Beyond the Gut: Metabolic Dysfunction-associated Steatotic Liver Disease in Inflammatory Bowel Disease

Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as a frequent and clinically meaningful comorbidity in inflammatory bowel disease (IBD). Once considered incidental, MASLD is increasingly recognized as a marker of systemic metabolic and inflammatory burden with important hepatic and extrahepatic consequences. Recent studies indicate that MASLD affects approximately 24–32% of patients with IBD, with similar prevalence in Crohn’s disease and ulcerative colitis after adjustment for metabolic risk factors. Importantly, liver fibrosis, the key prognostic hallmark in chronic liver disease, is detected in a substantial subset of patients and appears to progress over time. The pathogenesis of MASLD in IBD reflects the convergence of classical metabolic dysfunction with IBD-specific factors, including chronic systemic inflammation, gut–liver axis alterations, and changes in body composition. Although IBD is not yet systematically included in MASLD screening recommendations, emerging epidemiological and longitudinal evidence supports adapting established metabolic screening pathways to the IBD population using a risk-stratified case- finding approach. Pragmatic two-step algorithms, employing simple serum-based scores followed by transient elastography in selected patients, offer scalable and implementation-ready strategies. Management of MASLD in patients with IBD should align with general population guidelines while accounting for disease‑specific considerations. Lifestyle modification remains foundational, complemented by pharmacologic therapies in patients with fibrosis or high cardiometabolic risk. Integrating liver risk assessment into routine IBD care represents a critical step toward improving long-term hepatic and extrahepatic outcomes in this growing population.