Emily had been seeing her regular physician for years and years for an annual checkup.
And every year he would say, “Emily, you have got to stop drinking.”

“But I have never had a drink in my life, doctor,” she would reply. Emily's liver function
enzymes were always slightly elevated, which can be a side effect of alcohol use. But in Emily's situation, this was not the cause. By the time she was 85, she had only 4 percent of her liver function left and was diagnosed with cirrhosis. Did Emily have alcoholic cirrhosis? No. She had what is now known as celiac hepatitis.

In order to understand celiac hepatitis, it is necessary to understand the broader
category of celiac disease and gluten sensitivity. If you have not heard of these
conditions, don't fret – many physicians haven't, either.

What is celiac disease?

Although it has been described in the medical literature for centuries, the term “celiac disease” was not assigned to the disorder until the late 19th century. Classically, celiac disease is an intolerance to a protein called gluten that is found in wheat, rye and barley. In susceptible people, the body's immune system reacts against this protein and its subcomponents, causing damage to various parts of the body. In celiac disease, most of the damage occurs to the intestinal lining, but substantial evidence now shows that gluten can cause health effects in other parts of the body without significant intestinal involvement. This specific fact accounts for an underappreciation of glutenrelated
health effects with many clinicians who require intestinal findings to support the
diagnosis of celiac disease.

The current estimate of celiac disease in the U.S. and Europe is approximately 1
percent of the population. Celiac disease is defined by evidence of intestinal damage related to an immune reaction to gluten, and physicians often require an intestinal biopsy to make the diagnosis. Once defined, the only effective treatment is to avoid gluten completely in the diet.

Thomas O'Bryan, D.C., is a diplomat of both the National Board of Chiropractic
Examiners and of the Clinical Nutrition Board of the American Chiropractic Association.
He counsels patients on functional health and nutrition in his private practice in the Chicago area. As a certified clinical nutritionist and one of the world's most dedicated speakers on gluten-related health disorders, he has dedicated his current career to educating the public and clinicians on the effects of gluten on health. Accordingly, he feels the biggest challenge currently is to clarify the difference between celiac disease and nonceliac gluten sensitivity (NCGS). The lack of distinction is causing a great deal of confusion and significant numbers of missed diagnoses among patients.

A problem arises because in many circumstances gluten causes immune reactions and other health issues without involving the intestinal lining, and therefore a diagnosis of celiac disease is never made. These patients have NCGS, and by O'Bryan's conservative estimates, NCGS is 10 times more common than celiac disease. Other body systems that can be affected by gluten include the brain, the skin, the thyroid, the musculoskeletal system and, yes, the liver.

Gluten and the liver

The most common clinical effect of gluten on the liver is elevated levels of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST).

When liver tissue is damaged, it releases these enzymes into the bloodstream. Alcohol is the most common cause of liver enzyme elevation, but gluten sensitivity is a major cause as well. According to a recent Harvard study, one-third of the population has nonalcoholic fatty liver disease (see “An Unexpected Connection,” p. 10). Based on O'Bryan's experience and research, he estimates that 4 percent of these patients have gluten sensitivity as a cause of their liver condition.

Gluten damages the liver through two main mechanisms. First, in people with gluten intolerance, gluten causes the intestinal lining to become inflamed and leaky. Because the lining is more permeable, larger molecules of digested food that normally would not do so “sneak” across the intestinal lining into the bloodstream. Once across, the immune system sees the larger molecules as foreign material and launches an attack against them. This immune response not only targets these molecules but also spills over into normal tissues. As normal liver tissue is attacked, liver enzymes are released into the bloodstream. If this inflammation goes on chronically, scarring and even
cirrhosis can occur.

The other mechanism involves an increased toxic load on the liver. Gluten's irritation of the intestinal lining allows food toxins that would normally be eliminated as waste to escape into the body. The liver is one of the major organs responsible for ridding the body of toxins, so overloading the liver with toxins can also result in elevated liver enzymes. In both instances, the primary event is an intolerance of gluten and the resultant inflammation of the intestinal lining.

But if the intestine is involved, why isn't this celiac disease? By medical definition, celiac disease requires two key features of intestinal pathology. One is villous atrophy, and the other is infiltration of lymphocytes into the intestinal walls. The small intestine normally has small, finger-like projections called villi on the surface that assist in absorption of nutrients and fluid. When gluten causes inflammation, over time the villi become damaged and flattened, which is termed villous atrophy. Likewise, as chronic inflammation against gluten occurs, immune cells called lymphocytes lodge themselves within the intestinal wall. If neither of these pathologies exists, then a diagnosis of celiac disease is not made.

“Gluten sensitivity is a spectrum of ongoing pathology,” says O'Bryan. “At the severe
end, you have villous atrophy and lymphocytes in the intestinal walls, but at the other, the degree of intestinal damage is not enough to cause these features. As a result, only the people on the severe end of the spectrum are labeled as celiac disease, and many others go undiagnosed.”

