Hepatopancreatobiliary manifestations and complications associated with inflammatory bowel disease

Abstract

Diseases involving the hepatopancreatobiliary (HPB) system are frequently encountered in patients with inflammatory bowel disease (IBD). Hepatobiliary manifestations constitute some of the most common extraintestinal manifestations of IBD. They appear to occur with similar frequency in patients with Crohn's disease or ulcerative colitis. HPB manifestations may occur in following settings: 1) disease possibly associated with a shared pathogenetic mechanism with IBD including primary sclerosing cholangitis (PSC), small-duct PSC/pericholangitis and PSC/autoimmune hepatitis overlap, acute and chronic pancreatitis related to IBD; 2) diseases which parallel structural and physiological changes seen with IBD, including cholelithiasis, portal vein thrombosis, and hepatic abscess; and 3) diseases related to adverse effects associated with treatment of IBD, including drug-induced hepatitis, pancreatitis (purine-based agents), or liver cirrhosis (methotrexate), and reactivation of hepatitis B, and biologic agent-associated hepatosplenic lymphoma. Less common HPB manifestations that have been described in association with IBD include autoimmune pancreatitis (AIP), IgG4-associated cholangitis (IAC), primary biliary cirrhosis (PBC), fatty liver, granulomatous hepatitis, and amyloidosis. PSC is the most significant hepatobiliary manifestation associated with IBD and poses substantial challenges in management requiring a multidisciplinary approach. The natural disease course of PSC may progress to cirrhosis and ultimately require liver transplantation in spite of total proctocolectomy with ileal-pouch anal anastomosis. The association between AIP, IAC, and elevated serum IgG4 in patients with PSC is intriguing. The recently reported association between IAC and IBD may open the door to investigate these complex disorders. Further studies are warranted to help understand the pathogenesis of HPB manifestations associated with IBD, which would help clinicians better manage these patients. An interdisciplinary approach, involving gastroenterologists, hepatologists, and, in advanced cases, general, colorectal, and transplant surgeons is advocated.

Protein-losing enteropathy in a dog with lymphangiectasia, lymphoplasmacytic enteritis and pancreatic exocrine insufficiency

“…Drugs could be a definite cause of acute pancreatitis in patients with IBD, with mesalamine being the most frequently encountered although cases due to corticosteroids and metronidazole have also been described (Navaneethan and Shen 2010;Triantafillidis and Merikas 2010). Of note, the animal in this report only received metronidazole.…”

“…In humans, diseases involving the pancreas are frequently encountered in patients with IBD including acute and chronic pancreatitis (CP) (Navaneethan and Shen 2010), which may be subclinical (Barthet et al 1999). Acute pancreatitis associated with IBD may be related to gallstones, papillary injury of the duodenum, or Crohn's disease-associated granulomatous inflammation (Spiess et al 1992;Gschwantler et al 1995).…”

A review of liver disorders in inflammatory bowel disease (IBD)

“…The incidence of cholelithiasis in CD is doubled when compared to IBD-free controls and has been reported to be between 13% and 34% [6,152]. UC (which does not involve the small bowel) is not considered a risk factor for cholelithiasis.…”

“…This evidence has now immensely expanded, with hepatobiliary disease in IBD now known to constitute some of the disorder's most common extraintestinal manifestations [1][2][3][4][5][6][7][8]. Also, these hepatobiliary manifestations do not always parallel IBD disease activity, but instead may follow an independent natural course [5].…”

Extraintestinal Manifestations of Ulcerative Colitis

“…During treatment with UDCA, stenosis of bile ducts may occur and endoscopic intervention with dilatation has been showed to be effective (Stiehl, 2004). At the present time, liver transplantation is the only effective treatment especially for end-stage PSC or PSC with cholangiocarcinoma (Chapman, Fevery et al, 2010;Navaneethan & Shen, 2010). Orthotopic liver transplantation is the established treatment in PSC with 85% to 90% of 5-year survival rate (Gow & Chapman, 2000).…”