Hepatic Manifestations of Inflammatory Bowel Diseases

Sophie Restellini; Olivier Chazouillères; Jean-Louis Frossard

Disclosures

Liver International. 2017;37(4):475-489. 

In This Article

Abstract and Introduction

Abstract

Inflammatory bowel diseases are associated with various hepatobiliary disorders, reported both in Crohn's disease and ulcerative colitis. They may occur at any moment in the natural course of the disease. The prevalence of liver dysfunction rises from 3% to 50% accordingly to definitions used in different studies. Fatty liver is considered as the most common hepatobiliary complication in inflammatory bowel diseases while primary sclerosing cholangitis is the most specific one. Less frequently, inflammatory bowel diseases-associated hepatobiliary disorders include: autoimmune hepatitis/primary sclerosing cholangitis overlap syndrome, IgG4-associated cholangiopathy, primary biliary cholangitis, hepatic amyloidosis, granulomatous hepatitis, cholelithiasis, portal vein thrombosis and liver abscess. The spectrum of these manifestations varies according to the type of inflammatory bowel diseases. Treatments of inflammatory bowel diseases may cause liver toxicity, although incidence of serious complications remains low. However, early diagnosis of drug-induced liver injury is of major importance as it affects future clinical management. When facing abnormal liver tests, clinicians should undertake a full diagnostic work-up in order to determine whether the hepatic abnormalities are related to the inflammatory bowel diseases or not. Management of hepatic manifestations in inflammatory bowel diseases usually involves both hepatologists and gastroenterologists because of the complexity of some situations.

Introduction

Inflammatory bowel diseases (IBD) are associated with a variety of extraintestinal manifestations, including hepatobiliary disorders (HD).[1] HD are reported in both ulcerative colitis (UC) and Crohn's disease (CD), but are more commonly related to UC.[2] Their clinical course is often independent from that of the associated IBD. Screening for HD in IBD patients is important, as approximately 5% of adults will develop liver disease.[3] Moreover, chronic liver disease is also found in IBD patients with normal liver biochemical tests.[3] Because of the large spectrum of hepatobiliary disorders in IBD, the prevalence of liver dysfunction reported in the literature varies greatly. Differences in the definition across studies may also account for the prevalence variability. Indeed, when transient elevation of liver tests is also taken into consideration, the prevalence rises accordingly from 3% to 50%.[4]

Non-alcoholic fatty liver disease (NAFLD) is considered as the most common liver disease in IBD, even if most epidemiological studies are inconclusive.[2] Primary sclerosing cholangitis (PSC) is the most specific hepatobiliary complication associated with IBD, particularly in UC. PSC patients are prone to develop cholangiocarcinoma and colon cancer.[3] Less frequently, IBD-associated hepatobiliary disorders include: autoimmune hepatitis/PSC overlap syndrome, IgG4-associated cholangiopathy, primary biliary cholangitis (PBC), hepatic amyloidosis, granulomatous hepatitis, cholelithiasis, portal vein thrombosis and liver abscess. The spectrum of these manifestations varies according to the type of IBD. Granulomas, hepatic abscess, amyloidosis and gallstones are conventionally observed in CD while PSC and autoimmune hepatitis are usually described in UC.[5]

The pathogenesis of liver injury in IBD is not completely understood. Genetic, immunological and environmental factors that contribute to IBD pathogenesis may also contribute to associated hepatobiliary disorders.[6] Some complications are related to IBD itself and can be subsequently related to inflammation or malabsorption. Finally, some hepatobiliary disorders are caused by IBD treatment, as most of them are potentially hepatotoxic. Hepatitis B reactivation during immunosuppressive therapy is also a major concern.

The main goal of this review is to summarize the most recent knowledge regarding hepatobiliary manifestations related to IBD with a particular focus on the hepatotoxicity of concomitant drugs used in the treatment of IBD.

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