Coeliac disease and liver dysfunction

Celiac Disease and Liver Damage: The Gut-Liver Axis Strikes Back (Again)? A Retrospective Analysis in the Light of a Literature Review

Background/Objectives: An increasing number of studies have reported liver involvement in both children and adults with celiac disease (CD). This often manifests as isolated hypertransaminasemia or hepatic steatosis (HS). The aim of this study was to define the prevalence of hypertransaminasemia and HS in a pediatric population with CD before starting a gluten-free diet (GFD) and to analyze how the introduction of a GFD could modify this condition. We also conducted a state-of-the-art literature review of the association between hypertransaminasemia, metabolic dysfunction-associated steatotic liver disease (MASLD) and CD. Methods: We retrospectively reviewed the clinical charts of pediatric CD patients diagnosed in three different pediatric units of Sicily, analyzing clinical, laboratory, ultrasound, and histology data before and 12 months after the introduction of a GFD. Results: A total of 160 patients (65.0% females, median age 6.4 (0.8-13.2) years) were included; hypertransaminasemia and HS prevalences at diagnosis were 8.1% and 6.1%, respectively. Subjects with hypertransaminasemia were younger (p = 0.01) than those without and had higher frequencies of HS (p = 0.034) and anti-tissue transglutaminase (tTg) immunoglobulin (Ig)G positivity (p = 0.046). Subjects with HS were younger (p = 0.0001) and had a higher frequency of hypertransaminasemia (p = 0.029) compared to non-steatotic ones. After 12 months of a GFD, hypertransaminasemia and HS persisted in 53.8% and 50.0% of patients, respectively. Conclusions: The prevalences of hypertransaminasemia and HS in Sicilian pediatric CD patients seem to be lower than those reported in other geographical areas. A GFD can reverse the trend of liver involvement, although periods of longer than 12 months may be necessary. However, a GFD has been associated with an increased prevalence of HS, and so regular follow-up involving a nutritionist should be recommended to guide physicians in patient management.

Severe Liver Damage in an Obese Patient: Onset of Celiac Disease or Overlap Syndrome?

Celiac disease (CeD) is an enteropathy caused by the complex interaction between genetic, environmental, and individual immunological factors. Besides the hallmark of intestinal mucosal damage, CeD is a systemic disorder extending beyond the gastrointestinal tract and impacting various other organs, causing extraintestinal and atypical symptoms. The association between CeD and liver damage has been classified into three main categories: mild and asymptomatic liver injury, autoimmune liver injury, and liver failure. We present a case of severe liver damage with cirrhotic evolution in an obese 12-year-old boy who had been admitted due to generalized jaundice and localized abdominal pain in the right hypochondrium. In the course of investigating the etiology of severe liver disease, toxic, infectious, metabolic, obstructive, and genetic causes were excluded. Despite the patient's obesity, a diagnosis of CeD was established, and in accordance with autoimmune hepatitis (AIH) criteria, the patient was diagnosed with autoantibody-negative AIH associated to CeD.

High prevalence of celiac disease in autoimmune hepatitis: Systematic review and meta-analysis

BACKGROUND

Previous studies investigating the prevalence of celiac disease (CD) in individuals with autoimmune hepatitis (AIH) have shown highly variable results. We therefore aimed to examine the prevalence of CD in individuals with AIH.

METHODS

Two professional librarians searched PubMed, EMBASE, Cochrane and Web of Science Core Collection up until 7 February 2020. The search terms included 'celiac disease', 'celiac', 'transglutaminases', 'gluten', 'gliadin', 'EMA', 'TTG' and 'villous' combined with 'autoimmune', 'hepatitis', 'ANA', 'SMA' and 'LKM'. This search yielded 2419 unique publications. A systematic review based on the PRISMA guidelines resulted in 31 articles eligible for full text review. Fifteen articles were deemed relevant, with 8 being included in our main analysis. A fixed-effect inverse variance-weighted model was used, and heterogeneity was calculated.

RESULTS

Our main analysis included 567 individuals with AIH from eight studies, where biopsy-verified CD (equivalent to Marsh III) was seen in 23 individuals (4.1%). The pooled prevalence of CD in AIH was 3.5% (95% CI = 1.6%-5.3%) (heterogeneity: P = .874; I2  = 0.0%), which is clearly higher than the 1% CD seen in most general populations. When also including studies where CD had been diagnosed through positive serology without biopsy (15 studies: n = 1817 individuals with AIH), the pooled prevalence of CD was 2.9% (95% CI = 2.1%-3.8%) (heterogeneity: P < .001; I2  = 66.8%).

CONCLUSION

Our results demonstrate a higher prevalence of CD in individuals with AIH compared to the general population. CD screening may be considered in patients with AIH.

