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Clinical Case Summary

Liver diseases in pregnancy encompass gestational liver diseases, pre-existing liver diseases and coincidental hepatic conditions(1).
Here, we present a case of an asymptomatic previously healthy 33-year-old women, presented with markedly elevated aminotransferases (aspartate-aminotransferase (AST) 503 IU/L and alanine-aminotransferase (ALT) 1497 IU/L) in her 8^thweek of gestation. Her twin pregnancy was the result of the 5^th attempt of assisted fertilization with clomiphene. Extensive investigations ruled out etiologies such as acute and chronic viral hepatitis, autoimmune liver diseases and Wilson's disease and drug induced liver injury. There were not enough criteria to diagnose acute fatty liver of pregnancy, HELLP syndrome, pre-eclampsia, nor hyperemesis gravidarum. The patient developed pruritus with elevated serum bile acid concentration in the 10^th week of gestation and diagnosis of intrahepatic cholestasis of pregnancy (ICP) with a 1^st trimester presentation was diagnosed. ICP in the 1^st trimester of pregnancy is an exceptionally rare condition and only 10 case reports involving 12 subjects have been identified through PubMed search with only a single case with such a high value of ALT(2). After a multidisciplinary board discussion ursodeoxycholic acid (UDCA) treatment was initiated in a dose of 250mg bid with a resolution of symptoms and normalization of laboratory parameters in a month upon therapy initiation. UDCA therapy was then stopped with normal laboratory findings and no pruritus till the 3^rd trimester when an elevation of bile acid levels was reported, and UDCA treatment was reinstituted with an optimal result. She delivered 2 healthy female infants in the 35th week of gestation by caesarean section, with subsequent resolution of symptoms and normal liver function postpartum. This case demonstrates an atypical presentation of ICP in early pregnancy and highlights the efficacy and safety of UDCA therapy in managing this condition.

References

References:
1. Williamson C, Nana M, Poon L, Kupcinskas L, Painter R, Taliani G, et al. EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy. J Hepatol. 2023;(August):433–93. Available from: https://doi.org/10.1016/j.jhep.2023.03.006
2. Keitel V, Vogt C, Häussinger D, Kubitz R. Combined Mutations of Canalicular Transporter Proteins Cause Severe Intrahepatic Cholestasis of Pregnancy. Gastroenterology. 2006;131(2):624–9.

Table for poster presentation

List of previous case reports published with intrahepatic cholestasis of pregnancy presenting in the 1^st trimester.

Figures for poster presentation

Laboratory parameters, symptoms, and therapy throughout the pregnancy.

UNCOMMON PRESENTATION OF INTRAHEPATIC CHOLESTASIS OF PREGNANCY IN THE FIRST TRIMESTER - A CASE REPORT

Frane Pastrovic 1, Ivica Grgurevic 1

1 University Hospital Dubrava, Zagreb, Croatia

Conference

UEG Week Vienna 2024

Topics

Hepatobiliary

Submission format

Clinical Case

Session

Clinical Cases (Posters)

Published

2024

UEG Mistakes In Articles

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Upper and lower gastrointestinal endoscopy examinations are performed daily as routine diagnostic procedures in a large number of patients with nonspecific indications, such as heartburn, pain, anaemia, bleeding, workup of portal hypertension and so on. Most of the examinations will point to a classic diagnosis (e.g. peptic disease, cancer, variceal management), but sometimes we see patients who've had multiple diagnostic endoscopic procedures in the previous few months with nonconclusive findings. The diagnostic mistakes discussed here are those that sprang to mind based on our endoscopic experience and they are discussed in an evidence-based approach. For therapeutic endoscopic procedures (e.g. ERCP and resections), we present the most important mistakes that are often seen in our practice and have major consequences for the patient. We propose, from our experience, a simple approach to avoid these mistakes.

Mistakes in endoscopy and how to avoid them

Jacques Deviere, Arnaud Lemmers

Topics

Endoscopy

Published

2024

UEG Standards and Guidelines

Clinical Practice Guideline

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Introduction

Inflammatory bowel disease (IBD), which includes Crohn’s disease (CD) and ulcerative colitis (UC), requires meticulous diagnostic and monitoring protocols to optimize patient outcomes. This document synthesizes key advancements and recommendations for clinical indices, endoscopic scoring, imaging, histological assessment, and tools for evaluating IBD disability. Emphasizing validated, reproducible methods aligns with the ongoing evolution of precision medicine in IBD care, including training. The methodology of the guidelines update process is described in part 1.

ECCO-ESGAR-ESP-IBUS Guideline on Diagnostics and Monitoring of Patients with Inflammatory Bowel Disease: Part 2: IBD scores and general principles and technical aspects

Henit Yanai

Publisher

European Crohn’s and Colitis Organisation

Guideline

Clinical Practice Guideline

Topics

IBD

Citation

Journal of Crohn's and Colitis, Volume 19, Issue 7

Published

2025

UEG Standards and Guidelines

Consensus

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Abstract

Objectives

To provide a consensus statement and recommendations on MR imaging in primary sclerosing cholangitis (PSC).

