Primary sclerosing cholangitis (PSC) is an idiopathic inflammatory disorder of the biliary tract characterized by diffuse biliary tract stricture formation, progressive chronic cholestasis and the development of secondary biliary cirrhosis. Biliary tract ischemia can produce morphological changes identical to PSC. We propose the existence of a localized renin-angiotensin system within the liver and extend the hypothesis that aberrant production of angiotensin II within the portal tract is the critical event contributing to the pathogenesis of PSC. A chronic reparative and proliferative state caused by chronic ischemia may promote carcinogenesis. Proof of this hypothesis will have implications for future therapeutic approaches given that current treatments for PSC aimed at reducing inflammation or the effects of cholestasis have proven ineffective.
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