celiac disease ( cd ) is an immune - mediated disease , leading to small bowel atrophy that resolves upon the introduction of a gluten free diet ( gfd ) . cd can affect extraintestinal organs , such as the skin , pancreas , heart , and liver . previous studies have suggested that up to 9% of patients with hypertransaaminasaemia and negative investigations to identify chronic liver disease , have cd . studies have reported that patients with cd have an increased incidence of auto - immune and cryptogenic liver disease compared to the general population . the cryptogenetic liver disorder associated with cd kaukinen , et al . showed that gfd may inhibit progression to hepatic failure , even in cases being considered for liver transplantation . there is a little information on the association between liver disorders and cd in iran . the only published study by emami et al . on iranian patients in isfahan showed that serological screening for cd should be routinely performed in patients with abnormal liver function test ( lft ) . moreover , they found effects of gfd in the improvement of abnormal lft . designing similar study in order to evaluate the prevalence of liver dysfunction in patients with newly diagnosed cd patients and the effects of a gfd therefore , the aim of this study was to evaluate the prevalence of liver dysfunction in patients with newly diagnosed cd patients and also the effects of a gfd were studied . newly diagnosed patients with cd , referred to taleghani hospital , tehran , iran , between september 2007 and september 2011 were recruited . the diagnosis of cd was based on duodenal biopsies with histological abnormalities characteristic of cd ( the presence of any of the following : intraepithelial lymphocytes , crypts hyperplasia and villous atrophy ) and serology consistent with a diagnosis of cd ( positive immunoglobulin a ( iga ) class human anti - tissue transglutaminase antibody , endomysial antibody and total serum iga [ if iga deficient and igg class human anti - tissue transglutaminase antibody ( ttgg ) was positive ] ) . lfts , serum bilirubin , aspartate aminotransferase ( ast ) , alanine aminotransferase ( alt ) and alkaline phosphatase ( alp ) , were measured in all the patients . the serum levels of bilirubin ( normal range : 0.2 - 1.3 ) , ast ( normal range : 15 - 35 iu / l ) and alp ( normal range : 64 - 306 for adults and 180 - 1200 for children ) were measured by routine laboratory methods . patients with hypertransaminasemia had a cirrhosis screen performed to investigate possible causes of liver dysfunction . hypertransaminasemia was defined by an increase in ast and ( or ) alt > 2n . the cirrhosis screen consisted of measuring serological markers for viral hepatitis , metabolic liver diseases and serum protein electrophoresis . serologic markers for viral hepatitis , including hepatitis b surface antigen ( hbsag ) and hepatitis c virus antibody were determined with commercially available ( elisa)enzyme - linked immunosorbent assay kits ( dia pro ) diagnostic bioprobes ( it is mentioned in the parenthesis , diagnostic bioprobes , srl . , italy ) . serum levels of ferritin , tsh ( sigma / aldrich , usa ) , caeruloplasmin , copper , ana ( anti - nuclear antibody ) , anti - smooth muscle antibody , anti - mitochondrial antibody and alpha - fetoprotein ( dia pro diagnostic bioprobes , srl . , history of taking medications , using alcohol , exposure to hepatic toxins and co - morbidities , such as diabetes mellitus , were considered . iu / l , increased serum bilirubin greater than 2 mg / dl and/or elevated serum alp above 306 iu / l for adults and 1200 for children were considered as evidence of liver dysfunction . in patients with abnormal alp values , serum levels of calcium and phosphate were determined . patients with undiagnosed causes of abnormal lft were reviewed after 6 months and serum levels of ast , alt , billirubin and alp were re - checked . the patients were assured that their private information would be kept confidential and a written informed consent was obtained from them . the study was approved by the ethics committee of the gastroenterology and liver diseases research center , shahid beheshti university of medical sciences . newly diagnosed patients with cd , referred to taleghani hospital , tehran , iran , between september 2007 and september 2011 were recruited . the diagnosis of cd was based on duodenal biopsies with histological abnormalities characteristic of cd ( the presence of any of the following : intraepithelial lymphocytes , crypts hyperplasia and villous atrophy ) and serology consistent with