Celiac Disease and Elevated Liver Enzymes: A Review

Aminotransferases are commonly found to be elevated in patients with celiac disease in association with two different types of liver dysfunction: cryptogenic liver disorders and autoimmune disorders. The purpose of this review is to discuss the mechanisms by which aminotransferases become elevated in celiac disease, clinical manifestations, and response to gluten-free diet. Many studies have shown that celiac patients with cryptogenic liver disease have normalization in aminotransferases, intestinal histologic improvement and serologic resolution after 6-12 months of strict gluten-free diet. In patients with an underlying autoimmune liver disease, simultaneous treatment for both conditions resulted in normalized elevated aminotransferases. The literature suggests that intestinal permeability may be at least one of the mechanisms by which liver damage occurs. Patients with celiac disease should have liver enzymes routinely checked and treated with a strict gluten-free diet if found to be abnormal. Lack of improvement in patients who have strictly adhered to gluten-free diet should prompt further workup for other causes of liver disease.

Celiac Disease and Portal Hypertension: A Causal Association or Just a Coincidence?

INTRODUCTION

Celiac disease (CD) has been linked to portal hypertension (PHT) of varied etiology, but the causality association has never been proved. We aim to study the prevalence of CD in patients of PHT of different etiology.

METHODS

A prospective observational study was conducted from June 2017 to December 2018 involving all the cases of PHT of varied etiology. Consecutive patients of PHT with chronic liver disease (CLD) of defined etiology like ethanol, viral hepatitis (B or C), Budd-Chiari syndrome (BCS), autoimmune-related cirrhosis, and cryptogenic CLD (cCLD) (group A) and those with noncirrhotic PHT (NCPHT), which included noncirrhotic portal fibrosis (NCPF) and extrahepatic portal vein obstruction (EHPVO) (group B), were screened for CD by IgA anti-tTG antibody followed by duodenal biopsy in serology-positive patients.

RESULTS

Out of a total of 464 patients, group A constituted 382 patients, CLD related to ethanol (155), cCLD (147), hepatitis B (42), hepatitis C (21), autoimmune (10), and BCS (7), whereas 82 patients were in group B with NCPF (64) and EHPVO (18). Total 29 patients were diagnosed with CD in both groups, 17 in group A (4.5%) and 12 in group B (14.6%). In group A, 13 patients with cCLD, two with HBV-related CLD, one with BCS, and one with autoimmune-related CLD were concomitantly diagnosed as CD. In group B, CD was diagnosed in 12 patients of NCPF (11) and EHPVO (1). Liver histology showed chronic hepatitis in two patients and was normal in three patients.

CONCLUSION

CD is common in PHT of different etiology, especially in cCLD, NCPH and autoimmune hepatitis; however, the etiological basis for this association is still to be defined. The likelihood of CD is higher in liver disease than the general population, and these patients should be screened for CD.

Prevalence of celiac disease among pediatric patients with cryptogenic cirrhosis and effect of gluten-free-diet

BACKGROUND

Liver involvement in celiac disease (CD) is classified into autoimmune and cryptogenic. The association between CD and autoimmune liver diseases like autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis is well-established; however, the data on patients with cryptogenic cirrhosis, particularly from India, are scanty. So we did this study to find the prevalence of CD in patients with cryptogenic cirrhosis.

METHODS

This was a prospective observational study, involving children of less than 18 years old attending Pediatric and Gastroenterology clinic with a diagnosis of cryptogenic cirrhosis. The patients were evaluated for CD and divided into two groups: chronic liver disease (CLD) with CD, and CLD without CD. Both the groups were followed up for 6 months. CLD with CD group was treated with gluten-free-diet (GFD) and CLD without CD group was followed up without any specific intervention except standard care of CLD.

RESULTS

Out of 84 patients, 11 (13.1%) were diagnosed as CLD with CD. There was an improvement in hemoglobin levels, liver function tests, and Child-Pugh score after initiation of GFD in CLD with CD group.

CONCLUSION

The prevalence of CD in cryptogenic cirrhosis was 13.1%. Screening for CD is recommended for cryptogenic cirrhosis. Hepatic functions improve with a GFD in CD patients with cirrhosis.

Coeliac disease and the liver: spectrum of liver histology, serology and treatment response at a tertiary referral centre

BACKGROUND

Coeliac disease (CD) is a gluten-sensitive enteropathy diagnosed on the basis of ESPGHAN criteria and clinical response to gluten-free diet (GFD). Histological abnormalities on liver biopsy have been noted in CD but have seldom been described.

AIMS

To assess the histological spectrum of 'coeliac hepatitis' and possibility of reversal of such features after a GFD.

METHODS

Twenty-five patients with concomitant CD and hepatic derangement were analysed for clinical profile, laboratory investigations and duodenal and liver biopsy. A histological comparison of pre- and post-GFD duodenal and liver biopsies was carried out, wherever possible.

