History and admission findings: A 31-year-old woman was admitted because of heptomegaly and abnormal liver functions. For years she had suffered from diarrhoea but its cause had never been elucidated. She was underweight and had mild ankle edema. The liver margin was palpable at 20 cm below the midcostal margin, but the abdominal examination was otherwise unremarkable.
Investigations: Sonography revealed a very large fatty liver. Biopsy showed fatty infiltration of nearly all the hepatocytes, without significant inflammation and fibrosis. Small-intestinal biopsy showed the typical histology of coeliac disease. Laboratory tests indicated abnormal liver function with increased transaminases, alkaline phosphatase, GPT and LDH, but no sign of inflammatory aetiology. These findings suggested that the liver changes were due to the coeliac disease.
Treatment and course: After the patient had been put on a gluten-free diet the diarrhoea stopped and she started to gain weight. The liver function tests briefly became worse, but over the following 6 weeks normalized completely. The patient gained 5 kg in the subsequent 18 months and the liver became sonographically normal. The small-intestinal biopsy now showed merely discrete villar atrophy.
Conclusion: Coeliac disease should be considered in any case of fatty liver of unknown cause. Strict gluten-free dietary treatment of the underlying cause can quickly lead to complete regression of the hepatic changes.