title: Liver failure unmasks celiac disease in a child.
abstract: BACKGROUND
  Liver involvement in celiac disease (CD) varies from asymptomatic mild non-specific hepatitis to liver failure. Here we report the first child with liver failure due to a sclerosing cholangitis associated with CD.
  
  
  METHODS
  An 11 year old girl presented with fatigability for 1 year and jaundice and abdominal distension for 3 weeks. On examination, the growth parameters were below 3rd percentile; she had splenomegaly and severe ascites. Liver function tests revealed elevated liver enzymes (ALT 84 U/L, total bilirubin 98.7 μmol/L, and direct 58.3 μmol/L, gamma-glutamyltransferase 111 U/L, INR 2.7, and albumin 16 g/L). Extensive investigations excluded infectious, metabolic, structural, and endocrine causes of chronic liver disease. Because of the short stature and anemia, CD was suspected, and serological evaluation revealed increased IgA antibodies to tissue transglutaminase (385 units; normal, 0-20 units). Histopathological examination of small intestinal biopsies showed total villous atrophy consistent with celiac disease. Liver biopsy showed bridging fibrosis, portal tract expansion by lymphocytes, plasma cells, and neutrophils, bile ductular proliferation, and periductular fibrosis. Magnetic resonance cholangiography revealed beading and narrowing appearance of intra- and extrahepatic bile ducts. The histopathological and imaging findings are diagnostic of sclerosing cholangitis. The child was initiated on ursodeoxycholic acid, gluten free diet for life, and steroid that was tapered over 3 months. At 3 month follow up, liver function tests completely normalized.
  
  
  CONCLUSIONS
  CD is a potentially treatable cause of liver failure. All patients with severe unexplained liver disease should undergo serological screening for CD.
authors.affiliation: Division of Pediatric Gastroenterology, Children's Hospital, King Fahad Medical City, Riyadh, Saudi Arabia. aa_alhussaini@yahoo.com
authors.forename: Abdulrahman
authors.initials: A
authors.lastname: Al-Hussaini
authors.forename: Amna
authors.initials: A
authors.lastname: Basheer
authors.forename: Albert J
authors.initials: AJ
authors.lastname: Czaja
mesh_terms: D001706:Biopsy; D002446:Celiac Disease / Q000150:complications* / Q000175:diagnosis / Q000178:diet therapy; D002648:Child; D002756:Cholagogues and Choleretics / Q000627:therapeutic use; D049448:Cholangiopancreatography, Magnetic Resonance; D015209:Cholangitis, Sclerosing / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D055050:Diet, Gluten-Free; D018450:Disease Progression; D005260:Female; D006801:Humans; D017093:Liver Failure / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D008111:Liver Function Tests; D011237:Predictive Value of Tests; D013256:Steroids / Q000627:therapeutic use; D016896:Treatment Outcome; D014580:Ursodeoxycholic Acid / Q000627:therapeutic use
chemical_list: D002756:Cholagogues and Choleretics; D013256:Steroids; D014580:Ursodeoxycholic Acid