S5458 Hepatitis: A Rare Initial Presentation of Celiac Disease

Introduction: Celiac hepatitis is a common manifestation of celiac disease, accounting for 13%-60% prevalence. It is a gluten-dependent injury resolved on a gluten free diet (GFD), typically after 12 months of strict adherence. Histological changes also improve after a GFD. Celiac patients have both an increased risk of subsequent liver disease and risk of death from liver cirrhosis than the general population. Case Description/Methods: A 25-year-old man with no past medical history had a pre-employment bloodwork, which included liver function tests. Aspartate aminotransferase and alanine aminotransferase were 3 times the normal limit. This finding led to a thorough investigation, including a viral panel, an autoimmune liver panel, iron, and copper studies. Autoimmune workup included anti-mitochondrial antibody, anti-smooth muscle antibody, anti-sp100 antibody, anti-neutrophil cytoplasmic antibodies, antinuclear antibody, IgG4, and IgA tTG. All bloodwork included was unremarkable except celiac serology, which prompted upper endoscopy despite the lack of gastrointestinal symptoms. Duodenal biopsies demonstrated intraepithelial lymphocytes, duodenal villus atrophy, and prominent crypts. The patient was started on a GFD with subsequent normalization of transaminases in 6 months. Discussion: The mechanisms underlying celiac hepatitis are poorly understood. Intestinal permeability has been seen to be quantitatively higher in patients with celiac disease and elevated transaminases than in those with normal liver tests. The phenomenon is gluten-dependent, evidenced by normalization of both intestinal permeability and elevation of transaminases with a GFD. It has been hypothesized that increased intestinal permeability may facilitate toxin entry into portal circulation, leading to liver injury. Most patients with celiac hepatitis have no symptoms or signs of liver disease. Mild to moderate (less than 5 times the upper limit of normal) levels of aspartate aminotransferase and/or alanine aminotransferase are typical. This is independent of primary biliary cholangitis, primary sclerosing cholangitis, or autoimmune hepatitis, which might be associated with celiac disease. This case reflects the importance of celiac serology while evaluating transaminase elevation.