RESULTS

Fifteen patients presenting with CD subsequently developed abnormal liver function tests; 10 patients presenting with liver disease were found to have tissue positive transglutaminase in 70% and antigliadin antibodies in 60%. Serological markers for autoimmune liver disease (AILD) were positive in eight patients. Liver histology ranged from mild reactive hepatitis, chronic hepatitis, steatosis to cirrhosis. Liver biopsies after a GFD were available in six cases, of which five showed a decrease in steatosis, portal and lobular inflammation and fibrosis score.

CONCLUSION

Coeliac hepatitis could be a distinct entity and the patients may present with either CD or secondary hepatic derangement. Evaluation for the presence of CD is recommended for patients presenting with AILD, unexplained transaminasaemia or anaemia. This is one of the very few studies demonstrating the continuum of liver histological changes in 'coeliac hepatitis'. Trial of a GFD may result in clinicopathological improvement of 'coeliac hepatitis'.

Hypertransaminasemia in Newly Diagnosed Pediatric Patients With Celiac Disease

OBJECTIVES

The aim of the present study was to determine the proportion of pediatric patients with celiac disease (CD) who had transaminases obtained at diagnosis and to determine the proportion with hypertransaminasemia.

METHODS

Data from newly diagnosed patients with CD at Nationwide Children's Hospital from February 2007 to March 2014 were retrospectively reviewed. Alanine transaminase (ALT) and aspartate transaminase (AST) values at diagnosis and after initiation of a gluten-free diet (GFD) were assessed.

RESULTS

Of 388 patients (mean age 10.1 ± 4.4 years, 235 girls), 185 (47.7%) had transaminases obtained at the time of diagnosis. Twenty-eight of one hundred eighty-five (15.1%) had an elevated ALT and/or AST level with an average ALT 2.52 × upper limit of normal (ULN) and AST 1.87 × ULN. Those with hypertransaminasemia were younger than those with normal levels (6.31 ± 4.75 vs 11.00 ± 4.28 years, P < 0.0001). Sex, symptoms at diagnosis, and weight, height, and body mass index z scores were not predictive of elevated transaminases. Of the 21 patients with hypertransaminasemia at diagnosis who had repeat laboratory test results after starting the GFD, 15 (71.4%) normalized whereas 6 (28.6%) remained elevated.

CONCLUSIONS

There is variation in practice among pediatric gastroenterologists in the assessment of transaminases in children with CD. Hypertransaminasemia is present at diagnosis in a significant proportion of children with CD although at a lower frequency than previously reported. Younger patients are more likely to have an elevation in transaminases. Abnormal transaminases normalize in the majority of patients within 1 year after initiation of a GFD.

Celiac disease-related hepatic injury: Insights into associated conditions and underlying pathomechanisms

BACKGROUND

Celiac disease (CD) is the most common autoimmune enteropathy. Clinical manifestations may range from a typical malabsorption syndrome to several apparently unrelated extra-intestinal symptoms.

AIM

Here we specifically focus on the spectrum of CD-related liver disorders and the underlying pathomechanisms.

METHODS

A computer-based search up to August 2015 was completed using appropriate keywords. References from selected papers were also reviewed and used if relevant.

RESULTS

An unexplained hypertransaminasemia with nonspecific histologic hepatic changes is the most common hepatic presentation. CD however can coexist with a number of liver disorders such as Autoimmune Hepatitis, Autoimmune Cholangitis, Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis requiring a specific treatment in addition to gluten-free diet. CD has also been associated with Viral Hepatitis, Fatty Liver, Non-Alcoholic Steatohepatitis and some severe cryptogenic hepatopaties in the liver transplantation list. Pathomechanisms underlying hepatic injury in CD are multiple, appear still not completely defined and may probably co-occur.

CONCLUSIONS

An ever-increasing number of CD-related liver injuries exist, probably representing a continuum of a same disorder where genetic predisposition, timing, and duration of previous gluten exposure might influence the reversibility of liver damage. Evidences, although not conclusive, support therefore testing for CD also in cryptogenic hepatobiliary conditions where the relationship with CD has not yet been fully investigated.

Association between celiac disease and chronic hepatitis C

Celiac disease is characterized by a gluten-induced damage of the small bowel in sensitive individuals that may cause malabsorption. Non-intestinal inflammatory diseases may trigger immunologic gluten intolerance in susceptible people and the HCV virus may be considered as a suitable candidate. Interferon therapy could precipitate symptom onset in subjects with silent celiac disease. In fact, symptoms such as diarrhea, anemia, and weight loss may occur during interferon therapy and are associated with serological positivity of anti-tranglutaminase antibodies. To date, considering the available literature data, it is very difficult to support a firm association between HCV chronic hepatitis and celiac disease. Thus, such a serological screening in HCV patients before starting interferon therapy should not be recommended. However, serology for celiac disease must be considered in patients who develop diarrhea and/or weight loss during such therapy.

