A new section in MEJDD which is aimed to improve chinical decision making by presenting a real patient by an experienced clinician and who discuss the case and provide an evidence base decision making for diagnosis and treatment of patient in daily clinical practice. Recurrent Cholestasis in a 13 Year-old Boy A 13 year-old boy with generalized intermittent pruritis from three years preceding referred to Shariati Hospital for ERCP. His pruritis was aggravated at night and relieved by warm baths. It was associated with jaundice. During the attacks, he had acholic stool and dark urine. The patient had three attacks in the preced-ing years, each of which lasted for about 3-4 months. Associated symptoms were anorexia and mild weight loss (3kg /3 months). All complaints began after an attack of gastroenteritis. Between attacks, the patient was completely asymptomatic with no com-plaints. History of pruritis has many differential diagnoses. Many of these are primary skin disorders such as xerosis, atopic der-matitis, lichen simplex chronicus, and psoriasis, to name a few; this patient had no history of any allergic reaction or skin lesions. 1 Still, drug and allergic history are important and must be assessed. Likewise, some systemic diseases can cause pruri-tis, such as: renal and thyroid diseases, malignancies, multiple sclerosis, infection with human immune deficiency virus (HIV) and iron deficiency anemia. Therefore, it is imperative that a de-tailed history be taken and the necessary workup performed for patients. Another etiology is cholestasis, which looks more plau-sible as it is similarly associated with jaundice, acholic stool, dark urine, is aggravated at night and relieved with warm baths. Itching in cholestasis is typically generalized although it is most severe on the palms and soles. Dry skin, hot and humid weather, and wearing constricting clothes can worsen this type of itching. The pathogenesis of pruritis in cholestasis is incompletely un-derstood, but accumulation of bile acids in the bloodstream can be a probable explanation. On the other hand, absence of pruritis in many patients with elevated bile acids and lack of correlation between pruritis and bile acid concentrations make this hypoth-esis a less approved culprit. Alternatively, leakage of pruritogens into the bloodstream can be another plausible etiology. 2