Copyright ©The Author(s) 2021.
World J Hepatol. Dec 27, 2021; 13(12): 1828-1849
Published online Dec 27, 2021. doi: 10.4254/wjh.v13.i12.1828
Table 1 Main features of hepatobiliary manifestations associated with inflammatory bowel diseases
Hepatobiliary manifestation
Main features
PSCThe most frequent (50%-80% of PSC patients have IBD, and 2%-8% of IBD patients have PSC)
No medical treatment approved. Therapies directed towards PSC complications
Increased risk of cholangiocarcinoma and colorectal cancer (surveillance needed)
Small duct PSCHistological evidence of PSC, but normal cholangiogram
More benign disease course than classic PSC (cholangiocarcinoma risk not increased)
PSC-AIH overlap syndromeCoexistence of biochemical and histological features of AIH and PSC-associated biliary tract alterations
Better response to steroids and immunosuppressants than PSC
IgG4-related sclerosing cholangitisPart of the IgG4-related systemic disease
Characterized by histological evidence of IgG4+ plasma cells infiltrate
Good response to steroids
Granulomatous hepatitisRare, generally in Crohn’s disease
Autoimmune or drug-induced pathogenesis
Good response to steroids
Gallstone diseaseIncidence increased in IBD, more in Crohn’s disease
Bile salts malabsorption underlying the pathogenesis
NAFLDNot strictly associated with IBD; similar risk factors in the general population
Higher NAFLD prevalence in patients with severe IBD activity
Pyogenic liver abscessRare, mainly in Crohn’s disease
Penetrating disease, steroid treatment and malnutrition are risk factors
Portal vein thrombosisIncreased risk in IBD, especially during severe disease flare and after surgery. Prophylactic treatment indicated in these settings
AminosalicylatesLow risk of DILI
LFT monitoring not necessary
ThiopurinesDILI quite frequent (prevalence of about 3%); both dose-independent and dose-dependent toxicities are possible
Regular LFT monitoring indicated
MethotrexateDILI quite frequent, with a prevalent dose-dependent mechanism
Regular LFT monitoring indicated
Folic acid supplementation indicated during treatment
Anti-tumour necrosis factor-αLow risk of DILI, mainly with infliximab
LFT monitoring not necessary
Anti-integrinsLow risk of DILI
LFT monitoring not necessary
Anti-interleukin 12/23Low risk of DILI
LFT monitoring not necessary
TofacitinibData in IBD still scarce
Alanine aminotransferase elevation quite frequent in rheumatoid arthritis, but generally mild
Hepatitis B reactivationA relevant concern
Antiviral therapy indicated in HBsAg positive patients
LFT monitoring indicated in HBsAg negative/anti-HBc positive patients
Vaccination indicated in naïve patients
Hepatitis C reactivationNot a relevant concern
Table 2 Management of patients with inflammatory bowel disease undergoing immunosuppressive therapy according to hepatitis B status
Hepatitis B status
HBsAg positive/anti-HBc positive (chronic hepatitis B)Antiviral treatment (start 3-4 wk before and continue at least 12 mo after the immunosuppressive treatment)
HBsAg negative/anti-HBc positive (occult hepatitis B)Liver function tests monitoring every 2-3 mo
HBsAg negative/anti-HBc negative/anti-HBs negative (naïve for hepatitis B)Vaccination (indicated at diagnosis)
HBsAg negative/anti-HBc negative/anti-HBs positiveCheck previous hepatitis B vaccination. Dose hepatitis B virus-DNA if uncertainty