Liver disease can be a complication of inflammatory bowel disease (IBD), such as ulcerative colitis (UC) or Crohn’s disease. The liver, which processes the food you ingest, can develop inflammation if IBD isn’t treated appropriately. Unfortunately, some drugs used to treat IBD may also damage the liver.

According to a study published in 2019 by the American Gastroenterological Association, the prevalence of nonalcoholic liver diseases in patients with UC was more than double that of the general population. Considering the increased risk, it makes sense to take precautions. Laura Raffals, MD, a gastroenterologist at the Mayo Clinic in Rochester, Minnesota, recommends that people with UC have their liver enzymes checked annually. It’s also wise to be aware of the common symptoms of liver disease so you can address the problem before it gets worse. According to the Crohn’s & Colitis Foundation, these symptoms include the following:

Fatigue or low energy
Itchy skin
Jaundice (yellowing of the skin and the whites of the eyes)
Pain or a feeling of fullness in the upper right abdomen
Fluid retention
Easy bruising

Here are five conditions related to the liver or ducts that transport bile (a fluid produced by the liver that helps with digestion) that may develop alongside ulcerative colitis.

1. Primary Sclerosing Cholangitis

Primary sclerosing cholangitis (PSC) is the main form of liver disease associated with ulcerative colitis, according to Donald Jensen, MD, a hepatologist at Rush University Medical Center in Chicago. Around 60 to 80 percent of patients with PSC also have ulcerative colitis, notes the National Organization for Rare Disorders.

PSC causes scarring of the bile ducts that drain bile from the liver to the intestine. While PSC was once thought to target middle-aged men, that perception may be changing. According to a European study published in May 2021 in the Spanish medical journal Gastroenterología y Hepatología, nearly half of the participants with PSC were women, which was higher than expected.

Research published in October 2018 in Gastroenterology concluded that about 8 percent of people with IBD have PSC, but more than half of people with PSC develop some form of inflammatory bowel disease. “We don’t know why they’re connected, and there is no effective treatment for PSC,” says Dr. Jensen.

2. Fatty Liver Disease

Fatty liver disease can be a common complication of IBD, but it’s also related to many other conditions, including pregnancy, diabetes, and obesity. It occurs when fat builds up in the liver, either from a problem with fat metabolism in the liver or excess fat in the body. People with fatty liver disease rarely have liver-related symptoms. But there is a correlation between the severity of colitis and fatty liver changes in people with IBD. The study published by the American Gastroenterological Association found that nearly 2 percent of people with UC had nonalcoholic fatty liver disease.

3. Autoimmune Hepatitis

Autoimmune hepatitis is caused by chronic inflammation of the liver when your immune system starts attacking cells in your own liver, notes the Mayo Clinic. It’s different than a viral infection, like those associated with other types of hepatitis, such as hepatitis A, B, or C. Jensen says that autoimmune hepatitis is rare in IBD. But people with autoimmune hepatitis can often have a type of IBD that looks a lot like colitis. Autoimmune hepatitis is treated independently of UC, with drugs to decrease inflammation, typically a high-dose corticosteroid such as prednisone, which is eventually reduced. Sometimes a second medicine called azathioprine (Imuran) is used. Azathioprine is an immunomodulator, meaning it modifies the activity of the immune system, reducing inflammation.

4. Gallstones

Gallstones form when bile, produced by the liver and stored in the gallbladder, hardens into small, stonelike pieces. If one or more stones block the mouth of the gallbladder, you can experience severe pain. The blockage can lead to serious complications. “When gallstones pass from the gallbladder to the bile ducts, it can be associated with inflammation or pancreatitis,” Jensen says.

Dr. Raffals notes that ulcerative colitis does not lead to gallstones, but gallstones are common in older patients with IBD. They’re also more common in patients with Crohn’s disease than those with UC, per the Crohn’s and Colitis Foundation.

5. Pancreatitis

Inflammation of the pancreas, or pancreatitis, may be caused by gallstones blocking a bile duct shared by the gallbladder and the pancreas. “Pancreatitis and inflammatory bowel diseases often present similarly, so patients may be misdiagnosed,” says Raffals.

Though it’s uncommon, pancreatitis could also be a side effect of drugs used to treat IBD, such as azathioprine, the anti-inflammatory mesalamine (Lialda), or steroids.

Symptoms of pancreatitis include severe abdominal pain, vomiting, nausea, and fever. If your doctor determines that medications are the cause, you’ll need to stop taking them to resolve the inflammation. But don’t go off any meds without your doctor’s approval. A surgical procedure to take out lodged stones can resolve pancreatitis caused by gallstones.

When to Get Help for Liver Pain

Symptoms such as pain in the upper right side of the abdomen, itching, jaundice, and fever could be an alert for a potential liver complication, says David Bernstein, MD, chief of hepatology at Northwell Health in Manhasset, New York. If you experience these issues, contact your doctor for an evaluation. Blood tests can usually confirm liver disease, but additional testing using an ultrasound, X-ray, or liver biopsy may be necessary to make a specific diagnosis. Treatment may include vitamin supplementation and modifying your diet to prevent nutrient deficiencies.

Additional reporting by Agata Blaszczak-Boxe.

Liver Conditions Linked to Ulcerative Colitis