Methods

The European Society of Gastrointestinal and Abdominal Radiology (ESGAR) convened a multinational European panel of experts selected based on a literature review and their leadership in the field. A modified Delphi process was adopted to draft a list of statements. For each statement, the panelists indicated the level of agreement using a 5-point Likert scale, where 1 means “no agreement,” 2 means “poor agreement,” 3 means “slight agreement,” 4 means “fair agreement,” and 5 means “complete agreement.” The median score for each statement was collected. The level of evidence was reported according to the Oxford Centre for Evidence-Based Medicine. Descriptive statistics were used to rate agreement levels and the consensus’ internal reliability.

Results

The 12 voting committee members were from Italy (n = 4, 33.4%), Austria (n = 2, 16.7%), Sweden (n = 1, 8.3%), France (n = 1, 8.3%), the United States (n = 1, 8.3%), Switzerland (n = 1, 8.3%), and Belgium (n = 2, 16.7%). The final questionnaire consisted of 55 statements. The agreement reached by the expert panel was complete for 23 statements (41.8%), fair for 16 (29.1%), slight for 15 (27.2%), and poor for 1 (1.9%). Statements that received complete agreement were used to structure a reporting template.

Conclusions

This statement paper recommends how and when to perform MRI in PSC patients. A structured reporting template has been created to improve quality care and communication among radiologists and clinicians.

Key Points

Question A standard MR protocol and the most common imaging features to be reported are fundamental for the correct evaluation of primary sclerosing cholangitis (PSC) patients.

Findings Twelve expert radiologists reported which are the most important imaging features and how and when to perform MR in PSC patients.

Clinical relevance The identified statements reported in this paper and the structured reporting template are useful for radiologists and clinicians to help correctly manage PSC patients.

ESGAR consensus statement on MR imaging in primary sclerosing cholangitis

Davide Ippolito

Publisher

European Society of Gastrointestinal and Abdominal Radiology

Guideline

Consensus

Topics

Radiology & Imaging

Citation

Eur Radiol (2025)

Published

2025

UEG Mistakes In Articles

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The introduction and general use of new immunosuppressive agents, including biologic agents and small molecules, has revolutionised the therapeutic management of inflammatory bowel disease (IBD). Such immunosuppression may expose patients to opportunistic infections, which can be challenging to recognise. These infections are crucial due to their association with morbidity or mortality and the challenges regarding effective treatment. New evidence in this field and vaccination strategies for immunosuppressed IBD patients led to updated European Crohn’s and Colitis Organization (ECCO) guidelines in 2021. Here we discuss the errors to avoid when managing the risk of opportunistic infections in IBD patients. The discussion is based on evidence, whenever possible, and our clinical experience.

Mistakes in opportunistic infections and vaccinations in IBD and how to avoid them

Paul McLellan, Julien Kirchgesner

Topics

IBD

Citation

Kirchgesner J and McLellan P. Mistakes in opportunistic infections and vaccinations in IBD and how to avoid them. UEG Education 2022; 22: 26–28.

Published

2022

UEG Podcast Episode

Journal Podcast

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Episode 6: UEG Journal October Spotlight

Mohsan Subhani, Maria Manuela Estevinho

Topics

Endoscopy Hepatobiliary IBD Pancreas

Published

2025

UEG Standards and Guidelines

Consensus

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Abstract

Background

The incidence and prevalence of inflammatory bowel disease [IBD] have increased significantly in low- and middle-income countries [LMICs] in recent decades. Managing IBD in these settings presents substantial challenges. This consensus aims to describe the epidemiology of IBD in LMICs and to highlight the key challenges in its diagnosis and treatment.

Method

The consensus-defining strategy followed the previous European Crohn’s and Colitis Organisation [ECCO] consensus guidelines [available at www.ecco-ibd.eu]. The authors reviewed the available evidence and formulated statements accordingly. Provisional ECCO statements and supporting text were drafted based on a comprehensive literature review and further refined through two voting rounds, which included external reviewers and national representatives from ECCO’s 36 member countries. The final ECCO statements, representing a consensus of at least 80% agreement among participants, were approved during an online meeting. Consensus statements should be interpreted in context with their accompanying commentary rather than in isolation and should not be used solely to guide patient management. The supporting text was finalized under the guidance of each working group leader [VP, HY, TK, AH] and subsequently integrated by the consensus leader [AE].

Results

Data on IBD epidemiology in LMICs remain limited. Public and healthcare professional awareness and timely access to early diagnostic modalities, advanced medical and surgical therapies, and specialist multidisciplinary care are key gaps in IBD care in LMICs. The complexity and chronic nature of IBD, along with the necessity for a multidisciplinary approach, pose significant challenges to adopting a holistic management strategy in LMICs.

Conclusion

There is a critical need for further studies to assess the specific needs of LMICs. Such research will help guide resource allocation and improve IBD management in these settings.

ECCO Consensus on management of Inflammatory Bowel Disease in low-and middle-income countries

Alaa El-Hussuna

Publisher

European Crohn’s and Colitis Organisation

Guideline

Consensus

Topics

IBD

Citation

Journal of Crohn's and Colitis; 2025

Published

2025

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