Early ReportCoeliac disease hidden by cryptogenic hypertransaminasaemia
Introduction
Retrospective studies have shown that many patients with untreated coeliac disease show liver involvement characterised by elevated concentrations of serum transaminase, or aminotransferase, and a liver histology consistent with a nonspecific reactive hepatitis.1, 2, 3 In these patients liver damage was proved to be gluten-dependent, as confirmed by disappearance of histological and biochemical signs of the hepatic lesions after following a strict gluten-free diet for a few months.4 Also, hypertransaminasaemia of unknown, cryptogenic, origin has occasionally been reported in childhood as an early biochemical sign of coeliac disease free of gastrointestinal symptoms.4, 5 The finding of unexplained raised serum transaminase concentrations is not as rare as originally thought. Because diagnostic tests for coeliac disease are not included among investigations for cryptogenic hypertransaminasaemia at present, some cases of coeliac disease may therefore go unrecognised. Early identification of gluten-sensitive enteropathy is important because strict adherence to a gluten-free diet can prevent neoplastic and systemic complications and improve symptoms of associated diseases.6, 7, 8, 9, 10 These assumptions have prompted us to investigate coeliac disease in a series of patients with cryptogenic hypertransaminasaemia, to establish how many of them have coeliac disease, and so to find out whether an unexplained increase in serum transaminases can be considered a high-risk condition for gluten-sensitive enteropathy.
Section snippets
Patients
600 consecutive adult patients were referred to the outpatient liver clinic of S Orsola Policlinic between September, 1995, and June, 1997, because of raised serum transaminases. Nearly all of them were symptom-free (a few patients found they were easily fatigued) and had become aware of their hypertransaminasaemia as a consequence of routine blood tests. 55 (9%) of them were classified as having cryptogenic hypertransaminasaemia after the exclusion of every known cause of liver disease.
Viral
Results
Five (9%) of the 55 patients with cryptogenic hypertransaminasaemia were positive for both IgG to gliadin and IgA to endomysium, whereas IgA to gliadin was found in only four of these patients. IgG to gliadin was also present in another patient who was not positive for antibodies to endomysium. Antibody titre ranged from one in 40 to one in 320 for antibodies to endomysium and from one in ten to one in 160 for antibodies to gliadin. For the six patients who were positive for antibodies,
Discussion
The clinical presentation of gluten-sensitive enteropathy can be deceptive, varying tremendously from patient to patient, and appears to depend on the length of small intestine damaged.16 Whereas the typical symptoms of diarrhoea, flatulence, weight loss, and fatigue (overt malabsorption syndrome) are frequently found in people with coeliac disease, diffuse small-bowel involvement, atypical, single-symptom, or even symptom-free forms of the disease are associated with a mucosal lesion limited
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