Liver involvement in pediatric celiac disease

Celiac disease (CD) is an intestinal inflammatory disease that manifests in genetically susceptible individuals when exposed to dietary gluten. It is a common chronic disorder, with a prevalence of 1% in Europe and North America. Although the disease primarily affects the gut, the clinical spectrum of CD is remarkably varied, and the disease can affect many extraintestinal organs and systems, including the liver. The hepatic dysfunction presenting in CD ranges from asymptomatic liver enzyme elevations or nonspecific reactive hepatitis (cryptogenic liver disorders), to chronic liver disease. In this article, we review the clinical presentations and possible mechanisms of CD-related liver injury to identify strategies for the diagnosis and treatment of these disorders in childhood.

Prevalence of Celiac Disease in Children with Autoimmune Hepatitis and vice versa

OBJECTIVE

Celiac disease is an autoimmune disorder in which the risk of autoimmune liver disease is high. Autoimmune hepatitis is a chronic and progressive entity and the risk of its being associated with other autoimmune disorders such as celiac disease is high also. The aim of this study was to determine the prevalence of celiac disease in patients with autoimmune hepatitis and vice versa.

METHODS

In a cross-sectional study children with autoimmune hepatitis underwent serological screening and endoscopy for celiac disease. In patients with celiac disease, serum aminotransferases were measured and, if abnormal, autoantibodies related to autoimmune hepatitis were checked and needle liver biopsy was performed.

FINDINGS

Of the 96 patients, 64 had autoimmune hepatitis and 32 celiac disease. Among patients with autoimmune hepatitis only three (4.7%) were compatible with celiac disease. In the group of patients with celiac disease, autoimmune hepatitis was confirmed in four (12.5%) cases. We consider important to state that 3.1% of this group had celiac hepatitis.

CONCLUSION

Autoimmune liver disease is sometimes associated with latent celiac disease. Serological screening for celiac disease should be routinely done in patients with abnormal serum aminotransferases, particularly those with chronic liver disease. On the other hand, celiac disease is often accompanied by other autoimmune diseases, including autoimmune hepatitis.

Systemerkrankungen

Systemerkrankungen als Ursache einer Lebererkrankung sind häufig, ohne dass man genaue Zahlen angeben kann. Die verschiedenen Grunderkrankungen sind für sich betrachtet zwar selten, nur dadurch, dass viele Erkrankungen in Betracht gezogen werden müssen, ergibt sich eine relative Häufung. Durch Fortschritte auf dem Gebiet der molekularbiologischen Diagnostik insbesondere bei den Stoffwechselerkrankungen lassen sich heute bereits viele der in Frage kommenden Grunderkrankungen eindeutig nachweisen. Allerdings ist bei keiner der Erkrankungen ein hundertprozentiger molekularbiologischer Nachweis möglich. Damit ergibt sich eine sichere Diagnose nur bei einem positiven Nachweis. Bei fehlendem Nachweis einer bisher bekannten für die Erkrankung spezifischen Mutation bleibt die Zuordnung entweder enzymatischen Tests oder klinischer Diagnose vorbehalten. Insbesondere bei der Manifestation als akutes Leberversagen ist die für die Diagnosesicherung erforderliche Zeit damit oft nicht vorhanden.

Should We Look for Celiac Disease among all Patients with Liver Function Test Abnormalities?

BACKGROUND

Celiac disease (CD) has been found in up to 10% of the patients presenting with unexplained abnormal liver function tests (LFT). As there is no precise data from our country in this regard, we investigated the prevalence of CD in patients presenting with abnormal LFT.

METHODS

From 2003 to 2008, we measured IgA anti-tissue transglutaminase (t-TG) antibody (with ELISA technique) within the first-level screening steps for all patients presenting with abnormal LFT to three outpatient gastroenterology clinics in Isfahan, IRAN. All subjects with an IgA anti-tTG antibody value of >10 μ/ml (seropositive) were undergone upper gastrointestinal endoscopy and duodenal biopsy. Histopathological changes were assessed according to the Marsh classification. CD was defined as being seropositive with Marsh I or above in histopathology and having a good response to gluten free diet (GFD).

RESULTS

During the study, 224 patients were evaluated, out of which, 10 patients (4.4%) were seropositive for CD. Duodenal biopsies were performed in eight patients and revealed six (2.7%) cases of Marsh I or above (four Marsh IIIA, two Marsh I), all of them had good response to GFD. The overall prevalence of CD among patients with hypertransaminasemia, autoimmune hepatitis, and cryptogenic cirrhosis was determined as 10.7% (3/28), 3.4% (2/59), and 5.3% (1/19), respectively.

CONCLUSION

Serological screening with IgA anti-tTG antibody test should be routinely performed in patients presenting with abnormal LFT and especially those with chronic liver diseases including hypertransaminasemia, autoimmune hepatitis, and cryptogenic cirrhosis.

