Crohn's disease and primary sclerosing cholangitis: a case report and review of the literature

Evans syndrome in a young man with rare autoimmune associations and transplanted liver

Evans syndrome is classically characterised by two or more cytopenias occurring either concomitantly or sequentially. Most commonly, these are autoimmune haemolytic anaemia and immune thrombocytopenia purpura. It is mostly associated with specific autoimmune conditions such as systemic lupus erythematosus and lymphoproliferative disorders. We present a case report of Evans syndrome in a young man with primary sclerosing cholangitis and Crohn’s disease, neither of which are classically associated with the condition. The case also further adds to the number of case reports of Evans syndrome occurring in patients following liver transplantation.

Risk factors for colorectal neoplasia in patients with underlying inflammatory bowel disease: a multicenter study

BACKGROUND

This study sought to evaluate the risk factors for the development of colitis-associated neoplasia (CAN) in Chinese patients with inflammatory bowel disease (IBD).

METHODS

IBD patients who developed CAN between 1999 and 2016 were identified from eight medical centers. In addition to initial pathology evaluation, a CAN diagnosis was confirmed by two expert pathologists. Patients with CAN (n = 29) were compared with non-CAN controls (n = 87). Matching was performed for gender and IBD type with a ratio of three controls to one subject.

RESULTS

Of the 29 patients with CAN, 8 (27.6%) had colorectal cancer (CRC), 20 (69.0%) had a final diagnosis of low-grade dysplasia and 1 (3.4%) had high-grade dysplasia. Multivariate analysis revealed that an older age at the time of IBD diagnosis and a longer IBD duration were independent risk factors for the development of CAN, with odds ratios of 1.09 [95% confidence interval (CI): 1.04-1.14, P < 0.001] and 1.14 (95% CI: 1.03-1.27, P = 0.013), respectively. Comparison between IBD patients with CRC and those with dysplasia indicated that the former were older at the time of IBD diagnosis (P = 0.012) and had longer IBD durations (P = 0.019).

CONCLUSIONS

Older age at the time of IBD diagnosis and longer IBD duration were found to be associated with the development of CAN in IBD patients.

Rapid Progression of Primary Sclerosing Cholangitis Complicated with Ulcerative Colitis

Primary sclerosing cholangitis is a cholestatic condition with unknown etiology and long-standing, progressive course, leading to cirrhosis and requiring orthotropic liver transplant. In approximately 80%, primary sclerosing cholangitis is accompanied by inflammatory bowel disease, and in most cases the recognition of bowel disease precedes the diagnosis of primary sclerosing cholangitis. We describe a case of 22-year-old male diagnosed simultaneously with primary sclerosing cholangitis and ulcerative colitis, with a medical history suggesting uncommon prior development of the liver disease. Five months after the initial diagnosis, we observed advanced lesions of bile tree due to progression of primary sclerosing cholangitis, which led to the unusually fast necessity for the orthotopic liver transplant.

Metastatic hepatocellular carcinoma in a patient with Crohn's disease treated with azathioprine and infliximab: a case report and literature review

Hepatocellular carcinoma most commonly occurs in patients with underlying liver disease or cirrhosis. We describe a case of hepatocellular carcinoma in a 34-year-old man with Crohn's disease treated with azathioprine and infliximab. The patient had no history of liver disease and a complete autoimmune and viral workup was unremarkable. Unfortunately, the patient developed widespread metastatic disease and passed away 5 months after his initial diagnosis. The mechanism of hepatocellular carcinoma in patients' with Crohn's disease is poorly understood and may include both autoimmunity and treatment-related complications. Previous case reports suggest the possibility of a concerning association between azathioprine therapy and the development of hepatocellular carcinoma in patients with Crohn's disease. Clinicians may consider early imaging in patients with Crohn's disease presenting with concerning symptomatology or abnormal liver enzymes, especially in those being treated with azathioprine alone or in combination with infliximab. Future research may help to uncover additional risk factors for this exceedingly rare diagnosis in this patient population.