a diagnosis of cd ( positive immunoglobulin a ( iga ) class human anti - tissue transglutaminase antibody , endomysial antibody and total serum iga [ if iga deficient and igg class human anti - tissue transglutaminase antibody ( ttgg ) was positive ] ) . lfts , serum bilirubin , aspartate aminotransferase ( ast ) , alanine aminotransferase ( alt ) and alkaline phosphatase ( alp ) , were measured in all the patients . the serum levels of bilirubin ( normal range : 0.2 - 1.3 ) , ast ( normal range : 15 - 35 iu / l ) and alp ( normal range : 64 - 306 for adults and 180 - 1200 for children ) were measured by routine laboratory methods . patients with hypertransaminasemia had a cirrhosis screen performed to investigate possible causes of liver dysfunction . hypertransaminasemia was defined by an increase in ast and ( or ) alt > 2n . the cirrhosis screen consisted of measuring serological markers for viral hepatitis , metabolic liver diseases and serum protein electrophoresis . serologic markers for viral hepatitis , including hepatitis b surface antigen ( hbsag ) and hepatitis c virus antibody were determined with commercially available ( elisa)enzyme - linked immunosorbent assay kits ( dia pro ) diagnostic bioprobes ( it is mentioned in the parenthesis , diagnostic bioprobes , srl . , italy ) . serum levels of ferritin , tsh ( sigma / aldrich , usa ) , caeruloplasmin , copper , ana ( anti - nuclear antibody ) , anti - smooth muscle antibody , anti - mitochondrial antibody and alpha - fetoprotein ( dia pro diagnostic bioprobes , srl . , history of taking medications , using alcohol , exposure to hepatic toxins and co - morbidities , such as diabetes mellitus , were considered . levels of ast and alt higher than 35 iu / l , increased serum bilirubin greater than 2 mg / dl and/or elevated serum alp above 306 iu / l for adults and 1200 for children were considered as evidence of liver dysfunction . in patients with abnormal alp values , serum levels of calcium and phosphate were determined . patients with undiagnosed causes of abnormal lft were reviewed after 6 months and serum levels of ast , alt , billirubin and alp were re - checked . the patients were assured that their private information would be kept confidential and a written informed consent was obtained from them . the study was approved by the ethics committee of the gastroenterology and liver diseases research center , shahid beheshti university of medical sciences . ninety eight patients with confirmed cd ( 40 males and 58 females ) with mean age of 32  17.1 were studied . one patient with hbsag was excluded in this survey and referred to gastroenterologist for further evaluation . therefore , 8 patients ( 5 females and 3 males ) with mean age of 26.4  4.8 years ( range : 19 - 33 years ) were studied and maintained gfd . marsh ii was reported in 2 patients , marsh iiia in three , marsh iiib in two and marsh iiic in one . there was no medical history of significant co - morbidities , excess alcohol consumption or exposure to known hepatotoxic agents . none of the biopsies showed evidence of steatohepatitis . at the beginning of the study , all 8 ( 8.1% ) cd patients with undiagnosed liver dysfunction had normal billirubin levels with mean value of 0.95  0.2 mg / dl ( range : 0.7 - 1.3 mg / dl ) . eight patients had abnormal alt level and 5 of these 8 patients had abnormal ast . mean ( sd ) ast and alt levels were 42.6  16.5 iu / l ( range : 16 - 66 iu / l ) and 69.3  9.3 iu / l ( range : 52 - 81 mean ( sd ) concentration of alp was 240.3  118.7 iu / l ( range : 108 - 428 two of 8 patients with elevated levels of alp had low levels of calcium , representing metabolic disorder . six months after using gfd , mean ast and alt levels decreased to 24.5  5.1 iu / l ( range : 18 - 31 ) ( p : 0.04 ) and 24.6  6 billirubin levels decreased to 0.9  0.2 mg / dl ( range : 0.7 - 1.1 mg / dl ) , although , not statistically significant differences were found ( p : 0.33 ) . concentration of alp reduced to 180.3  50.6 iu / l ( range : 108 - 260 iu / l ) 6 months after using gfd and the differences with alp values before gfd was not statistically significant ( p : 0.09 ) . except for 1 case with persistent abnormal lft 's , the rest of 7 cases lft 's have normalized after 6 month of gfd . the prevalence of reactive hepatitis in this cohort was 8% with almost complete resolution following gfd . table 1 represents the serum levels of billirubin , ast , alt and alp before and after following gfd . liver function test results among celiac patients with hypertransaminasemia of no other cause , before and 6 months after gluten