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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. 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

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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

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