2 Recently, it has been hypothesized that anti-endomysial antibodies may also play a direct role. 9 Most patients with this form of hepatitis have no symptoms or signs of liver disease. 9, 10 and 11 Mild to moderate serum levels of AST and/or ALT (with an AST/ALT ratio less than one) are the most common and often only laboratory manifestations, whereas the bilirubin, alkaline fosfatase and γ-glutamyl transferase

are normal. 2 and 11 Usually, autoantibodies other than the CD ones are not present. 6 Liver biopsy is of limited value in this context due to the nonspecific nature of the histological findings and the high rate of response after gluten exclusion. 2 The histological analysis most commonly shows no abnormalities or non-specific hepatitis, but occasionally fibrosis and cirrhosis can occur. 11 and 12 Studies have reported non-specific findings like focal ductular Navitoclax manufacturer proliferation, bile duct obstruction, Kuppfer cell hyperplasia, minimal macrovesicular steatosis and minor inflammatory infiltration. 6 and 13 Nevertheless, liver biopsy may be useful in the case of coexisting specific hepatic disorder or when there is a lack of response to diet. 2 The decision to perform it must

therefore be individualized. A gluten-free diet leads to aminotransferases normalization in 75–95% of cases within a year. 10, 11 and 14 In those patients with persistent elevations despite good compliance to gluten exclusion, an alternative etiology should be investigated. Rarely, CD-associated liver disease can manifest as chronic hepatitis, cirrhosis AP24534 solubility dmso and acute liver failure. 2, 12 and 14 Screening for CD must be considered in all patients presenting with abnormal liver tests and cryptogenic cirrhosis. 5, 11 and 12 There is a well established relation between CD and autoimmune mediated chronic liver diseases, probably sharing immunological mechanisms Nintedanib (BIBF 1120) and susceptibility. AIH, PBC and PSC, with its typical histological features, have all

been reported.1, 3, 4, 12, 13 and 15 Two studies found that AIH patients have a higher prevalence of CD, from 4% to 6.4%.15 and 16 Few of these patients have the classical intestinal manifestations, instead they tend to have nonspecific symptoms such as fatigue and malaise.4, 8 and 10 The clinical impact of gluten withdrawal on the outcome of the liver disorder remains unclear, but it is hypothesized that it may play a role in preventing the evolution to end-stage liver disease.2 and 12 Nevertheless dietary treatment is necessary to improve symptoms of CD (if present) and to avoid severe chronic complications.1 Testing for AIH is recommended in CD patients with abnormal liver tests. Conversely, screening for CD should be considered for patients with AIH, irrespectively of the existence of gastrointestinal complaints.1 and 2 The prevalence of PBC is increased from 3 to 20-fold in patients with CD, as demonstrated by two large cohort studies.