What is the relationship between steatotic (fatty) hepatic disease and Inflammatory Bowel Disease (IBD)?

From the Guidelines

Steatotic hepatic disease (fatty liver disease) and inflammatory bowel disease (IBD) are closely linked, with patients with IBD having a higher prevalence of fatty liver disease, and management should focus on treating the underlying IBD while minimizing hepatotoxic drugs and implementing lifestyle modifications. The relationship between steatotic hepatic disease and IBD is complex and bidirectional, with chronic intestinal inflammation in IBD disrupting the gut barrier and allowing bacterial products to enter portal circulation and trigger liver inflammation, as well as malnutrition and malabsorption in IBD leading to metabolic disturbances that promote fat deposition in the liver 1. Medications used to treat IBD, such as corticosteroids and methotrexate, can also induce or worsen hepatic steatosis, highlighting the need for careful management of IBD medications in patients with fatty liver disease 1. Lifestyle modifications, including weight management, regular exercise, and avoiding alcohol, are crucial for both conditions, and nutritional support with adequate protein intake and vitamin supplementation can help address malnutrition 1. Regular liver function monitoring is essential, especially when using potentially hepatotoxic IBD medications, and the gut-liver axis represents the physiological basis for this relationship, with inflammatory mediators and altered gut microbiota playing key roles in the pathogenesis of both conditions 1. The most recent guidelines recommend a comprehensive approach to managing NAFLD and NASH, including lifestyle modifications, weight loss, and optimal management of comorbidities, as well as consideration of pharmacological treatments such as resmetirom for non-cirrhotic NASH with significant liver fibrosis 1. Overall, a multidisciplinary approach to managing steatotic hepatic disease and IBD is necessary to improve outcomes and reduce morbidity and mortality in these patients. Key considerations in managing these patients include:

• Treating the underlying IBD with appropriate medications while minimizing hepatotoxic drugs
• Implementing lifestyle modifications, including weight management, regular exercise, and avoiding alcohol
• Providing nutritional support with adequate protein intake and vitamin supplementation
• Regularly monitoring liver function, especially when using potentially hepatotoxic IBD medications
• Considering pharmacological treatments for NASH, such as resmetirom, in patients with significant liver fibrosis.

From the Research

Relationship Between Steatotic Hepatic Disease and Inflammatory Bowel Disease (IBD)

• The relationship between steatotic hepatic disease and IBD is complex, with studies suggesting that patients with IBD are at risk of developing metabolic-dysfunction associated steatotic liver disease (MASLD) due to shared risk factors such as gut dysbiosis and systemic inflammation 2.
• A cross-sectional study found that 18% of IBD patients had MASLD, which was associated with older age, higher body mass index, waist circumference, and triglyceride levels, as well as a higher prevalence of type 2 diabetes mellitus and hypertension 2.
• Another study found that IBD patients with type 2 diabetes mellitus (T2DM) had higher rates of hepatic steatosis (62.9% vs. 27.2%) and liver damage (55.4% vs. 26.6%) compared to IBD patients without T2DM 3.
• The use of biologic agents in IBD patients did not have a significant effect on presumed hepatic steatosis, but was associated with a slight increase in fibrosis-4 index (FIB-4) and nonalcoholic fatty liver disease (NAFLD) fibrosis score 4.
• Non-alcoholic fatty liver disease (NAFLD) is a common extra-intestinal manifestation of IBD, and its pathogenesis is influenced by genetic factors, inflammatory signals, and microbiota 5, 6.

Pathophysiological Mechanisms

• The liver-gut axis plays a key role in the pathophysiology of NAFLD in IBD patients, with intestinal inflammation and disturbances of the liver-gut axis contributing to liver steatosis 6.
• Systemic inflammation and metabolic dysregulation are also important factors in the development of MASLD in IBD patients 2.
• The study of liver steatosis in IBD patients may provide useful insights into the complex links between dietary fat intake, metabolic dysregulation, gut physiology, and intrahepatic cellular mechanisms underlying liver inflammation and damage 6.

Clinical Characteristics and Epidemiology

• IBD patients with MASLD tend to have a higher disease activity score and require more frequent surgical interventions 2.
• Triglyceride levels are a significant predictor of MASLD in IBD patients 2.
• The prevalence of NAFLD in IBD patients is estimated to be around 25% 5.
• IBD patients with T2DM have a higher median age at diagnosis and are more likely to have exclusive colonic involvement compared to IBD patients without T2DM 3.