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This case describes a presentation of a patient with clinical features of acromegaly, elevated growth hormone (GH) concentrations, a pituitary adenoma but with normal insulin-like growth factor-1 (IGF-1) concentrations in the context of previously undiagnosed liver cirrhosis. In this case, a diagnosis of acromegaly was made based on clinical grounds and failure of GH to suppress during oral glucose tolerance testing despite a normal IGF-1 screening test. Following liver transplantation, the patient's IGF-1 concentrations rose significantly in keeping with a diagnosis of active acromegaly. This case demonstrates the importance of history, physical examination and clinical judgement in the diagnosis of this rare disease. It also highlights the vital role played by the liver in the GH/IGF-1 axis.