Can Gluten Cause Liver Damage?
What is the best diet to heal your liver? Do you think of the liver as an organ that aids digestion? Many do not, and so you might not think there is a logical connection between liver health and digestive health. Your diet can play a huge role in the healing process.
However, all of the blood leaving the stomach and intestines first passes through the liver. The liver filters this blood coming from the digestive tract before passing it to the rest of the body. The liver also detoxifies chemicals and metabolizes drugs and secretes bile that ends up back in the intestines.
You can see how liver health and digestive health are interrelated, and so I want to discuss how gluten and celiac disease may influence liver health.
Types of Liver Disease
Liver disease is a broad term for a number of diseases related to compromised liver health. It may include any of the following:
- Fatty Liver Disease (Hepatic Steatosis): Fatty liver disease is a condition in which there is a fat buildup in the liver. There are two types of fatty liver disease:
- Alcoholic fatty liver disease: caused by heavy alcohol consumption
- Non-alcoholic fatty liver disease (NAFL): caused by other factors that experts are still trying to understand
- Cirrhosis: Cirrhosis refers to scarring that results from liver diseases and other causes of liver damage, such as alcohol use. Other conditions, like cystic fibrosis and syphilis may also lead to liver damage and cirrhosis.
- Hepatitis: Hepatitis is a viral infection of the liver, typically caused by coming into contact with infected water or bodily fluids. Hepatitis causes inflammation and liver damage. There are five types of viral hepatitis, as well as autoimmune hepatitis.
- Autoimmune Hepatitis: Autoimmune hepatitis is not viral. Like other autoimmune diseases, it occurs when your immune system mistakes your liver cells for foreign aggressors and creates antibodies to attack them. This results in inflammation, and left untreated, it can lead to cirrhosis and liver failure.
The Link Between Celiac Disease and Liver Disease
Research has identified a link between celiac disease and liver disease. One large study compared the risk of nonalcoholic fatty liver disease diagnosed from 1997-2009 in over 26,000 individuals with celiac disease to over 130,000 matched reference individuals. Patients with any liver disease prior to celiac disease were excluded, as were individuals with a lifetime diagnosis of alcohol-related disorder to minimize misclassification of nonalcoholic fatty liver disease. The study found that individuals with celiac disease are at increased risk of nonalcoholic fatty liver disease compared to the general population. Excess risks were highest in the first year after celiac disease diagnosis, but persisted through 15 years beyond diagnosis with celiac disease.
Another study compared 202 celiac disease patients and 202 control patients and found that more than one-third of CD patients adhering to a GFD had concurrent NAFL, accounting for a three-fold increased risk compared to the general population. Interestingly, this study also found that the relative risk for NAFL was notably higher in non-overweight celiac disease patients
Potential Mechanisms to Explain the Link Between NAFL and Celiac Disease
There are a number of potential mechanisms being studied in an attempt to explain the link between celiac disease and liver disease.
Some researchers believe that cellular stress induced in celiac patients may trigger the onset of NAFL. Other studies point to intestinal permeability which is increased in both celiac disease and NAFL.
How Traditional Gluten Free Diets May Increase the Risk of NAFL
Again, NAFL is still not fully understood, with researchers still studying all of its possible mechanisms and causes. However, one undeniable contributor to NAFL is the excessive consumption of refined sugar and carbohydrates. Diets high in processed food and inflammatory oils and lacking in fiber, healthy fats, and protein put stress on the liver and contribute to obesity. Highly processed diets also tend to lack the important micronutrients needed to process energy through the liver, like B vitamins and choline.
Unfortunately, this type of highly processed diet is quite easy for many to achieve while adhering to a gluten-free diet. Yes, the increase in awareness in recent years around the gluten-free diet has had positive effects on availability of certain gluten-free products and more transparent labeling. However, it has also resulted in the increase in availability of processed gluten-free junk food. Particularly for those newly diagnosed, or who previously relied on packaged and processed foods, the refined grains and sugars found in many gluten-free foods can contribute to the inflammation, insulin resistance, and metabolic syndrome that often underlie NAFL.
In fact, one study followed newly diagnosed celiac disease patients who had just started a gluten free diet over the course of both one year and four years and found that Patients with celiac disease are at high risk of developing metabolic syndrome and fatty liver, which increases further with a gluten-free diet. The researchers recommended that patients be assessed for nutritional and metabolic features and counseled about a balanced diet and physical activity to mitigate this risk.
