In patients with inadequate response to UDCA, liver biopsy may provide the explanation and could undoubtedly inform risk stratification. For example, it may identify a previously unsuspected variant syndrome, steatohepatitis, or interface hepatitis of moderate or greater severity. It is also useful in AMA and ANA-specific antibody negative cholestatic patients to indicate an alternative process, e.g. sarcoidosis, small duct PSC, adult idiopathic ductopenia. Histopathology stages (by Ludwig and Scheuer systems)
Stage 1 – portal stage: Normal-sized triads, portal inflammation, subtle bile duct damage: Granulomas are often detected in this stage. Stage 2 – periportal stage: Enlarged triads, periportal fibrosis and/or inflammation, typically characterized by the finding of a proliferation of small bile ducts
Stage 3 – septal stage: Active and/or passive fibrous septa
Stage 4 – biliary cirrhosis: Nodules present, garland or jigsaw puzzle pattern

Treatment
Cholestasis
Medical therapy of PBC targets disease progression and symptom control. The first-line treatment for PBC is ursodeoxycholic acid (UDCA). UDCA has been the only drug available for two decades and more recently obeticholic acid (OCA), a semi-synthetic hydrophobic bile acid analogue, has been licensed in patients failing UDCA response or intolerant to UDCA. Several other agents have been studied, including immunosuppressants, but robust evidence of benefit is lacking.UDCA improves liver enzyme levels, slows down histological progression, and improves liver transplant-free survival. UDCA also reduces the need for liver transplantation. UDCA should be taken at a dose of 13 to 15 mg per kg of body weight per day, usually in two divided doses each day.
Classically, hemoperitoneum was an indication for emergency surgery to locate the source of bleeding and also to recover spilled blood from the peritoneal cavity and to use it for auto-transfusion if it has not been contaminated by ruptured bowel contents. The method of control depends on the source of blood loss. Vascular bleeding, i.e. from a blood vessel, would be treated by clamping and ligation of the offending vessel, or repair of the vessel in the case of major arteries such as the aorta or mesenteric arteries. Bleeding from the spleen most often requires splenectomy, or removal of the spleen, usually but not always in the form of a total splenectomy. Bleeding from the liver might be controlled by application of hemostatic sponges, thrombin, or more recently, argon beam cauterization.With modern diagnostic aids such as computed tomography (CT) scans, certain injuries such as low-grade lacerations of the spleen may be diagnosed early and observed, with surgical options deferred unless clinical deterioration obligates them. In rare occasions, rupture of an Abdominal Aortic Aneurysm may be repaired via an endovascular technique, though this is generally not performed in the setting of acute rupture. References


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