Purpose of Review <p>Fatigue is a prevalent and disabling symptom in primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC). Despite its profound impact on quality of life, fatigue remains under-recognized and difficult to manage. This review synthesizes evidence on its mechanisms and non-pharmacological management approaches.</p> Recent Findings <p>Fatigue pathogenesis involves central and peripheral mechanisms, gut-liver-brain axis dysfunction, and psychosocial influences. Non-pharmacological strategies such as structured exercise programs, cognitive-behavioral and acceptance-based therapies, somatic mind-body techniques (breathwork, meditation, mindful movement), and nutrition, have shown medium to large effect sizes for fatigue reduction across chronic conditions, with more recent evidence building in PBC and PSC.</p> Summary <p>Fatigue in cholestatic liver disease arises from multifactorial mechanisms and requires multimodal management. Systematic screening, exclusion of secondary contributors, and implementation of evidence-based non-pharmacological interventions holds promise to reduce fatigue and improve daily functioning for individuals living with PBC and PSC.</p>