Rick and Vikki Petersen both are chiropractors as well as certified clinical nutritionists.
Based on their 20 years in private practice in Sunnyvale, Calif., they agree with
O'Bryan's opinions about the number of people unaware of their intolerance to gluten.

“From our clinical experience, of patients that have lab elevations in liver function
enzymes, approximately 20 percent have gluten sensitivity,” says Rick Petersen.
Because of this frequency, they routinely screen most of their patients for gluten
sensitivity.

The Petersens say they are amazed at the number of patients with gluten sensitivity they have diagnosed since making functional health a focus of their practice. The symptoms are incredibly vast – headaches, memory loss, osteoporosis, thyroid dysfunction, sleep difficulty and abdominal discomfort are just a few of the common complaints.

Later this year, the Petersens are releasing a comprehensive book on the health effects of gluten sensitivity. The book describes the varied effects of gluten on our bodies and gluten's history in our diets. An entire chapter is dedicated to celiac hepatitis.

Making the diagnosis

One of the world's renowned researchers on celiac hepatitis is Joseph Murray, M.D., of Mayo Clinic Rochester. His research published in the medical journal Hepatology in 2007 acknowledges that elevated liver enzymes are the most common liver manifestation of gluten intolerance. In addition, other liver disorders including primary biliary cirrhosis, autoimmune hepatitis and primary sclerosing cholangitis are frequently associated with gluten sensitivity. The recommendation from his review was that celiac disease and gluten sensitivity should be evaluated in anyone with these liver conditions.

Given the limitations of intestinal biopsies in diagnosing gluten intolerance, the question arises as to how a diagnosis can actually be made. Fortunately, blood tests now enable accurate diagnosis in many people. Antibodies against gluten and gluten-related enzymes in the body are quite sensitive and specific at detecting gluten intolerance.
Many researchers no longer feel that an intestinal biopsy is needed for making the diagnosis of celiac disease or NCGS if antibody tests are positive.

Blame your parents

Gluten intolerance is primarily a genetic disorder. In people with celiac disease and NCGS, the HLA genes, which encode the development of immune system proteins, are aberrant. Specifically, people who have HLA DQ2 and HLA DQ8 genes are most susceptible to gluten intolerance. However, while screening for these genes through blood work is possible, antibody tests are more effective in making the diagnosis.

Because of the underlying genetic cause, those known to be at risk include anyone with a first degree relative with celiac disease or gluten sensitivity. Anyone with any autoimmune disorder should be screened for gluten-related disorders as well. These
screenings should occur even if symptoms are absent. Identifying gluten-related
antibodies and invoking treatment can prevent progressive health disorders later in life.

Delaying a diagnosis of gluten intolerance can have significant effects on long-term health. For example, in Emily's case, the failure to recognize gluten sensitivity as the cause of liver enzyme elevation eventually led to cirrhosis from chronic inflammation.
She was eventually diagnosed and is now on a gluten-free diet, but much of the liver damage is now irreversible. Just as detecting viral hepatitis can help prevent cirrhosis by allowing earlier treatment, the same applies for early detection of gluten intolerance.

The good news

In O'Bryan's clinical experience, all of his patients with elevated liver enzyme tests who were gluten sensitive reverted to normal within a few months of proper diet. However,
the medical literature indicates that this recovery will not occur in 100 percent of
patients. Early detection and elimination of gluten from the diet allows the liver to fully recover from the inflammatory damage, but the chance of permanent injury increases the longer gluten-induced immune reactions exist.

As greater awareness of gluten's effects on health becomes evident, these missed opportunities for early diagnosis will diminish. For now, you can do your part by discussing the potential presence of gluten intolerance with your own physician –
especially if you have a liver-related condition. Addressing a concurrent condition of celiac hepatitis with proper treatment will help your overall health and allow your liver to recover.

Gluten freedom

If it turns out you are gluten intolerant, avoiding gluten is not the end of the world. In all honesty, gluten-free diets can be incredibly healthy – with fruits, vegetables and many legumes being completely void of gluten. Also, there are many alternatives to wheat, barley and rye in bread-type products made from rice, corn, soy and others. An explosion of gluten-free foods has now surfaced in the market, and these continue to grow every day.

As we as a country move toward evidenced-based health care and preventive health, we are looking more closely at diet and lifestyle. Gluten is one of the most common dietary factors that contribute to poor health, and learning to detect gluten sensitivity and to change dietary habits will pave the way for other preventive health care measures.

Celiac hepatitis is an example where both prevention and early detection are important.
If this had been available for Emily, her cirrhosis would have never developed. There is indeed still much to learn about how our diet affects our health. We are what we eat

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