A recent review (Full text: LJ Saubermann et al. JPGN 2017; 64: 639-52)  discusses the hepatic issues and complications associated with inflammatory bowel disease.

Key topics:

• Primary Sclerosing Cholangitis (PSC)
• Autoimmune Hepatitis (AIH)
• Autoimmune Sclerosing Cholangitis (ASC)
• Portal Venous Thrombosis/hypercoagulability
• Cholelithiasis (more common in Crohn’s disease if diseased terminal ileum)
• Viral hepatitis
• Drug-Induced Liver Disease
• Fatty Liver disease

Many of these topics have been discussed previously on this blog.  A couple of pointers in this review:

PSC:

• Greater risk of colorectal carcinoma
• IBD-PSC patients are at higher risk for pouchitis
• GGT of >252 U/L “was highly sensitive (99%) and had good specificity (71%) for PSC” [or ASC]
• The authors recommend “screening all newly diagnosed patients with IBD with ALT and GGT
• Immunosuppressive therapy is NOT effective
• Vancomycin therapy is currently being tested (clinical trials: NCT02137668 & NCT01802073)

AIH:

• Less frequent in IBD patients than PSC
• Most common treatment is prednisone/azathioprine
• 40-80% of children have cirrhosis at AIH diagnosis, but “progression to end-stage liver disease is rare and …with appropriate treatment, 80% of patients achieve remission.”

ASC:

• ASC is an overlap syndrome between AIH and PSC
• “It is important that children with IBD and apparent AIH are routinely investigated for evidence of biliary disease with MRCP”
• “ASC responds to the same immunosuppressive combination therapy used for AIH”

HAV/HBV Immunization:

• HAV vaccination is effective in patients with IBD…although the rate [seroconversion] was significantly lower” in patients receiving anti-TNF therapy (92.4% vs 99.1% in one study).
• In those needing HBV immunization: “One strategy evaluated to improve HBV immunity in adults with IBD is an accelerated course with double vaccine doses at 0, 1, and 2 months.”

Methotrexate (MTX):

• “The extent of histological features of hepatotoxicity secondary to long-term MTX use in IBD has been infrequently described; however, the inicdence of significant abnormal histological findings appears to be rather low.”

My take: This article is a good starting point for liver-related issues in IBD.  For concerns regarding medications, the NIH livertox website is more useful and much more comprehensive.

Related blog entries:

DILI:

• Advice on drug-induced liver injury (DILI) | gutsandgrowth
• Liver Toxicity -Where to Look Online

PSC:

• Population-Based Outcomes for Primary Sclerosing Cholangitis
• Should we care about subclinical PSC?
• Screening for subclinical PSC in IBD? | gutsandgrowth
• Vedolizumab for Primary Sclerosing Cholangitis (with … – gutsandgrowth
• Population-based outcomes for PSC gutsandgrowth

AIH:

• Withdrawing Immunosuppression with Autoimmune Hepatitis
• Diagnosing Autoimmune Hepatitis
• Adult versus Pediatric Data for Autoimmune Hepatitis