Reviewed by: HU Medical Review Board | Last Reviewed: January 2018. | Last updated: March 2021
Your liver plays many important roles, including:
- Removing toxins
- Fighting infections
- Digesting food and storing nutrients
There are special considerations for people who have overlapping inflammatory bowel disease and liver disease. Medications that treat inflammatory bowel disease (IBD) can cause weight gain or liver damage, increasing your risk of fatty liver disease. Certain medications also can increase your risk of reactivating hepatitis viruses that damage the liver. Simply having inflammatory bowel disease is a risk factor for certain liver diseases, such as primary sclerosing cholangitis.
Fatty Liver Disease
Non-alcoholic fatty liver disease is the most common liver disease in the US and other Western countries.1 In this condition, extra fat builds up in liver cells not due to alcohol or other causes.2 It affects about 27% to 38% of the general population.2 Among people with inflammatory bowel disease, about 23% also have fatty liver disease.3 Another term for this disease is “hepatic steatosis.”
Link with inflammatory bowel disease.Fatty liver disease is linked to being overweight.2 Fatty liver disease was once an uncommon complication of inflammatory bowel disease, because people with IBD are often underweight.1 However, a growing number of people with IBD are overweight.
There are several explanations for the increase in overweight among people with IBD. Commonly used medications such as corticosteroids and biologic medications may lead to weight gain.1 Weight gain is also a side effect of medications used to treat symptoms and complications of IBD. Examples include pregabalin (Lyrica) for pain or antidepressants and antipsychotics used to treat anxiety or insomnia. Furthermore, it may be difficult to eat a balanced, nutritious diet. Many people with IBD avoid foods that make their symptoms worse or increase their risk of a blockage. Each person is different, but for many people this means eliminating hard-to-digest foods such as stringy vegetables. You may find that the diet you can tolerate is high in low-fiber, calorie-dense foods.
Medications used to treat IBD may contribute to fatty liver disease in other ways.1 Corticosteroids also cause fat build-up in the liver. Long-term use of methotrexate may cause liver damage, including scarring (fibrosis), fat accumulation, and inflammation.1
Diagnosis.Symptoms include pain in the upper right of the belly, yellowing of the skin and eyes (jaundice), and itching. However, many people with fatty liver disease do not have any symptoms.
Your health care provider will measure your height, weight, and waist circumference.2 Your provider will also do blood tests to check your cholesterol, blood sugar, and liver function, and for other causes of liver problems.
Your provider can look at your liver and spleen with an ultrasound, computed tomography (CT) scan, or magnetic resonance imaging (MRI).2 These will help your provider to see fat build-up and scarring. Your provider may suggest getting a liver biopsy. In this procedure, a sample of tissue is removed through small incisions. This sample provides information about the amount of fat in your liver, as well as inflammation and scarring. There are also non-invasive alternative tests that provide similar information.
Treatment.There is no standard medical treatment for fatty liver disease. Instead, the first course of treatment is to eat a healthy diet, increase exercise, and attempt to lose weight.2 Weight loss of as little as 5% to 10% improves liver function. Exercise, even without weight loss, also benefits the liver.
Of course, weight loss is difficult for everyone, and people with IBD have unique challenges. Many people with IBD find it difficult to eat a healthy, varied diet because of their symptoms. Exercise may seem daunting, when you are tired, in pain, and concerned about needing to use the bathroom frequently. Some people find starting with low-intensity cardiovascular exercise to be tolerable.4 For general health benefits, 30 minutes on most days is enough, even if you do it 10 minutes at a time.5 Realistically, though, there are times when you do not have the strength even to shower, let alone go for a walk. It is common for people with IBD to feel frustrated about being unable to care for themselves.
Your provider may encourage you to be vaccinated against hepatitis A and B. These diseases can damage your liver further. Limiting your alcohol use may also prevent further liver damage.
Primary Sclerosing Cholangitis
Primary sclerosing cholangitis (PSC) is a disease that damages bile ducts inside and outside the liver.6 Bile is a fluid that helps you to digest fat.7 It is made in the liver and leaves the liver through bile ducts. Bile is stored in the gallbladder or secreted into the small intestine.
