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HEPATIC COMPLICATIONS OF IBD. Preeti A. Reshamwala, MD University of Maryland Medical Center Division of Gastroenterology and Hepatology. ABNORMAL HEPATIC BIOCHEMISTRIES IN IBD PATIENTS. HEPATIC COMPLICATIONS OF IBD. Alcoholic liver disease Viral hepatitis Primary Sclerosing Cholangitis

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hepatic complications of ibd

HEPATIC COMPLICATIONS OF IBD

Preeti A. Reshamwala, MD

University of Maryland Medical Center

Division of Gastroenterology and Hepatology

hepatic complications of ibd1
HEPATIC COMPLICATIONS OF IBD
  • Alcoholic liver disease
  • Viral hepatitis
  • Primary SclerosingCholangitis
  • Nonalcoholic fatty liver disease
  • Medications/Drug Induced Liver Injury
  • Autoimmune Hepatitis
  • Nodular Regenerative Hyperplasia
  • Primary Biliary Cirrhosis
  • Portal Vein Thrombosis/Hepatic Vein Thrombosis
hepatic complications of ibd2
HEPATIC COMPLICATIONS OF IBD

Alcoholic liver disease

Viral hepatitis

Primary SclerosingCholangitis

Nonalcoholic fatty liver disease

Medications/Drug Induced Liver Injury

Autoimmune Hepatitis

Nodular Regenerative Hyperplasia

Primary Biliary Cirrhosis

Portal Vein Thrombosis/Hepatic Vein Thrombosis

hepatic complications of ibd3
HEPATIC COMPLICATIONS OF IBD

Alcoholic liver disease

Viral hepatitis

Primary SclerosingCholangitis

Nonalcoholic fatty liver disease

Medications/Drug Induced Liver Injury

Autoimmune Hepatitis

Nodular Regenerative Hyperplasia

Primary Biliary Cirrhosis

Portal Vein Thrombosis/Hepatic Vein Thrombosis

primary sclerosing cholangitis
PRIMARY SCLEROSING CHOLANGITIS
  • Most firmly established hepatobiliary disease associated with IBD
  • 70-80% cases associated with IBD
  • 87% = UC; 13% = Crohns disease
  • Prevalence of PSC in UC range from 2.4% to 7.5%
primary sclerosing cholangitis1
PRIMARY SCLEROSING CHOLANGITIS
  • Progressive inflammation, fibrosis, destruction of bile ducts
  • Intrahepatic and extrahepatic bile ducts
  • Can result in portal hypertension and cirrhosis
psc pathogenesis
PSC - PATHOGENESIS
  • Genetic susceptibility
  • Chronic portal bacteremia
  • Viral infection
  • Ischemic vascular damage
  • Immune dysregulation
psc diagnosis
PSC - DIAGNOSIS
  • Clinical symptoms
  • Biochemical abnormalities
  • Histological findings
  • Cholangiographic findings
psc treatment
PSC - TREATMENT
  • ? UDCA
  • Management of strictures/infections
  • Management of portal hypertension
  • Orthotopic liver transplantation
  • Cholangiocarcinoma: 6-11% of PSC patients
nonalcoholic fatty liver disease1
NONALCOHOLIC FATTY LIVER DISEASE
  • Hepatomegaly and steatosis = 25-40% of all IBD patients
    • Corticosteroid use
    • Malnutrition
    • Fluctuation in weight
    • Concomitant diseases
  • Treatment – avoid steroid medications, diet and lifestyle modification
autoimmune hepatitis
AUTOIMMUNE HEPATITIS
  • < 5% associated with IBD
  • Features of AIH found as “overlap syndrome” with PSC
  • Predominantly children
  • Standard diagnostic criteria
drug induced liver injury
DRUG INDUCED LIVER INJURY
  • Antibiotics
  • 5 – ASA
  • Corticosteroids
  • Thioguanine
  • 6-mercaptopurine
  • Infliximab
  • Methotrexate
  • Cyclosporine
drug induced liver injury1
DRUG INDUCED LIVER INJURY
  • Multiple medications used
  • DILI 14-40% IBD series
  • Role of metabolite monitoring
  • Drug withdrawal – if possible
  • Histology
nodular regenerative hyperplasia
NODULAR REGENERATIVE HYPERPLASIA
  • Nodular noncirrhotic liver disease
  • Believed to be a result of microcirculatory abnormalities leading to hypertrophy in some acini, atrophy in others
  • NO FIBROSIS
  • Mimics cirrhosis, associated with portal hypertension
nodular regenerative hyperplasia2
NODULAR REGENERATIVE HYPERPLASIA
  • Associated with use of TG
  • 20-55% of liver biopsies of patients on TG therapy
  • Pathogenesis - ?non-necrotizing endothelitis vascular abnormalities
  • 1/3 of patients will have abnormal aminotransferases or alkaline phosphatase
  • Hepatic synthetic function usually preserved
nodular regenerative hyperplasia3
NODULAR REGENERATIVE HYPERPLASIA
  • Treatment – drug withdrawal
  • Management of portal hypertension
primary biliary cirrhosis
PRIMARY BILIARY CIRRHOSIS
  • Rarely associated with IBD
  • Reported <2% patients with IBD
  • Rule out other cholestatic liver diseases, granulomatous liver diseases, infections
  • Antimitochondrial antibody
  • HISTOLOGY
thromboembolic phenomena
THROMBOEMBOLIC PHENOMENA
  • IBD patients – predisposition for hypercoagulable state
  • Reports of acute portal vein thrombosis and hepatic vein thrombosis – children
  • Often associated with septic pyelophlebitis
  • Chronic PVT/HVT can lead to portal hypertension and cirrhosis
  • Anticoagulation may be considered
conclusions
CONCLUSIONS
  • Monitor hepatic biochemistries
  • Eliminate alcohol use
  • Treat viral hepatitis
  • Recognize and limit the use of hepatotoxic drugs – difficult task
  • If no improvement in hepatic profile, biopsy is essential
  • Referral to hepatologist +/- transplant center