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Practice Rational Testing

Investigating mildly abnormal serum aminotransferase values

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4039 (Published 30 July 2010) Cite this as: BMJ 2010;341:c4039

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Abnormal liver function tests- don’t forget coeliac disease

Editor—Cobbald et al provided an excellent review of the
investigation of the patient with mildly abnormal serum aminotransferase
values.1 However, one medical condition that was not mentioned was coeliac
disease.

Population screening in the United Kingdom has suggested that coeliac
disease has a prevalence of 1%, and the majority of these patients are
unrecognised.2 The association of coeliac disease with either an isolated
hypertransaminasaemia or coexistent autoimmune liver disease is well
described.3 Persistently abnormal liver function tests may be the only
presenting feature of coeliac disease. Several studies have reported that
up to 9% of patients presenting with cryptogenic hypertransaminasaemia
have underlying undetected coeliac disease.3 Furthermore the liver
function tests normalise on a gluten-free diet.

The difficulty of early clinical detection, associated complications, and
availability of effective treatment with a gluten free-diet has led to a
debate about mass population screening for coeliac disease.4 The recent
NICE guidelines support an active case-finding approach and recommends
that patients with persistently raised liver enzymes of unknown cause, and
those with autoimmune liver disease should be considered for serological
testing.5

The relationship between coeliac disease and liver disease continues to be
a neglected association in clinical practice. Testing is sensitive,
specific, cheap and readily available. We would suggest that anti –tissue
transglutaminase (tTG) and anti-endomysial antibody (EMA) be included in
the screening tests for liver disease. These antibodies are not considered
part of the existing antibody profile and as such will not be tested for
without a specific request. We would urge clinicians to consider these
additional tests as part of their rational testing strategy for
investigating mildly abnormal serum aminotransferase values.

1. Cobbold JF, Anstee QM, Thomas HC. Investigating mildly abnormal
serum aminotransferase values. BMJ. 2010;341:c4039.

2. Evans KE, Leeds JS, Sanders DS. Be vigilant for patients with
coeliac disease. Practitioner. 2009;253:19-22.

3. Volta U. Pathogenesis and clinical significance of liver injury in
celiac disease. Clin Rev Allergy Immunol. 2009;36:62-70.

4. Evans KE, McAllister R, Sanders DS. Should we screen for coeliac
disease? No. BMJ. 2009;339:b3674.

5. Richey R, Howdle P, Shaw E, Stokes T; Guideline Development Group.
Recognition and assessment of coeliac disease in children and adults:
summary of NICE guidance. BMJ. 2009;338:b1684.

Competing interests:
None declared

Competing interests: No competing interests

12 August 2010
Kate E Evans
clinical research fellow
David S Sanders
Royal Hallamshire Hospital, Sheffield Hospitals NHS Foundation Trust. S10 2JF