298/mm
9.4/mm
1.1
Hepatitis virus panel, Serologic screen (ANA, AMA & anti-smooth muscle) including toxicology screen were all unrevealing.
Imaging studies, including abdominal ultrasound, CT scan, and MRCP, excluded biliary obstruction or structural abnormalities. Endoscopic US with liver biopsy revealed ductopenia, hepatocyte biliary metaplasia, moderate sinusoidal dilation, and increased echogenicity findings suggestive of intrinsic liver injury. The chronologic relationship between the onset of symptoms and the initiation of oral contraceptives, combined with the exclusion of other potential etiologies, concerning for a diagnosis of drug-induced liver injury with potential underlying Dubin-Johnson Syndrome.
There was gradual improvement in symptoms and down trending of liver enzymes including bilirubin levels following discontinuation of oral contraceptives and continuous use of ursodiol and cholestyramine during outpatient's follow-up about 1 month after discharge, a phenomenon in-keeping with hyperbilirubinemia & cholestasis caused by contraceptive induced liver injury which usually takes months before returning to normal levels.
Discussion: Oral contraceptives are typically well-accepted by users; nonetheless, infrequent adverse reactions affecting the liver and biliary system, such as cholestasis, may manifest 2 to 3 months after starting OCPs and resolve after cessation. The estrogens present in these pharmacological agents hinder the transport and excretion of bile acids by modifying the functionality of hepatic transport proteins, notably the bile salt export pump. This perturbation leads to the accumulation of bile acids and conjugated bilirubin within hepatocytes, thereby inducing intrahepatic cholestasis4.
Individuals possessing genetic predispositions, such as Dubin-Johnson Syndrome, exhibit heightened vulnerability. This uncommon autosomal recessive disorder arises from mutations in the MRP2 (Multidrug Resistance Protein 2) gene, which hinders the elimination of conjugated bilirubin into bile. Susceptible patients may manifest symptoms of hyperbilirubinemia (generalized jaundice, sclera icterus and orange colored urine) due to intrinsic hormonal imbalance or exposure to exogenous estrogens5.
In this instance, the patient's clinical manifestation of conjugated hyperbilirubinemia, in the absence of infectious, autoimmune, or structural abnormalities of the liver and hepatobiliary tree coupled with the histopathological findings from the liver biopsy, corresponded with a diagnosis of drug-induced liver injury. The improvement in symptoms after discontinuation of OCP’s underscores the potential for reversibility of this condition if promptly recognized with timely intervention.
Conclusion: This case illustrates a rare but significant complication of oral contraceptives, emphasizing the importance of considering drug-induced cholestasis in patients presenting with unexplained jaundice, particularly in those with potential genetic predispositions. Awareness of such complications and timely intervention can lead to favorable outcomes, underscoring the need for individualized risk assessment when prescribing oral contraceptives.
Recommended Citation
Calderon, Aura; Ajani, Taiwo; Derian, Nayiri; Matos, Catherine; Mogollon, Ivan; and Suarez, Andres, "Case Report: Oral Contraceptives-induced Cholestasis" (2025). Research Symposium. 164.
https://scholarworks.utrgv.edu/somrs/2025/posters/164
Included in
Case Report: Oral Contraceptives-induced Cholestasis
Background: Oral contraceptives represent one of the most prevalently utilized pharmacological interventions for contraception, renowned for their safety and efficacy. However, their advantageous safety profile, these pharmaceuticals are intermittently correlated with infrequent yet significant hepatobiliary complications, including drug-induced cholestasis and hyperbilirubinemia1. The estrogenic constituents of oral contraceptives are recognized for their capacity to disrupt bile acid transport within the hepatic system, culminating in intrahepatic cholestasis2. This phenomenon is particularly alarming in individuals possessing inherent genetic susceptibilities, such as Dubin-Johnson Syndrome, wherein bilirubin metabolism and excretion are already adversely affected3. The identification and comprehension of these adverse effects are imperative for ensuring timely diagnosis and effective management.
Case Presentation: A 19-year-old Hispanic female patient with no significant prior medical history presented with generalized worsening jaundice, intense pruritus, generalized fatigue and passage of orange colored urine. These symptoms began about one month before the presentation. She denied fever, RUQ abdominal pain or changes in bowel habit. She is not on any routine medication except for oral contraceptive (ethinyl estradiol & levonorgestrel) pill commenced about 2 months before onset of symptoms. Vital signs at presentation were normal, examination was significant for generalized jaundice including the sclera.
Laboratory evaluations revealed isolated conjugated hyperbilirubinemia, with bilirubin level of 26.5mg/dl.
Test
D. Bil
ALT
AST
ALP
GGT
Hgb
PLT
WBC
INR
values
26.5mg/dl
33 U/L
46 U/L
321 U/L
24 U/L
12.9g/dl
298/mm
9.4/mm
1.1
Hepatitis virus panel, Serologic screen (ANA, AMA & anti-smooth muscle) including toxicology screen were all unrevealing.
Imaging studies, including abdominal ultrasound, CT scan, and MRCP, excluded biliary obstruction or structural abnormalities. Endoscopic US with liver biopsy revealed ductopenia, hepatocyte biliary metaplasia, moderate sinusoidal dilation, and increased echogenicity findings suggestive of intrinsic liver injury. The chronologic relationship between the onset of symptoms and the initiation of oral contraceptives, combined with the exclusion of other potential etiologies, concerning for a diagnosis of drug-induced liver injury with potential underlying Dubin-Johnson Syndrome.
There was gradual improvement in symptoms and down trending of liver enzymes including bilirubin levels following discontinuation of oral contraceptives and continuous use of ursodiol and cholestyramine during outpatient's follow-up about 1 month after discharge, a phenomenon in-keeping with hyperbilirubinemia & cholestasis caused by contraceptive induced liver injury which usually takes months before returning to normal levels.
Discussion: Oral contraceptives are typically well-accepted by users; nonetheless, infrequent adverse reactions affecting the liver and biliary system, such as cholestasis, may manifest 2 to 3 months after starting OCPs and resolve after cessation. The estrogens present in these pharmacological agents hinder the transport and excretion of bile acids by modifying the functionality of hepatic transport proteins, notably the bile salt export pump. This perturbation leads to the accumulation of bile acids and conjugated bilirubin within hepatocytes, thereby inducing intrahepatic cholestasis4.
Individuals possessing genetic predispositions, such as Dubin-Johnson Syndrome, exhibit heightened vulnerability. This uncommon autosomal recessive disorder arises from mutations in the MRP2 (Multidrug Resistance Protein 2) gene, which hinders the elimination of conjugated bilirubin into bile. Susceptible patients may manifest symptoms of hyperbilirubinemia (generalized jaundice, sclera icterus and orange colored urine) due to intrinsic hormonal imbalance or exposure to exogenous estrogens5.
In this instance, the patient's clinical manifestation of conjugated hyperbilirubinemia, in the absence of infectious, autoimmune, or structural abnormalities of the liver and hepatobiliary tree coupled with the histopathological findings from the liver biopsy, corresponded with a diagnosis of drug-induced liver injury. The improvement in symptoms after discontinuation of OCP’s underscores the potential for reversibility of this condition if promptly recognized with timely intervention.
Conclusion: This case illustrates a rare but significant complication of oral contraceptives, emphasizing the importance of considering drug-induced cholestasis in patients presenting with unexplained jaundice, particularly in those with potential genetic predispositions. Awareness of such complications and timely intervention can lead to favorable outcomes, underscoring the need for individualized risk assessment when prescribing oral contraceptives.
