CHOLESTATIC HEPATITIS AFTER INGESTION OF CHAPARRAL LEAF - CONFIRMATION BY ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND LIVER-BIOPSY

The use of herbal and other ''natural'' health products by healthy and ill people is more common than is appreciated by many health care pro viders. Since most of these substances are not categorized as medicine s, they are exempt from U.S. Government approval processes, and are es sentially uncontrolled. In this article we describe a patient who deve loped painless jaundice, fatigue, and pruritus after taking chaparral tablets, 160 mg/ day, for similar to 2 months. Serial liver biopsies a nd serum chemistries documented severe cholestasis and hepatocellular injury, i.e., a severe cholangiolitic hepatitis. Serum enzyme levels w ere markedly elevated: alk. phos. to four-fold, alanine aminotransfera se and aspartate aminotransferase to 25-fold, total bilirubin to 30-fo ld, and gamma-glutamyl transpeptidase to 35-fold. Endoscopic retrograd e cholangiopancreatography showed smooth, but severely narrowed biliar y ducts without sclerosing cholangitis, distal obstruction, tumor, or stenosis. The diagnosis remained in doubt until the publication of two cases of chaparral hepatotoxicity. Because of the similarity of our p atient's illness to those cases we concluded that chaparral was almost certainly the cause. Chaparral, also known as creosote or greasewood, is used by some practitioners to treat a diverse group of ailments in cluding ethanol withdrawal. This report should heighten the awareness by primary care physicians and gastroenterologists that any chaparral herbal preparation is a potential hepatotoxin that can lead to serious illness. Thus, we suggest that every initial history, especially in p atients with liver disease of unclear etiology, should include questio ns regarding ingestion of herbal or ''natural'' products, and that phy sicians should advise their patients against ingesting chaparral and s hould warn patients of the potential health hazards in unregulated pro ducts sold as medicinals or health supplements.