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HEPATIC COMPLICATIONS OF IBD

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HEPATIC COMPLICATIONS OF IBD Powered By Docstoc
					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
1.    Alcoholic liver disease
2.    Viral hepatitis
3.    Primary Sclerosing Cholangitis
4.    Nonalcoholic fatty liver disease
5.    Medications/Drug Induced Liver Injury
6.    Autoimmune Hepatitis
7.    Nodular Regenerative Hyperplasia
8.    Primary Biliary Cirrhosis
9.    Portal Vein Thrombosis/Hepatic Vein
      Thrombosis
     HEPATIC COMPLICATIONS OF
               IBD
1.    Alcoholic liver disease
2.    Viral hepatitis
3.    Primary Sclerosing Cholangitis
4.    Nonalcoholic fatty liver disease
5.    Medications/Drug Induced Liver Injury
6.    Autoimmune Hepatitis
7.    Nodular Regenerative Hyperplasia
8.    Primary Biliary Cirrhosis
9.    Portal Vein Thrombosis/Hepatic Vein
      Thrombosis
     HEPATIC COMPLICATIONS OF
               IBD
1.    Alcoholic liver disease
2.    Viral hepatitis
3.    Primary Sclerosing Cholangitis
4.    Nonalcoholic fatty liver disease
5.    Medications/Drug Induced Liver Injury
6.    Autoimmune Hepatitis
7.    Nodular Regenerative Hyperplasia
8.    Primary Biliary Cirrhosis
9.    Portal Vein Thrombosis/Hepatic Vein
      Thrombosis
    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
           CHOLANGITIS

 Progressive inflammation, fibrosis, destruction
  of bile ducts
 Intrahepatic and extrahepatic bile ducts
 Can result in portal hypertension and cirrhosis
PRIMARY SCLEROSING
    CHOLANGITIS
     PSC - PATHOGENESIS

 Genetic susceptibility
 Chronic portal bacteremia
 Viral infection
 Ischemic vascular damage
 Immune dysregulation
         PSC - DIAGNOSIS

   Clinical symptoms
   Biochemical abnormalities
   Histological findings
   Cholangiographic findings
       PSC - TREATMENT

 ? UDCA
 Management of strictures/infections
 Management of portal hypertension
 Orthotopic liver transplantation
 Cholangiocarcinoma: 6-11% of PSC
  patients
NONALCOHOLIC FATTY
   LIVER DISEASE
    NONALCOHOLIC FATTY
       LIVER DISEASE
 Hepatomegaly and steatosis = 25-40% of all
  IBD patients
  1. Corticosteroid use

  2. Malnutrition

  3. Fluctuation in weight

  4. Concomitant diseases

 Treatment – avoid steroid medications, diet
  and lifestyle modification
AUTOIMMUNE HEPATITIS

 < 5% associated with IBD
 Features of AIH found as “overlap
  syndrome” with PSC
 Predominantly children
 Standard diagnostic criteria
AUTOIMMUNE HEPATITIS
    DRUG INDUCED LIVER INJURY

   Antibiotics
   5 – ASA
   Corticosteroids
   Thioguanine
   6-mercaptopurine
   Infliximab
   Methotrexate
   Cyclosporine
    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 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
    HYPERPLASIA
    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
        HYPERPLASIA

 Treatment – drug withdrawal
 Management of portal hypertension
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
 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
 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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posted:2/26/2012
language:English
pages:30