Celiac Disease and Elevated Liver Enzymes: A Still Not Fully Defined Pathogenesis.

Dear Editor,

We read, with great interest, the comprehensive review by Villavicencio Kim J and Wu GY that systematically addressed the issue of liver enzyme elevation in celiac disease (CD) patients.1

The Authors reviewed, in detail, the most relevant studies reporting the frequency of liver enzyme elevation in CD patients and the possible causes, discussing the hypothesis that this elevation may be a clue to associated liver disease or an epiphenomenon, possibly secondary to the increased intestinal permeability that is known to characterize CD patients, especially at diagnosis, before starting a gluten-free diet.2

We would like to add some considerations that, in our opinion, could have implications in the pathogenesis of hepatic injury in CD.

As known, it has been reported that CD is frequently associated with other extraintestinal autoimmune diseases or even with the mere presence of autoantibodies without concomitant autoimmune pathology.3–6

Among the autoimmune diseases potentially associated with CD, autoimmune hepatitis (AIH) is worthy of mention, as previously reported.1,3,7

Of considerable interest, it has been reported that celiac patients frequently have anti-filamentous actin IgA antibodies that have shown reliable and significant correlation with villous atrophy.8 These autoantibodies, although of IgG class, are also known to have very high specificity for AIH.7,9

This similarity between the two autoimmune diseases could be a clue that also supports possible immune-mediated pathogenesis of hypertransaminasemia in CD patients. Therefore, it would be relevant and worthy of study to analyze the presence of anti-actin antibodies in CD patients to verify whether these antibodies are markers of liver injury.

Finally, it should not be overlooked, the very remarkable issue of the potential development of hepatic steatosis, which, as appropriately mentioned by the Authors, is not uncommon in CD patients with celiac disease after starting a gluten-free diet.10