free diet we are aware of a link between cd and autoimmune disorder like autoimmune hepatitis , sclerosing cholangitis and primary biliary cirrhosis . however , most cd patients with elevated serum transaminases have no evidence of autoimmune disorder . it has been suggested that the hypertransaminasemia in cd patients may be multifactorial and a complication of prolonged existence of malabsorption , small intestinal bacterial overgrowth , iron overload disorder , hepatic steatosis , chronic intestinal inflammation and enhanced absorption of toxic substances . in this study , 8% of adult cd patients had cryptogenic liver disorder and we did not find any evidence of autoimmune liver diseases . in a comparable study , dicky , et al . in previous studies , the frequency of elevated transaminases in patients with cd was 36 - 55% . possible explanations for this high prevalence of a hypertransaminasemia in other studies may include the very different populations studied . european patients may be more likely to consume excess alcohol and have a greater prevalence of non - alcoholic staetohepatitis than iranian population . di biase , et al . evaluated a large population of children with cd in a prospective study . they found that hypertransaminasemia is presents in 40% of cd patients and autoimmune liver hepatitis is present in 2% of cases , while no other autoimmune liver diseases were found . assessed the association between an autoimmune liver disease and cd in a retrospective multicenter national survey between 1990 and 2005 in italy . assessment of hypertransaminasemia in some studies has led to a diagnosis of cd in 10% of patients , using serological methods . in bardella study , 13 out of 140 patients with elevated transaminases were seropositive for gliadin and endomysial antibodies . in a similar study , volta et al . reported that in 55 patients with unexplained hypertransaminasemia , 5 had cd . in a similar study , abdo et al . reported that cd serology was positive in 9% of patients with unexplained hypertransaminasemia . we believe these studies suggest that clinicians should consider cd in the evaluation of patients with hypertransaminasemia . in our study , 2 of the patients with newly diagnosed cd patients had elevated alp values , a result comparable to the bardella et al . , study . our study suggests that the hypertransaminasemia associated with cd resolves with the introduction of a gfd . this is in keeping with other studies that have reported an improvement in effects in the hypertransaminasemia associated with cd provided there was no evidence of underlying autoimmune , metabolic or viral liver disease . this study showed that cd may be associated with hypertransaminasemia in the absence of other possible causes of liver dysfunction and clinicians need to consider the diagnosis of cd , when patients present with hypertransaminasemia . furthermore , introduction of a gfd can improve the hypertransaminasemia and normalize the liver enzyme abnormality .
background : celiac disease ( cd ) is an immune mediated condition that leads to small bowel atrophy and improve with a gluten free diet ( gfd ) . 
 extra - intestinal manifestations of cd include hypertransaminasemia . in this study , 
 the effects of a gfd on hypertransaminasemia in patients with newly diagnosed cd were studied.methods:ninety eight new diagnosed consecutive patients with cd 40 males and 58 females ) with mean age of 32  17.1 were studied . 
 all patients with cd were treated with a gfd . 
 patients with hypertransaminasemia , at diagnosis , had a cirrhosis screen performed . 
 patients with a negative cirrhosis screen were reviewed , 6 months after the introduction of a gfd , and serum levels of liver transaminases were measured again.results:nine patients had hypertransaminasemia . 
 one patient was hepatitis b surface antigen positive and was excluded from this study . 
 the 8 remaining patients had no obvious cause for the hypertransaminasemia . 
 mean (  sd ) of baseline aspartate aminotransferase ( ast ) and alanine aminotransferase ( alt ) levels were 42.6  16.5 iu / l ( range : 16 - 66 
 iu / l ) and 69.3  9.3 iu / l ( range : 52 - 81 
 iu / l ) . 
 six months after treatment with a gfd , mean ast and alt levels decreased to 24.5  5.1 iu / l ( range : 18 - 31 
 iu / l ) ( p : 0.04 ) and 24.6  6 
 iu / l ( range : 17 - 32 
 iu / l ) ( p : 0.01 ) , respectively . in 7 patients 
 the hypertransaminasemia , at diagnosis had resolved.conclusions:this study provides further evidence that some patients with cd have a reversible hypertransaminasemia that resolves with a gfd .