Celiac disease in pediatric patients with autoimmune hepatitis: etiology, diagnosis, and management

Celiac disease (CD) is defined as a permanent intolerance to ingested wheat gliadins and other cereal prolamins, occurring in genetically susceptible people. Persistent elevation of serum aminotransferase activity is expression of liver damage related to CD, which occurs in two distinctive forms. The most frequent is a mild asymptomatic liver injury, with a moderate increase of serum aminotransferase activities and a mild inflammatory portal and lobular infiltrate on liver biopsy (celiac hepatitis), reversible on a gluten-free diet (GFD). More rarely, severe and progressive inflammatory liver damage, induced by an autoimmune process and identified as autoimmune hepatitis (AIH), can develop and it is generally unaffected by gluten withdrawal. Surveys that included only pediatric patients report a wide range of prevalence of CD in AIH of 11.5-46% (mean 21.5%). CD and AIH share selected combinations of genes coding for class II human leukocyte antigens, which could explain their coexistence. Increased intestinal permeability and circulation of anti-tissue transglutaminase (tTG) have also been considered as further potential causes of liver damage in CD patients. tTG in the liver and in other extraintestinal tissues could modify other external- or self-antigens and generate different neo-antigens, which are responsible for liver injury in patients with CD. Patients with AIH represent a population at high risk for developing CD; screening for CD should be integrated into the diagnostic routine of all patients with AIH, with or without gastrointestinal manifestations, before starting immunosuppressive treatments. The only currently available treatment for CD is the GFD and the supportive nutritional care for iron, calcium, and vitamin deficiencies. Due to the difficulties of a GFD, in the past decade researchers have become increasingly interested in therapeutic alternatives to continuous or intermittent use of a GFD in patients with CD. Interventions addressed to correct the defect in the intestinal barrier are currently at the most advanced stage of clinical trials. The impact of a GFD on the outcome of AIH is not clear but it seems to be ineffective in the treatment of AIH. The early detection and treatment of CD, however, may prevent progression to end-stage liver failure.

The liver in celiac disease: clinical manifestations, histologic features, and response to gluten-free diet in 30 patients

Descriptive reports of liver histologic features in celiac disease (CD) are sparse, and the effect of a gluten-free diet (GFD) on the course of liver injury is poorly understood. We reviewed liver biopsy specimens in 30 patients with CD and performed immunostains for IgG, IgG4, IgM, and IgA. Subsequent liver biochemical tests and compliance with the GFD were recorded. Of the patients, 19 had autoimmune-mediated liver disease (AILD; autoimmune hepatitis, 9; primary sclerosing cholangitis, 7; and primary biliary cirrhosis, 3). The remaining 11 patients had cryptogenic hepatitis (5), hepatitis C (2), steatohepatitis (2), sarcoidosis (1), and T-cell lymphoma (1). The liver disease diagnosis preceded the CD diagnosis in all groups except steatohepatitis. Although 82% of patients without AILD had symptomatic CD, only 26% of patients with AILD had such symptoms. The pathology of the specific liver disease was not atypical in histologic features or IgG/IgM ratios. While GFD improved cryptogenic hepatitis, it did not seem to affect AILD. We propose that AILD and cryptogenic hepatitis in patients with CD represent distinct clinical, histologic, and immunohistochemical entities rather than 2 ends of a spectrum of liver injury.

Liver complications in celiac disease

Celiac disease (CD) is characterized by sensitivity to gluten, which is found in dietary wheat, barley, and rye. Many extra-intestinal manifestations have been described in association with CD. Liver disease and CD share widespread risk factors. Liver disorders such as autoimmune hepatitis, elevation of liver enzyme levels, primary biliary cirrhosis, nonspecific hepatitis, primary sclerosing cholangitis, and nonalcoholic fatty liver disease have been reported in patients with CD. In this review, we provide information regarding liver disorders that may be found in association with celiac disease and the effect of the treatment of CD on these disorders.

Coeliac disease in autoimmune liver disease: a cross-sectional study and a systematic review

BACKGROUND

Several studies have reported an association between coeliac disease and autoimmune liver disease, but there is little information on the prevalence of coeliac disease in certain autoimmune liver diseases, particularly from non-European, non-American countries.

AIMS

To investigate prevalence of coeliac disease in autoimmune liver disease in Iran and to summarize previous literature.

METHODS

We investigated prevalence of coeliac disease among 100 autoimmune liver disease patients and compared it with the prevalence in healthy individuals. We also performed an extensive search of the English literature in PubMed Database.

RESULTS

We found substantially elevated prevalence of coeliac disease in patients with overlap syndrome (10-15%) compared to the general population (0.1-1%). To a lesser extent, the prevalence was high in patients with autoimmune hepatitis (2-4%). In our systematic review, prevalence of coeliac disease in autoimmune hepatitis in the majority of studies was 4% or more; several studies also reported such prevalence in primary biliary cirrhosis.

