In 1932, American gastroenterologist Dr Burrill Crohn first described the inflammation and irritation in the digestive system as a medical condition. It was further named after him; this condition of unexplained diarrhoea, weight loss and abdominal cramps that people experience frequently is called Crohn’s disease (CD).
Crohn’s disease is a chronic inflammatory bowel disease (IBD) that begins gradually but worsens over time with periods of remission that lasts for weeks or years. Although the condition largely affects the small intestine and the beginning of the large intestine, some medical practitioners say that people with CD are also at a higher risk for liver problems.
Dr Ravindra B S, director and head of department, gastroenterology and hepatobiliary sciences, Fortis Hospital, Bengaluru, says that it is important to screen the liver of a person who has Crohn’s disease/IBD every four to six months to check its functioning.
According to Dr Sudeep Khanna, senior consultant gastroenterology, Indraprastha Apollo Hospitals, Delhi, only five to eight per cent of people with CD develop liver disease. He adds that a regular liver function test (LFT) helps in early detection since the liver disease may be dormant or asymptomatic.
Does CD directly affect the liver?
Dr Gaurav Gupta, senior consultant and chief surgeon, liver transplant and HPB surgery, Fortis Hospital, Mumbai, says that CD is the inflammation of the intestines and there is no direct correlation between the condition and the liver. “However, people who have CD often develop primary sclerosing cholangitis (PSC) which leads to liver problems,” he adds.
Dr Gupta says PSC is the inflammation of the bile ducts that causes ‘beading’ (strictures and dilations that make the bile ducts look like a necklace of beads). The beading obstructs the flow of bile outside the liver, leading to its accumulation in the liver, causing jaundice and consequently liver damage. “When the accumulated bile hardens, it can also form stones within the gallbladder that block the ducts,” says Dr Gupta.
Happiest Health probed further on the probable association between CD and the development of PSC.
Dr Gupta says the only evident associative factor could be that CD and PSC are both auto-immune conditions. However, he clarifies that PSC need not always occur in all people with CD. It can be a separate entity too.
Dr Ravindra says that PSC is a primary manifestation of IBD and explains that the autoimmune elements attack the bile tubes and cause inflammation.
The fatty liver and CD connection
“Fatty liver has more to do with obesity and the excessive intake of red meat than CD,” says Dr Khanna.
Dr Ravindra however mentions that non-alcoholic fatty liver disease (NAFLD) has been observed to be associated with people who have CD.
According to the Crohn’s and Colitis Foundation, a US-based non-profit organisation dedicated to the management of Crohn’s disease, fatty liver disease is the most common liver complication of IBD. It states that in some people with IBD, the liver can become inflamed or damaged; in about five per cent of them, the disease can be serious.
Confirming CD’s association with NAFLD, a 2017 study of 168 patients published in the journal, Inflammatory Bowel Disease, said that about 13 per cent of the people that were included in the study had both NAFLD and either ulcerative colitis or Crohn’s disease. The researchers also found that in people who had both IBD and NAFLD, IBD lasted for a significantly longer time.
Dr Ravindra recalls the case of a 33-year-old woman who had recurrent pain which drove her several times to doctors seeking relief desperately in vain. Her family was baffled at her trauma given the fact that intermittent stomach pain was all she had. She grappled with stomach pain for almost a year without a cause being pinpointed. A CT scan of the abdomen showed that her small intestine had thickened and ulcerated and she was advised to undergo surgery.
Later the woman underwent a special endoscopy called enteroscopy, a procedure to examine the organs, from the mouth to the large intestine, with the help of a thin tube attached to a camera. Further, the results along with a biopsy showed that she was suffering from Crohn’s disease.
The role of medication
Dr Khanna says that immune suppressants (that keep the body’s immune system in check) and certain medicines that stop inflammation used for the treatment of CD may cause liver problems.
However, Dr Ravindra adds that this may happen in very rare cases as regular liver function tests help detect the problem at an early stage.
Dr Gupta doesn’t see any direct role of CD medications in the development of liver problems.
How to know if its PSC
Dr Gupta says PSC manifests as jaundice and itching all over the body (due to the increased concentration of bile salts).
According to Dr Ravindra, the liver condition in people with CD presents itself in three ways – asymptomatic, when mild changes are detected in the LFT; symptomatic, which presents as itching, tiredness, weakness and jaundice and third, as a presentation of liver disease like jaundice itself with symptoms like itching and leg swelling. “The people who already have a liver disease when screened have associated IBD,” he says.
Speaking on the diagnostic procedure, Dr Khanna says an initial blood test (LFT) shows the cholestatic pattern of PSC. Abnormalities in the pattern indicate biliary obstruction. Magnetic Resonance Imaging (MRI) highlights small strictures in the bile ducts and if further confirmation is required, an endoscopic retrograde cholangiopancreatography (ERCP) is suggested, he adds.
ERCP is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems and Dr Khanna says an ERCP is rarely required unless there is a large stricture in the main bile duct which is outside the liver.
“Endoscopy into the bile ducts is carried out to detect cancer of the bile ducts,” says Dr Khanna.
“Primary sclerosing cholangitis is not curable and can only be controlled,” says Dr Gupta who adds that the condition can be treated with steroids and immune suppressants. But he warns that despite medication, PSC can continue to progress and gradually lead to permanent liver damage and conditions like liver cirrhosis and bile duct cancer.
Dr Khanna says that the treatment is directed toward the symptomatic management of PSC to stabilise the liver and facilitate its adequate functioning.
Dr Ravindra says treatment depends upon the severity of the condition. “When the bile ducts are inflamed and swollen, medication is the best treatment. Stents work best to widen the ducts when they have narrowed.
“Only in severe liver diseases like liver cirrhosis, liver protectors are given (supplements/drugs that protect the liver) and if the condition continues to progress, surgery and liver transplant are advised.
Does diet help?
“Not really,” says Dr Gupta. “Diet doesn’t play a significant role in the management of PSC but a low carbohydrate, low salt diet can help manage a fatty liver,” he says.
Dr Ravindra adds that drinking warm water in the morning, reducing red meat, milk and high-fibre foods and including boiled vegetables and fruits in the diet generally help manage a liver condition better.
He also suggests lifestyle changes like a six to seven-hour gap between meals, an early dinner, and 15 to 20 minutes of exercise daily.