PSC causes inflammation and scar formation in the bile ducts. Overtime, scarring causes the ducts to become narrow. The bile begins to build up in the liver and causes liver damage.6
Link with inflammatory bowel disease. There is a strong link between PSC and inflammatory bowel disease. Although only 5% of people with inflammatory bowel disease develop PSC,8 about 75% of people with PSC have inflammatory bowel disease. PSC mainly affects people with ulcerative colitis.9 In people with Crohn’s disease, PSC is only seen in Crohn’s colitis, which affects the large intestine. If Crohn’s disease only affects your small intestine, you are not at higher risk of PSC.8
Diagnosis. Symptoms include fatigue and itching. If PSC is advanced, you might also have yellowing of the skin and eyes (jaundice), bleeding within the digestive tract, swelling in the abdomen, or confusion.8 Occasionally, PSC causes pain in the upper right part of the belly. However, in many patients, PSC does not cause any symptoms.8
Your health care provider will do blood tests to check how well your liver is working.6 If the results indicate that you may have PSC, the next step is to look at liver and bile ducts to see if there is a blockage.8 Ultrasound or CT scan may be used to check for a blockage in the bile ducts.
Other tests used to check for PSC are:
- Magnetic resonance cholangiography. This procedure uses MRI to create a picture of the bile ducts.6 Your doctor will look for signs of scarring and stretched out, sac-like areas (“beading”) along the bile duct.8
- Endoscopic retrograde cholangiopancreatography. This procedure combines endoscopy with a contrast material and x-ray.9 The contrast material allows your doctor to see narrow or blocked areas within the bile ducts. Your doctor can also take tissue samples or open up narrowed areas during this procedure.
Treatment. No treatments have been found that cure or slow PSC.6,8 Instead, medications are given to treat symptoms and complications. Medications can relieve itching. Antibiotics are given to treat infection. People with PSC may have trouble absorbing fat-soluble vitamins, such as vitamins A, D, E, and K. Therefore, vitamin supplements may be given to prevent malnutrition.6
It may be possible to open narrow areas of the larger bile ducts with “endoscopic dilation.” An endoscope is guided through the esophagus, stomach and small intestine to the blocked bile ducts.8 A balloon inserted through the scope is inflated, opening up the area that has gotten narrow.
If PSC leads to liver failure, liver transplantation may be needed.6
Hepatitis B and C
Hepatitis B and C infections cause inflammation of the liver. These infections are caused by viruses that spread through body fluids, including blood. People with inflammatory bowel disease used to be at a higher risk of hepatitis B or C infection because of surgery and the need for blood transfusions.10 However, new cases of viral hepatitis in people with inflammatory bowel disease have decreased. Reasons for the decrease include increased hepatitis B vaccination, safer transfusions, and improvements in surgical procedures.10 In fact, hepatitis B infection in the general population has decreased 82% since 1991, when routine vaccination of children started.11
Link with inflammatory bowel disease. Hepatitis B or C infection may not cause any symptoms. Sometimes the infection clears on its own. In this case, you may not know that you have had a viral hepatitis infection. In other cases, you may need treatment with antiviral medications.12,13
The immunosuppressants used to treat IBD could reactivate hepatitis B after it has been treated or cleared. In other words, while the immune system is suppressed, the hepatitis B virus may become active again.10
Your provider may want to test and vaccinate you against hepatitis B before starting treatment for IBD.14 If you have been infected with hepatitis B, you may need to take antiviral medications to prevent hepatitis B from flaring up during immunosuppressive therapy for IBD.14
For people with hepatitis C, immunosuppressants do not seem to reactive the virus or worsen liver function.10,14 However, corticosteroids may worsen hepatitis C infection and increase liver damage.10,14
Diagnosis. Most people do not have symptoms of hepatitis B or C.12,13 However, hepatitis B or C can cause flu-like symptoms: fatigue, muscle soreness, stomach pain, and fever. You might have dark yellow urine, light-colored stools, or jaundice.
Hepatitis B and C infections are diagnosed with a blood test.12,13 If you have a hepatitis infection, your health care provider may recommend getting a sample of liver tissue (biopsy). The liver biopsy provides information whether your liver is scarred (fibrosis), and how much scarring there is.
Treatment.Treatment for viral hepatitis infection not always necessary. Sometimes your immune system clears it on its own. When treatment is needed, antiviral medications are used to reduce or eliminate the virus.12,13 If hepatitis leads to liver failure, liver transplantation may be needed.12,13