CONCLUSIONS

Since coeliac disease is common among patients with autoimmune liver disease, screening autoimmune liver disease patients for coeliac disease is indicated. Although the magnitude of benefit from a gluten-free diet in reversing autoimmune liver disease in patients with coeliac disease is controversial, it may reduce the risk of further complications of coeliac disease.

Celiac disease in childhood: evaluation of 140 patients

OBJECTIVE

Celiac disease (CD) is a lifelong gluten-sensitive intestinal enteropathy that is multifactorial in its etiology. In the present study, we evaluated basic anthropometric, clinical, laboratory, and histological features of 140 Turkish children with CD. We particularly underscored the association of CD with other autoimmune diseases.

MATERIALS AND METHODS

During the period from 1999 to 2005, CD was diagnosed in 140 children according to ESPGAN criteria. The age, gender, clinical findings, hematological, and biochemical parameters at diagnosis were noted. Symptoms and signs were recorded. Endoscopic intestinal biopsies were taken from all children.

RESULTS

Of the 140 children with CD, 75 (53.6%) were female, and 65 (46.4%) were male. Mean age was 8.56 ± 4.43 years (range 13 months to 18 years). The most frequent symptom was failure to thrive (81.4%), followed by chronic diarrhea (60%). Of the children with CD, nine (6.4%) had type 1 diabetes mellitus (DM), six (4.3%) had familial Mediterranean fever, three (2.1%) had alopecia areata, three (2.1%) had vitiligo, three (2.1%) had Down syndrome, two (1.4%) had lung tuberculosis, two (1.4 %) had autoimmune hepatitis, two (1.4%) had growth hormone deficiency, one (0.7%) had osteogenesis imperfecta, and one (0.7%) had Floating Harbor Syndrome. Elevated serum levels of ALT, CK and AST were detected in 48(34.8%), 50 (38.2%) and 67 (48.6%) children, respectively.

CONCLUSION

The spectrum of clinical findings is very wide. In order to avoid overlooking CD in patients with extra intestinal symptoms and signs, physicians, especially pediatricians, should be informed about new atypical manifestations of CD.

Seronegative autoimmune hepatitis presenting after diagnosis of coeliac disease: a case report

The relationship between liver dysfunction and coeliac disease is well established, ranging from transaminitis to chronic liver disease. In this report, we describe for the first time the development of a 'seronegative' autoimmune hepatitis in a teenager previously diagnosed with coeliac disease. He had normal liver function tests (LFTs) at diagnosis and was strictly compliant with a gluten-free diet. On screening blood tests at 1 year post diagnosis, he presented with raised LFTs leading to a diagnosis of autoimmune hepatitis on liver biopsy, successfully treated with mycophenolate mofetil. By using screening LFTs, we may well have prevented this patient from developing disease complications.

[Elevated liver enzymes in rheumatoid arthritis : differential diagnostic considerations based on a case report]

Elevated liver enzymes in patients with rheumatoid arthritis may have various causes. These can range from the rheumatic disease itself, the anti-rheumatic medication or be the manifestation of an associated autoimmune disease. We present the case of a 19-year-old female with known seropositive rheumatoid arthritis who developed severe liver damage after 9 months of anti-rheumatic therapy with leflunomide and adalimumab. Both drugs were stopped. In addition to the underlying disease and the specific anti-rheumatic drugs, a temporary therapy with flucloxacillin as well as an association with newly diagnosed celiac disease had to be considered as possible causes of elevated liver enzymes. Following repeated liver biopsy, autoimmune hepatitis was assumed and prednisolone and azathioprine were initiated. Elevated liver enzymes and bilirubin rapidly returned to normal values.

Celiac disease and non-organ-specific autoantibodies in patients with chronic hepatitis C virus infection

OBJECTIVE

Considering that celiac disease (CD) is an autoimmune-based entity and the hepatitis C virus is suspected of being able to trigging autoimmune reactions, it has been hypothesized that hepatitis C virus infection might predispose to CD. The aim of this study was to investigate CD-related antibodies in a large series of hepatitis C virus-infected subjects that were also tested for non-organ-specific autoantibodies (NOSA) as indirect marker of autoimmune disorders.

METHODS

Two hundred and forty-four patients with chronic hepatitis C virus infection (HCV-patients) and 121 patients with HCV-negative liver disease (non-HCV-patients) underwent NOSA determination and celiac serology (firstly, anti-tissue transglutaminase antibodies, then the cases which tested positive were subsequently evaluated for the presence of antiendomysial antibodies). Serum samples from 42 of the HCV-patients who underwent interferon-alpha therapy after enrollment were tested for celiac antibodies and NOSA even after stopping treatment. Additionally, sera from 1,230 blood donors were assayed for celiac serology as healthy control population.

