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A CASE OF CRYPTOGENIC LIVER DISORDER IN CELIAC DISEASE
M K Leger, J McGrath
Department of Medicine, Memorial University of Newfoundland, St John’s, Newfoundland
Case Report: A 43 year old women with congenital hepatic fibrosis was referred to the Gastroenterology clinic upon moving back to Newfoundland. She had moved all over the country due to the nature of her husband’s work and been followed by half a dozen gastroenterologists.
She had presented with a GI bleed as a child and was subsequently diagnosed with congenital hepatic fibrosis. Since then, she has had multiple episodes of GI bleeding from esophageal varices, which were treated endoscopically. Otherwise she was doing quite well.
In clinic she complained about chronic diarrhea and fatigue. On examination she did not have any decompensated features of liver disease. She was very thin, but there was no ascites, peripheral edema, jaundice or encephalopathy. Investigations revealed marked hypochromic microcytic anemia, with a MCV of 65.7; mild transaminitis; bone mineral density showing mild osteopenia; and diffuse liver fibrosis with signs of portal hypertension on ultrasound.
On reviewing her old charts it was noted she had chronic mild elevation of her transaminases, which had been presumed to be from her liver disease. However, given her marked anemia and chronic diarrhea it was suspected her transaminitis may be secondary to Celiac disease. An endoscopy was performed which showed severe scalloping of the duodenal folds. Bloodwork for TTG was positive.
A gluten free diet was started, and over the following 9 months her transaminitis had completely normalized, diarrhea had improved with modest weight gain, and improvement of her microcytic anemia.
Celiac disease can present with a spectrum of liver injuries, mainly inflammatory in nature. This can present uncommonly as a cryptogenic liver disorder, i.e. with mild elevation of the transaminases as the only sign of disorder. Even though this patient had underlying liver disease to account for the transaminitis, it was not the only cause. This suggests that other causes of liver dysfunction, such as Celiac disease, must still be ruled out with abnormal liver function tests.