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Hepatobiliary manifestations of inflammatory bowel disease

Gad Friedman, MD, FRCPC
Alain Bitton, MD, FRCPC
Section Editor
Paul Rutgeerts, MD, PhD, FRCP
Deputy Editor
Shilpa Grover, MD, MPH


Diseases of the liver and biliary tract are common extraintestinal manifestations of inflammatory bowel disease (IBD) (table 1) [1-3]. Primary sclerosing cholangitis (PSC) is one of the more common hepatobiliary complications of IBD, particularly in patients with ulcerative colitis. It is estimated that approximately 5 percent of patients with ulcerative colitis develop PSC and that ulcerative colitis is present in up to 90 percent of patients with PSC [4]. (See "Primary sclerosing cholangitis: Epidemiology and pathogenesis".)

Abnormal liver biochemical tests are present in up to 30 percent of patients with IBD and do not appear to correlate with disease activity [5]. As a result, persistently abnormal liver biochemical tests should generally be evaluated. This topic review will focus upon the other hepatobiliary manifestations that can occur in patients with IBD. The association of IBD with PSC is discussed elsewhere. (See "Primary sclerosing cholangitis: Epidemiology and pathogenesis", section on 'PSC and inflammatory bowel disease'.)


Most of the drugs used in the medical management of inflammatory bowel disease (IBD) have been associated with liver toxicity, although the overall incidence of serious complications is low [6,7]. The following are among the reactions that can be seen:

Sulfasalazine can cause both hepatocellular and cholestatic enzyme abnormalities, often related to a hypersensitivity reaction. Newer sulfa-free aminosalicylate preparations deliver increased amounts of the pharmacologically active ingredient of sulfasalazine (5-aminosalicylic acid [5-ASA], mesalamine) to the site of active bowel disease and are associated with a lower systemic toxicity. 5-ASA can rarely cause pancreatitis. (See "Sulfasalazine and 5-aminosalicylates in the treatment of inflammatory bowel disease".)

Azathioprine can cause a spectrum of hepatic injury, ranging from asymptomatic aminotransferase elevations (in approximately 5 percent of patients) to cholestasis, veno-occlusive disease, and peliosis hepatis. Mercaptopurine (6-MP), a metabolite of azathioprine, can also cause hepatocellular and cholestatic hepatitis. Thus, patients treated with azathioprine or 6-MP should have their liver biochemistries monitored regularly. Liver abnormalities usually resolve after discontinuation of therapy. (See "Immunomodulator therapy in Crohn disease", section on 'Toxicity'.)


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Literature review current through: Sep 2016. | This topic last updated: Jan 28, 2015.
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