RESULTS

Positive anti-endomysial antibodies (AEA) were found in 5/244 (2%) HCV-patients, 1/121 (0.8%) non-HCV-patients and 2/1,230 (0.16%) blood donors, with a significant difference between HCV-patients and blood donors (P = 0.02; Odds ratio 12.8; 95% Confidence Interval 2.4-66). NOSA were found in 51 HCV-patients but only one of them had positive AEA. Eight out of 42 HCV-patients treated with interferon-alpha developed NOSA under therapy and none of them had CD antibodies.

CONCLUSIONS

AEA occur in 2% of HCV-patients and their presence is independent of other patterns of autoimmunity.

[Hepatic involvement in celiac disease]

Celiac disease (CD) is an autoimmune enteropathy triggered by gluten ingestion in genetically susceptible individuals. Hypertransaminasemia has been observed in up to 40% of untreated celiac patients and is usually resolved by a gluten-free diet. The most common type of liver disease associated with CD is non-specific reactive hepatitis, while association with viral hepatitis or autoimmune-mediated liver diseases such as autoimmune hepatitis, primary biliary cirrhosis or primary sclerosing cholangitis is less frequent. Therefore, a practical recommendation would be to look for liver disfunction in patients with CD as well as to perform diagnostic tests for CD in patients with hypertransaminasemia or cholestasis of unknown etiology.

[Idiopathic portal hypertension associated with celiac disease: one case]

We describe for the first time a case of idiopathic portal hypertension (IPH) in a 31 year old patient with coeliac disease (CD). She had splenomegaly, pancytopenia and an unexplained portal hypertension in the absence of any histological abnormalities of the liver. The diagnosis of coeliac disease was based on histological and serological data. Treatment included a splenectomy and a splenorenal shunt.

Liver involvement in celiac disease

Celiac disease may present as a cryptogenic liver disorder being found in 5-10 % of patients with a persistent and cryptogenetic elevation of serum aminotransferase activity. In fact, a wide spectrum of liver injuries in children and adults may be related to CD and in particular: (1) a mild parenchymal damage characterised by absence of any clinical sign or symptom suggesting a chronic liver disease and by non-specific histological changes reversible on a gluten-free diet; (2) a chronic inflammatory liver injury of autoimmune mechanism, including autoimmune hepatitis, primary sclerosing cholangitis and primary biliary cirrhosis, that may lead to fibrosis and cirrhosis, generally unaffected by gluten withdrawal and necessitating an immunosuppressive treatment; (3) a severe liver failure potentially treatable by a gluten-free diet. Such different types of liver injuries may represent a spectrum of a same disorder where individual factors, such as genetic predisposition, precocity and duration of exposure to gluten may influence the reversibility of liver damage. A rigorous cross-checking for a asymptomatic liver damage in CD individuals and conversely, for CD in any cryptogenic liver disorder including end-stage liver failure is recommended.

Alteraciones hepáticas en la enfermedad celíaca del adulto. Caracterización clínico-patológica y evolución

BACKGROUND AND AIM

The clinical manifestations of adult celiac disease are highly varied and may include liver disease. The present study aimed to characterize liver abnormalities and outcome after a gluten-free diet in patients with celiac disease diagnosed in a hepatology clinic.

MATERIAL AND METHOD

The clinical records of patients diagnosed with celiac disease during a 7-year period were reviewed.

RESULTS

Of 1916 patients attending a first consultation at the clinic, 10 were finally diagnosed with celiac disease. All patients had been referred for evaluation of persistent elevation of liver enzyme levels. All patients were young (mean age 30 years, range 21-39 years) and there were more women than men (eight women, 80%). Six patients (60%) had additional manifestations attributable to undiagnosed celiac disease, sometimes since childhood. In all patients, elevation of liver enzyme levels was moderate and overall liver function was preserved. Liver biopsy was performed in five patients and all showed chronic periportal infiltrate. Immunohistochemical studies revealed that the infiltrate was mainly composed of CD8-positive T lymphocytes. In all patients, a gluten-free diet was followed by normalization of liver enzyme levels.

CONCLUSIONS

Although celiac disease is not highly frequent, it should be considered in the differential diagnosis of patients with persistent abnormalities of liver markers. The most conspicuous histopathological change is periportal T-cell infiltrate. Liver abnormalities in celiac disease are generally mild and improve after a gluten-free diet.

Holmes-Adie syndrome, autoimmune hepatitis and celiac disease: A case report

A 35-year-old female patient presented with the following symptoms of Holmes-Adie syndrome: photophobia, enlargement of the left pupil unresponsive to light, Achilles areflexia. The pilocarpine test was positive. No tumor or other neurological abnormality was found. She had a 19-year history of autoimmune hepatitis. Flares up were observed following each 3 deliveries. At age of 31 she presented with diarrhea and weight loss. Abdominal tumor was detected by ultrasound. The surgically removed tumor was histologically a benign mesenteric multicystic lymphangioma. Simultaneously, celiac disease was diagnosed. Gluten-free diet resulted in a significant improvement of celiac disease, but not of autoimmune hepatitis. Autonomic neuropathy was proven by standard cardiovascular tests. The patient was a homozygous carrier for HLA DQ2 antigen characteristic for celiac disease and heterozygous for HLA DR3 B8 frequent in autoimmune liver diseases. Our novel observation on association of Holmes-Adie syndrome with autoimmune hepatitis and celiac disease is suggestive for a common immunological background for all three entities present in a patient with mesenteric multicystic lymphangioma.

