Hepatobiliary Associations With Inflammatory Bowel Disease
Hepatobiliary Associations With Inflammatory Bowel Disease
Hepatobiliary disease is not uncommon in patients with inflammatory bowel disease (IBD). The most common autoimmune hepatic associations are primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH). The immunosuppressant medications used in the treatment of IBD also have potential hepatotoxicity. PSC is most commonly associated with IBD, specifically ulcerative colitis. AIH, a more classic autoimmune disease diagnosed commonly in isolation of other conditions in the same individual, is less commonly associated with IBD. Additionally, a subgroup of patients have features of both PSC and AIH, termed overlap syndrome, that is also sometimes seen in IBD patients. This review will discuss the most common liver disease associations seen in patients with IBD: PSC, AIH and overlap syndrome. Additionally, the most common drug-related hepatotoxicities encountered when treating IBD will be reviewed.
The association between inflammatory bowel disease (IBD) and hepatobiliary disorders was first described in the late 1800s. Over the past century, knowledge of this association has grown dramatically. IBD has been associated with an increased risk of other autoimmune diseases. Primary sclerosing cholangitis (PSC) is one of the most common extraintestinal manifestations of IBD, particularly in ulcerative colitis (UC) patients. Autoimmune hepatitis (AIH) is also seen, and recently an overlap syndrome has been described in some patients, who have classic features of more than one autoimmune liver disease – either PSC, AIH or primary biliary cirrhosis (PBC). There has also been an increase in hepatotoxicity as a sequela of the broadening pharmacologic armamentarium used to treat the underlying IBD.
A true estimation of the prevalence of hepatobiliary disease in IBD patients is difficult to determine. Performance of liver biopsies and cholangiograms on a large number of patients is neither ethical nor feasible. A review of over 500 patients with IBD, however, found abnormal serum aminotransferases in almost a third of individuals, although the level of elevation was generally quite small (less than twice the upper limit of normal [ULN]). Elevation of serum aminotransferases showed no correlation with active versus inactive IBD. The age-adjusted risk of death was 4.8-times higher in those with elevated serum aminotransferases than those with normal values, after excluding for other known liver disease. They also found that the patients with elevated serum aminotransferases were less likely to be on 5-aminosalicylates, but found no difference in other medication use between the two groups. The exact etiology of the abnormalities in the subjects of this study was unclear, owing to the fact that a formal workup was not performed in the majority of patients. Only 6% had identifiable liver disease (5% PSC).
Abstract and Introduction
Abstract
Hepatobiliary disease is not uncommon in patients with inflammatory bowel disease (IBD). The most common autoimmune hepatic associations are primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH). The immunosuppressant medications used in the treatment of IBD also have potential hepatotoxicity. PSC is most commonly associated with IBD, specifically ulcerative colitis. AIH, a more classic autoimmune disease diagnosed commonly in isolation of other conditions in the same individual, is less commonly associated with IBD. Additionally, a subgroup of patients have features of both PSC and AIH, termed overlap syndrome, that is also sometimes seen in IBD patients. This review will discuss the most common liver disease associations seen in patients with IBD: PSC, AIH and overlap syndrome. Additionally, the most common drug-related hepatotoxicities encountered when treating IBD will be reviewed.
Introduction
The association between inflammatory bowel disease (IBD) and hepatobiliary disorders was first described in the late 1800s. Over the past century, knowledge of this association has grown dramatically. IBD has been associated with an increased risk of other autoimmune diseases. Primary sclerosing cholangitis (PSC) is one of the most common extraintestinal manifestations of IBD, particularly in ulcerative colitis (UC) patients. Autoimmune hepatitis (AIH) is also seen, and recently an overlap syndrome has been described in some patients, who have classic features of more than one autoimmune liver disease – either PSC, AIH or primary biliary cirrhosis (PBC). There has also been an increase in hepatotoxicity as a sequela of the broadening pharmacologic armamentarium used to treat the underlying IBD.
A true estimation of the prevalence of hepatobiliary disease in IBD patients is difficult to determine. Performance of liver biopsies and cholangiograms on a large number of patients is neither ethical nor feasible. A review of over 500 patients with IBD, however, found abnormal serum aminotransferases in almost a third of individuals, although the level of elevation was generally quite small (less than twice the upper limit of normal [ULN]). Elevation of serum aminotransferases showed no correlation with active versus inactive IBD. The age-adjusted risk of death was 4.8-times higher in those with elevated serum aminotransferases than those with normal values, after excluding for other known liver disease. They also found that the patients with elevated serum aminotransferases were less likely to be on 5-aminosalicylates, but found no difference in other medication use between the two groups. The exact etiology of the abnormalities in the subjects of this study was unclear, owing to the fact that a formal workup was not performed in the majority of patients. Only 6% had identifiable liver disease (5% PSC).
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