Cases of liver disease are rising rapidly across the United States. A study published in July 2018 in the BMJ determined that deaths due to cirrhosis — a chronic liver disease — are expected to triple in the United States by 2030. Researchers blame this jump on the growing number of cases of alcoholic liver disease and nonalcoholic fatty liver disease (NAFLD).

Liver disease is also a problem for people living with an inflammatory bowel disease (IBD) like Crohn’s disease (CD). In a study of 168 patients published in April 2017 in the journal Inflammatory Bowel Diseases, about 13 percent had both NAFLD and either ulcerative colitis or Crohn’s disease. The researchers also found that patients who had both IBD and NAFLD had a significantly longer duration of IBD. It’s been previously reported that up to 20 percent of people with IBD also have liver disease, the study notes.

“We’re just starting to understand [the association between liver disease and Crohn’s disease],” explains Benjamin Click, MD, a gastroenterologist at the Cleveland Clinic. “There may be interactions between the liver and IBD activity, or the microbiome and the medications we use to manage IBD that we don’t fully understand, so it’s important to be aware of the association and to be proactive about minimizing risk factors.”

Risk Factors for Fatty Liver Disease

NAFLD is a condition of increased accumulation of fat in the liver from causes other than alcohol consumption, according to the Inflammatory Bowel Diseases study. It's associated with metabolic risk factors, such as abdominal obesity, insulin resistance, and hypertension. “Previously, we’d see IBD patients that were thin and weren’t able to gain weight because of their disease, but now we see people with both obesity and IBD, much more than previously,” says the lead author of the study, Bincy Abraham, MD, the director of the inflammatory bowel disease program at Houston Methodist Hospital in Texas.

A population study published in May 2019 in the journal Gastroenterology identified nearly 160,000 patients with Crohn’s disease. Of those, just 2.4 percent had NAFLD and less than 1 percent had nonalcoholic steatohepatitis (NASH), a specific type of NAFLD in which a buildup of fat causes inflammation and damage to liver cells. Still, nearly half of all patients who had both CD and NAFLD were obese, and 60 percent of people with both CD and NASH were obese. When compared with people who have CD but not NAFLD, patients who had both diseases were much more likely to also have diabetes, hypertension, or to be obese. According to a study published in May 2018 in the Indian Journal of Endocrinology and Metabolism, 70 percent of people who have type 2 diabetes also have NAFLD.

Common Liver Complications Among People With IBD

Fatty liver disease is the most common liver complication of IBD, according to the Crohn's and Colitis Foundation. Other common complications include:

Autoimmune hepatitis, which is inflammation in the liver that occurs when the immune system attacks liver cells, rather than from a viral infection like other forms of hepatitis.
Gallstones, which occur when bile that’s used in digestion and stored in the gallbladder hardens and forms stones that can’t pass. “Patients that have Crohn’s disease have a higher risk of gallstones because CD causes malabsorption of nutrients in the small intestine,” says Dr. Abraham.
Primary sclerosing cholangitis (PSC), or inflammation of the bile ducts in the liver. This inflammation, which affects less than 3 percent of patients with CD, leads to scarring of the bile ducts and eventually the liver, preventing bile from flowing normally.

According to the Crohn’s and Colitis Foundation, most liver disease is reversible; however, about 5 percent of people living with IBD experience serious liver disease that may lead to liver failure. NAFLD is the most common liver disease in patients with CD, says Dr. Click, but it can sometimes be reversed through diet and exercise. If you cannot reduce the fat content in the liver, it may lead to cirrhosis or permanent scarring, he explains. Fatty liver disease can also lead to an increased risk of heart disease, liver cancer, and kidney disease, according to the Mayo Clinic.

Late-stage liver disease can cause the abdomen and legs to swell, and the skin and eyes to turn yellow, according to the Crohn's and Colitis Foundation. But early signs of liver disease are hard to detect. For example, NAFLD usually causes no symptoms, but it may cause fatigue and abdominal pain, according to the Mayo Clinic. “Unfortunately, liver disease is often asymptomatic until there has been a significant degree of damage to the liver, so addressing risk factors is critical to avoiding liver disease in the first place,” says Click.

How to Prevent Liver Disease When You Have Crohn’s

Maintaining a healthy weight through diet and exercise is the best way to lower your risk of developing liver disease, advises Abraham. And sticking with an active lifestyle that can be modified during a flare-up is key for people who suffer from CD. “It all comes down to what the patient enjoys, so they will keep it up,” she says. “Do something routinely and keep it as a habit — even if it’s exercising for 5 to 10 minutes each day, that’s better than nothing at all.”

Exercising can help you eat better, too. A study published in January 2019 in the International Journal of Obesity looked at almost 2,700 adults who did not exercise or diet regularly. Researchers found that when people began to exercise regularly over a 15-week period, they were more likely to choose to eat healthy foods, including produce and lean meats, over fried foods, sugary drinks, and other foods attributed to weight gain. They were also less likely to snack.

Eating a diet low in processed foods and simple carbohydrates and high in fiber can be hard to maintain if you’re living with Crohn’s. High-fiber foods like whole grains and vegetables including broccoli are hard to digest and can exacerbate Crohn’s symptoms, according to the Crohn's and Colitis Foundation. Abraham suggests cooking vegetables to make them easier to digest — steam veggies to ensure no nutrients are lost in the process. Peeled fruits (fruit peels contain fiber and can be difficult for people with CD to digest) can also be a good source of low-calorie energy. Abraham says that the most important rule of weight loss is to make sure you’re burning more calories than you’re eating and to eat a balanced diet.

Click adds that high blood cholesterol, called hyperlipidemia, can also lead to a fatty liver. Your liver makes all the cholesterol your body needs, so eating foods like fatty or skin-on meats or full-fat dairy products adds excess cholesterol to your body and causes your liver to produce more cholesterol, he explains. According to the American Heart Association, foods that are high in trans and saturated fats, like animal products and hydrogenated oils, have the worst impact on blood cholesterol levels.

How Often to Get Screened for Liver Disease

Since liver disease usually only shows symptoms during the very advanced stages, such as cirrhosis or liver failure, identifying the disease while it’s still in the early stages is crucial in treating or even reversing it. Regular monitoring of liver enzymes — which can be an indication of liver disease — is a key step in early detection.

“[If a patient has Crohn’s disease, their physician] should be doing annual labs at a minimum,” says Abraham. “If there is a family history of liver disease, they can be evaluated early or more frequently.” She suggests that people who have an increased risk of liver disease — either due to family history or an underlying condition such as obesity or diabetes — should talk to their doctor about getting tested every six months.