Another meta analysis of a number of studies exploring this link underscored a gluten-free diet as a possible contributor. It found that at the time of diagnosis, the frequency of NAFL and nonalcoholic steatohepatitis in individuals with celiac disease appeared to be similar to that of the general population. This suggests that the development of fatty liver seems to happen after diagnosis, with one major change in the lifestyles of those diagnosed being their diet. This isn’t to suggest that a person diagnosed with celiac disease shouldn’t follow a gluten-free diet, rather to suggest that celiac disease patients should pay careful attention to follow a gluten-free diet that focuses on healthy, whole, unprocessed foods.
Gluten and Gallbladder Dysfunction
The gallbladder stores and concentrates the bile that is produced by the liver to break down fats, remove toxins, and store vitamins and minerals. The bile is then released from the gallbladder into the first section of the small intestine (the duodenum), where it helps your body to break down and absorb fats from food. Due to this interdependent relationship between the gallbladder and liver, researchers have also identified a link between the health of the gallbladder and celiac disease. They have found that patients with celiac disease may experience impaired gallbladder motility, and in elderly patients, predisposition to gallstones. Because of this relationship, it is recommended that those experiencing gallbladder dysfunction be screened for gluten sensitivity and celiac disease.
Gluten and Autoimmune Hepatitis
We know that celiac disease is often found in association with other autoimmune diseases, and this applies to autoimmune hepatitis as well. One study investigated this relationship by assessing the prevalence of IgA and IgG anti-tissue transglutaminase (tTG) antibodies in autoimmune hepatitis, and by verifying whether the ﬁndings were associated with clinical and
histological features of celiac disease. The study showed a high prevalence of celiac disease in patients with autoimmune.
A growing body of research and a number of case studies have demonstrated that in cases of joint autoimmune hepatitis and celiac disease, a gluten free diet can not only resolve the illness, it can also negate the need for the medications being used to treat it.
For example, one case study followed a 50-year-old male with long-standing autoimmune hepatitis. He had been on the immunosuppressive medication azathioprine for 10 years, and even after adding high-dose corticosteroids, his key lab levels remained high and disease unmanaged. Celiac disease was diagnosed through an antibody test and endoscopic biopsy. Once a strict gluten-free diet was advised and implemented, his autoimmune hepatitis went into remission alongside the use of his prior medications. In this case, a gluten-free diet was able to help reverse liver dysfunction. It also provides important information to other patients and practitioners that screening for gluten sensitivity and celiac disease can be crucial in patients with autoimmune hepatitis and persistent elevation of liver enzymes despite immunosuppressant treatment.
The Risks of Undiagnosed or Silent Celiac and Non-Celiac Gluten Sensitivity on the Liver
When celiac disease or non-celiac gluten sensitivity goes undiagnosed or is experienced without symptoms (known as silent celiac disease), patients are often left trying to manage symptoms. This can lead to the use of over-the-counter or prescription drugs for symptoms such as pain and inflammation, heartburn, and depression.
Unfortunately, many of these medications can be hard on the liver leading to increased liver stress and risk of disease. At the same time, they aren’t even getting to the root of the issue – an intolerance to gluten.
Incredibly, drug-induced liver injury (DILI) is the fourth leading cause of liver damage in Western countries and is the most frequent cause of market withdrawal of a drug and rejection of applications for a marketing license in the United States.
- Pain and inflammation: Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) can also contribute to liver toxicity. These medications are often taken without much consideration for minor ailments, but research is clear that they can lead to drug-induced liver injury.
- Heartburn: Research has shown that use of proton pump inhibitors (PPIs) increases risk of occurrence of fatty liver disease for patients with celiac disease. Since PPIs can also damage stomach acid and negatively impact digestion, their use should be limited.
- Depression: Data on antidepressant-induced liver injury are more limited than other drugs, but research has shown that antidepressants can induce liver toxicity. This can present as increases in liver enzyme levels, jaundice, dark urine or pale stool, loss of hepatocellular functions, and acute liver failure. It can also present as nonspecific symptoms such as fatigue, weakness, anorexia, nausea, vomiting, and upper right abdominal pain.
While we know that there is a clear link between celiac disease and liver disease, we are still learning why this link exists and what mechanisms drive it. The more we understand about the causes that underlie both diseases, the more we can proactively manage our health.
What we do know is that those diagnosed with celiac should be mindful in choosing whole unprocessed foods that support liver health, and should be regularly screened for markers of liver health. Thoughtful dietary choices will go a long way in supporting not only liver and gut health, but overall health and longevity as well.
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