Celiac disease is an autoimmune condition where consuming gluten, a protein found in wheat, barley, and rye, damages the small intestine, impairing nutrient absorption. Beyond its intestinal effects, celiac disease can impact the liver. Liver involvement is a recognized complication for some individuals, often presenting without noticeable symptoms.
Liver Conditions Linked to Celiac Disease
Celiac disease can manifest through various liver abnormalities. Elevated liver enzymes, known as transaminitis, are the most common liver manifestation in individuals with untreated celiac disease, observed in about 13% to 60% of cases at diagnosis. These enzyme levels, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST), typically normalize once a strict gluten-free diet is adopted.
Beyond enzyme elevations, celiac disease is associated with a higher incidence of fatty liver disease, now often referred to as metabolic dysfunction-associated steatotic liver disease (MASLD). This condition involves the accumulation of fat in liver cells and appears more frequently in those with celiac disease. Other autoimmune liver conditions also show a notable association with celiac disease. Autoimmune hepatitis (AIH), where the immune system attacks liver cells, is found in a higher percentage of celiac patients, with prevalence rates ranging from 3.5% to 6.4%.
Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), both affecting the bile ducts, have also been linked to celiac disease. Studies indicate a higher prevalence of celiac disease in individuals with PBC, sometimes as high as 11.8%. Similarly, celiac disease is found in about 1.6% to 3% of PSC patients, suggesting an immune connection between these conditions. In some instances, these liver issues, including unexplained elevated enzymes or cryptogenic liver disease, can be the initial indicators of undiagnosed celiac disease.
Why Celiac Affects the Liver
The mechanisms connecting celiac disease to liver complications are complex. One significant factor is increased intestinal permeability, often termed “leaky gut,” characteristic of active celiac disease. When the intestinal barrier is compromised, toxins, microbial products, and dietary antigens can pass from the gut into the bloodstream and reach the liver via the portal circulation. This influx can trigger an immune response and inflammation within the liver.
Chronic systemic inflammation, a hallmark of untreated celiac disease, also plays a role in liver injury. The ongoing inflammatory state affects various organs throughout the body, including the liver, contributing to cellular damage and dysfunction. Autoimmune cross-reactivity also contributes to liver damage. The immune system, primed to react to gluten-derived proteins, might mistakenly target liver cells due to molecular similarities or a broader autoimmune predisposition. Antibodies, such as anti-actin antibodies, have also been associated with autoimmune hepatitis.
The genetic background, particularly certain HLA types, can predispose individuals to both celiac disease and other autoimmune conditions, including those affecting the liver. Severe nutritional deficiencies and malabsorption, common in untreated celiac disease, can indirectly impact liver health over time. When the small intestine’s ability to absorb vital nutrients is impaired, the liver’s metabolic functions may be strained.
Identifying and Treating Liver Issues
Identifying liver involvement in individuals with celiac disease begins with liver function tests (LFTs). These tests measure levels of liver enzymes like AST and ALT, which can indicate liver cell damage or inflammation. Elevated LFTs are a common finding at the time of celiac disease diagnosis. If abnormalities are detected, further investigations, such as imaging studies or a liver biopsy, might be performed to assess the extent and nature of the liver condition.
The primary approach to managing celiac-related liver issues is strict adherence to a gluten-free diet. This dietary change often leads to the normalization of elevated liver enzymes and a general improvement in liver health. For many patients, the liver’s condition improves significantly within 6 to 12 months of adopting a gluten-free diet.
If liver abnormalities persist despite consistent adherence to a gluten-free diet, or if more severe liver conditions are diagnosed, additional specific treatments may be necessary. These specialized treatments are typically managed by a gastroenterologist or hepatologist. Regular medical follow-up is important for individuals with celiac disease, especially if liver enzymes were initially elevated, to monitor liver health and ensure ongoing management.