Celiac disease: current concepts in diagnosis and treatment

Celiac disease is a complex autoimmune enteropathy that affects the small bowel in genetically predisposed individuals. It is thought that celiac disease is the result of an inappropriate T cell-mediated immune response against ingested gluten protein. The characteristic lesion of the small intestinal mucosa includes loss of absorptive villi and infiltration of the lamina propria with inflammatory cells. The clinical presentation of celiac disease varies greatly depending on patient's age, duration and extent of the disease, and the presence of extraintestinal manifestations. Unfortunately, most patients with celiac disease have either silent or atypical presentations, thus escaping diagnosis for several years. Medical nutrition therapy with lifelong adherence to a strict gluten-free diet is the only accepted treatment of celiac disease. Individuals at risk for this entity should undergo appropriate serologic testing, but there is no evidence to support mass screening.

Celiac sprue (the great modern-day imposter)

PURPOSE OF REVIEW

To review the current epidemiological information on celiac disease and the various presentations and associated.

RECENT FINDINGS

Epidemiologic studies reveal celiac disease to be common, occurring in approx. 1% of the population. It is being diagnosed worldwide, even in developing countries. The classic mode of presentation has become less common, with diarrhea or a malabsorption syndrome as the mode of presentation in fewer than 50% of individuals. The other major modes of presentation are iron-deficiency anemia, osteoporosis, screening of family members, or incidentally at endoscopy done for dyspepsia or reflux. Neurological presentations may include peripheral neuropathy or ataxia. Arthritis is commonly found in patients with celiac disease when systematically sought. Patients often have a previous diagnosis of irritable bowel syndrome. Autoimmune diseases occur more frequently (three to ten times more) in those with celiac disease than the general population. However, this increased incidence of autoimmune diseases is not prevented by early diagnosis of celiac disease.

SUMMARY

We will review the various associated diseases/presentations of celiac disease. The heterogeneity of the symptoms can make the diagnosis challenging and certainly the great modern-day imposter.

Cirrhosis in children with celiac disease

BACKGROUND

Liver involvement represents an extra-intestinal feature of celiac disease (CD) and shows a clinical spectrum varying from nonspecific reactive hepatitis to cirrhosis. Here we report the association of cirrhosis with CD in 5 children.

PATIENTS AND METHODS

The mean age of the patients was 9.4 +/- 2.8 years. Viral, metabolic, and autoimmune etiology of liver disease was ruled out. Intestinal and liver biopsies were performed to confirm the histologic diagnosis in all subjects.

RESULTS

Three of the patients had chronic diarrhea and hepatosplenomegaly in whom diagnoses of CD and cirrhosis were established at presentation simultaneously. In the other 2 patients, CD was diagnosed following an initial diagnosis of cirrhosis. At diagnosis, alanine aminotransferase (range, 64-271 IU/L) and aspartate aminotransferase (range, 90-225 IU/L) values were elevated. After 1 to 5 years of a gluten-free diet (GFD), normalization of serum aminotransferase levels and clinical improvement were observed in 3 patients with strict GFD. The other 2 patients without improvement of the liver disease had poor dietary compliance.

CONCLUSION

CD may be associated with severe hepatic damage in children and strict GFD may have beneficial effect on the course of liver disease. Serologic screening of CD should be included in differential diagnosis of chronic liver disease of unknown origin.

Narrative review: celiac disease: understanding a complex autoimmune disorder

Celiac disease is a common autoimmune disorder that has genetic, environmental, and immunologic components. It is characterized by an immune response to ingested wheat gluten and related proteins of rye and barley that leads to inflammation, villous atrophy, and crypt hyperplasia in the intestine. The disease is closely associated with genes that code for human leukocyte antigens DQ2 and DQ8. Transglutaminase 2 appears to be an important component of the disease, both as a deamidating enzyme that can enhance the immunostimulatory effect of gluten and as a target autoantigen in the immune response. Sensitive and specific serologic tests, including those for anti-transglutaminase antibody, are facilitating fast and noninvasive screening for celiac disease. Thus, they are contributing to a more accurate estimate of the prevalence of the disease and its association with other disorders. Celiac disease is associated with increased rates of anemia, osteoporosis, cancer, neurologic deficits, and additional autoimmune disorders. A gluten-free diet is the mainstay of safe and effective treatment of celiac disease, although its effect on some of the extraintestinal manifestations of the disease remains to be determined.