Teaching Points:

• LFT abnormalities may manifest itself in a cholestatic or hepatocellular pattern
  • Cholestatic pattern
    • elevation of bilirubin, high alk phos in relation to AS and ALT elevation
  • Hepatocellular pattern
    • Elevation of AST and ALT in relation to alk phos and bilirubin levels
• Pattern can determine initial imaging work-up
  • Clear cholestatic pattern
    • May proceed to EUS, MRCP or ERCP since these studies would be indicated despite getting abdominal ultrasound
  • Clear hepatocellular pattern
    • May proceed to CT initially
  • If picture is mixed:
    • Can start off with abdominal ultrasound
• Differentials of cholestatic LFTs in IBD patients
  • Primary sclerosing cholangitis – occurs in about 10-15% of IBD patients (more associated with ulcerative colitis)
  • Primary biliary cirrhosis – associated with anti-mitochondrial antibody
    • Seen in middle aged female with chronic onset, manifesting with pruritis and gradual jaundice
  • Viral hepatitis
  • Autoimmune hepatitis
  • Post-obstructive etiologies including pancreatic CA, cholangio, gallstone, etc.
  • Alcoholic hepatitis
• Patients on 6-MP or azathioprine for their IBD need to have their enzymatic TPMT levels checked.
  • Metabolites of 6-MP can cause cytopenia and also hepatotoxicity.