5 versus 33.9 years; P < 0.003). Males with a truncating variant were younger (31 ± 12 years) than those with missense variant (40 ± 13 years); likewise, females with a truncating variant were younger (26 ±6 years) than those with a missense variant (40 ± 13 years) (P < 0.001). There was no significant association between truncating sequence variations and severity of either acute or chronic biliary complications (severe biliary complications defined as

acute pancreatitis, recurrent cholangitis, segmental spindle-shape dilatation of the biliary tree filled with gallstones): odds ratio (OR) = 0.8 (95% confidence interval [CI] 0.3-3.7, P = 0.8). These complications were more frequent in men (71% versus 45%, P = 0.05, OR 2.9, 95% CI 1.0-9.6), that in women, independently of age at onset of symptoms and type of variant. About half of the women who had pregnancy experienced LY2835219 in vitro ICP. The frequency and severity of ICP did not differ in patients with missense (44%) and truncating variant (69%) (P = 0.2). In patients without an

ABCB4 detectable variant the clinical characteristics Rapamycin purchase were similar to those observed in patients with gene variation. Of note, in a subset of patients the phospholipid/bile acid ratio measured in hepatic bile (ratio of control gallbladder bile >25%) did not differ between the two groups: 11%, range 4%-16% (n = 7) versus 12%, range 1.4%-16% (n = 8) in patients with and without the ABCB4 variant, respectively. In the overall cohort, biliary cirrhosis was detected in only two patients. Both patients had a missense heterozygous variant (location Glutathione peroxidase and nucleotide changes: c.523A>G and c.959C>T). Intrahepatic

cholangiocarcinoma leading to death was observed in a noncirrhosis female patient with a heterozygous splicing mutation (c.1005+5 G>A). All the patients received ursodeoxycholic acid (UDCA) (8-10 mg/kg/day) as the mainstay treatment after the diagnosis had been made. All the patients with severe chronic biliary complications had sphincterotomy. Patients with symptomatic intrahepatic bile duct dilatations filled with gallstones had repeated endoscopic procedures to remove the stones. All the patients with or without detectable variant and free of intrahepatic bile duct dilatations with gallstones became asymptomatic up to now. The only exception was a patient who did not tolerate UDCA because of bile acid-induced watery diarrhea. Among patients presenting with symptomatic cholelithiasis, three main features defined the syndromatic phenotype termed LPAC: recurrence of biliary symptoms after cholecystectomy, intrahepatic lithiasis, and age <40 years. The results of the present study may be summarized as follows: (1) half of the patients with the LPAC phenotype have detectable sequence variations of the ABCB4 gene, most of them being heterozygous missense.