Non alcoholic fatty liver disease in a young male with celiac disease
Zain Majid1,&, Ghous Bux Somoro1, Muhammad Manzoor Ul Haque1, Raja Taha Yaseen1, Shoaib Ahmed Khan1, Inamullah Khan Achakzai1, Muhammad Ali Khalid1, Nasir Hassan Luck1
1Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan
Zain Majid, Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan
A young emaciated male, known case of celiac disease came with the complains of diarrhea along with 5kgs of weight loss in 3 months' time. He had severe electrolyte abnormalities along with low albumin, low calcium and a high phosphate with deranged liver function test. Ultrasound abdomen had shown fatty liver. Nutrition consult was sought and he was found to have a BMI of 6.8kg/m2. He was started on nutrition support along with supportive therapy, which resulted in weight gain and improvement in his condition.
Celiac disease is an autoimmune disease characterized by gluten sensitivity, affecting genetically affected individuals . It has intestinal and many extra intestinal features, while diagnosis requires both serological evidence along with small intestinal biopsy suggestive of the disease .
Patient and observation
A 22-year-old emaciated male presented to the gastroenterology clinic
of our department with the complains of diarrhea and weight loss
since the last 3 months. His old record revealed him to be a diagnosed
case of celiac
disease, having been diagnosed 3 years prior to this admission,
which was based upon his Tissue Transglutaminase serology (TTG
serology) and duodenal
biopsy report (Figure 1).
He was later started on gluten free diet (GFD) and was initially
compliant on it for a year. Later on, he became non-compliant and
had been so ever
since then. Currently his loose stools were watery in consistency,
occurring 7-8 times per day. They were foul smelling, being difficult
to flush, associated
with tenesmus and with weight loss of around 5 kgs during this
same time period. He did not complain of decrease in his appetite
during this time
nor had any history of fever, nausea, vomiting or of dysphagia.
On examination, he appeared severely wasted with thin brittle hair along with
dry skin and had prominent costal margins (Figure
His initial lab reports showed a low hemoglobin 10.2 g/dL along with a low platelet
count 102,000 109fL. He was also found to have a severe electrolyte
in-balance along with a low potassium (2.5 mEq/L), a low calcium
(7.6 mg/dL), low albumin 1.8 g/dL, high phosphate 6.4 mg/dL and
deranged LFTs with a
TBR 0.48 U/L, ALP 303 U/L, SGPT 101 U/L, SGOT 65 U/L GGT 29 U/L.
His iron profile, B12 and folate levels were sent along with lipid
were all within normal limits. Ultrasound abdomen was later done
and revealed diffuse fatty liver. His currently height was 132cm,
while his weight was
of 11.5kg along with a BMI 6.8 kg/m2. A nutritionist was immediately
taken on board and he was started on blendized diet along with
total parenteral nutrition and with replacement of his deranged
electrolytes. His condition
later improved within a week followed by weight gain of 3 kgs in
one week. His oral intake gradually improved and his intravenous
was gradually tapered off. He regained 4 kg of weight and was later
discussed and advised for regular follow-ups.
Many forms of hepatic diseases can be seen in those affected with celiac disease, including non alcoholic fatty liver disease and Nonalcoholic steatohepatitis (NASH) . Non-alcoholic fatty liver disease or NAFLD is said to the commonest cause of chronic liver disease in the developed world [3, 4]. Celiac disease is seen in 4 to 13% in those having NASH . The exact mechanism of this association is not known but it is plausible that this may be due to the increased intestinal permeability along with malabsorption of choline, a lipotropic factor and vitamin B6 . According to one study, celiac disease is more often seen amongst those NAFLD patients having a BMI less than 27 kg/m2 . This risk of NAFLD in celiac disease is mainly seen during the first year of life and does remain even after that . It is said that GFD may help those celiac patients who have NAFLD, but the long term effects of this are still unknown .
Our case report suggests the importance of timely checking of LFTs in celiac disease patients, which could help prevent further complications in these patients.
The authors declare no competing interests.
All the authors have read and agreed to the final manuscript.
Figure 1: low-power
view showing moderate villous stunting and crypt hyperplasia,
consistent with Marsh class 3b (H&Ex40)
Figure 2: physical
appearance of the patient
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