Liver blood test (LBT) abnormalities are common in people with inflammatory bowel disease (IBD). The majority are self-limiting, with only 5% having clinically significant liver disease. Liver conditions most frequently associated with IBD include primary sclerosing cholangitis, metabolic dysfunction-associated steatotic liver disease and drug-induced liver injury (DILI). A combination of clinical assessment, blood tests and imaging can be used to help establish the causality and severity of abnormal LBTs in people with IBD.

The use of immunomodulatory therapies for IBD has increased the incidence of abnormal LBTs. Most cases are self-limiting and clinically significant injury is rare, particularly with the newer therapeutic agents. Azathioprine and antitumour necrosis factor-α therapies have the greatest risk of liver injury. A clear timeline of drug initiation or dose escalation is essential when interpreting abnormal LBTs to identify DILI. Signs of serious liver dysfunction should prompt immediate cessation of the drug. Otherwise, a patient-centred approach is required when deciding on drug alteration, including the assessment of therapeutic efficacy and the availability of alternative treatment options.