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HEPATIC COMPLICATIONS OF IBD

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  1. HEPATIC COMPLICATIONS OF IBD Preeti A. Reshamwala, MD University of Maryland Medical Center Division of Gastroenterology and Hepatology

  2. ABNORMAL HEPATIC BIOCHEMISTRIES IN IBD PATIENTS

  3. 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

  4. 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

  5. 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

  6. 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%

  7. PRIMARY SCLEROSING CHOLANGITIS • Progressive inflammation, fibrosis, destruction of bile ducts • Intrahepatic and extrahepatic bile ducts • Can result in portal hypertension and cirrhosis

  8. PRIMARY SCLEROSING CHOLANGITIS

  9. PSC - PATHOGENESIS • Genetic susceptibility • Chronic portal bacteremia • Viral infection • Ischemic vascular damage • Immune dysregulation

  10. PSC - DIAGNOSIS • Clinical symptoms • Biochemical abnormalities • Histological findings • Cholangiographic findings

  11. PSC - TREATMENT • ? UDCA • Management of strictures/infections • Management of portal hypertension • Orthotopic liver transplantation • Cholangiocarcinoma: 6-11% of PSC patients

  12. NONALCOHOLIC FATTY LIVER DISEASE

  13. 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

  14. AUTOIMMUNE HEPATITIS • < 5% associated with IBD • Features of AIH found as “overlap syndrome” with PSC • Predominantly children • Standard diagnostic criteria

  15. AUTOIMMUNE HEPATITIS

  16. DRUG INDUCED LIVER INJURY • Antibiotics • 5 – ASA • Corticosteroids • Thioguanine • 6-mercaptopurine • Infliximab • Methotrexate • Cyclosporine

  17. DRUG INDUCED LIVER INJURY • Multiple medications used • DILI 14-40% IBD series • Role of metabolite monitoring • Drug withdrawal – if possible • Histology

  18. 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

  19. NODULAR REGENERATIVE HYPERPLASIA

  20. 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

  21. NODULAR REGENERATIVE HYPERPLASIA • Treatment – drug withdrawal • Management of portal hypertension

  22. 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

  23. 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

  24. 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