Hepatobiliary manifestations in inflammatory bowel disease: A practical approach

Table 1 Possible, drug induced liver injury, prevention and what to do

Drug	Prevention	Hepatic injury	Treatment
5-Amino salicilyc acid	Check before start treatment annual check	Drug induced hepatitis; Drug induced cholestasic; Granuloma formation (sulfa)	Stop drug; Follow-up
Tiopurines (azathioprine/6MP)	Check before treatment: TPMT and liver test; Check every week in first month, withing 2 wk in 2nd mo, every 3 mo	Drug induced hepatitis; Drug induced cholestasic; Sinusoidal obstruction syndrome; Nodular regenerative hyperplasia; Peliosis hepatitis	Drug induced hepatitis and cholestasic are idyosincratic reactions; More cases in the first three months of treatment; Stop drug
Methotrexate	Check before start treatment; Check every 2 wk until 2nd mo; Check every 3 mo; Add folic acid	Fibrosis/cirrhosis; Steatohepatitis	Stop MTX if ALT > 3 times; Despite alcohol; Comsume; Fibroscan

6MP: 6-mercapthopurine; MTX: Methotrexate; TPMT: Thiopurine methyltransferase; ALT: Alanino transferase.

Table 2 Summary of different diseases according to liver disease pattern

Type of manifestation	Diagnostic	Treatment
	Cholestasis
PSC	MRCP	UDCA
SDD	Liver biopsy	UDCA
IgG4 cholangitis	MRCP + liver biopsy + Ig4 subclass in blood	Glucocorticoids
PBC	AMA serology or liver biopsy in some cases	UDCA
DILI	Approach based in ruling out others diagnosis and likelihood depending the drug and latency	Withdrawal the drug and steroids in some hypersensibility cases
Cholangiocarcinoma	MRCP + CA199 markers	Surgery, chemotherapy, liver transplantation (special cases)
	Hepatocelular pattern
NAFLD	Abdominal US, fatty liver indexs, ruling out other diagnosis, liver biopsy in some cases	Change style of life with loose weight, calories restricted diet, exercise and control IBD inflammatory activity
AIH	Serology (ANA, ASM, LKM1, IgG, liver biopsy). Simplified autoimmune hepatitis score	Azathioprine ± steroids
Chronic viral hepatitis	Serology, non-invasive fibrosis tests	DDA in HCV and long-term antiviral in HBV
DILI		Withdrawal the drug and steroids in some hypersensibility cases
	Mix pattern
Overlap/AIC	MRCP + liver biopsy	Azathioprine ± steroids + UDCA
DILI		Withdrawal the drug and steroids in some hypersensibility cases
Chronic viral hepatitis	Serological markers	DDA in HCV and long term antiviralin HBV

MCRP: Magnetic resonance cholangiopancreatography; UDCA: Ursodeoxycholic acid; ANA: Anti-nuclear antibodies; SMA: Anti-smooth muscle antibodies; LKM1: Liver kidney microsome type 1; DDA: Direct-acting antiviral; HCV: Hepatitis C virus; HBV: Hepatitis B virus; AIC: Anterior insular cortex; DILI: Drug induced liver injury; PSC: Primary sclerosing cholangitis; AIH: Autoimmune hepatitis; NAFLD: Non-alcoholic fatty liver disease; US: Ultrasonography; ASM: Anti-smooth muscle; IBD: Inflammatory bowel disease; IgG: Immunoglobulin G; SDD: Small duct disease.