Letter to the Editor Open Access
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 14, 2023; 29(2): 410-412
Published online Jan 14, 2023. doi: 10.3748/wjg.v29.i2.410
Celiac disease screening in patients with cryptogenic cirrhosis
Janaina Luz Narciso-Schiavon, Leonardo Lucca Schiavon
Janaina Luz Narciso-Schiavon, Leonardo Lucca Schiavon, Gastroenterology Division, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis 88040-900, SC, Brazil
ORCID number: Janaina Luz Narciso-Schiavon (0000-0002-6228-4120); Leonardo Lucca Schiavon (0000-0003-4340-6820).
Author contributions: Narciso-Schiavon JL and Schiavon LL designed the research; Narciso-Schiavon JL wrote the paper; and Schiavon LL reviewed the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Janaina Luz Narciso-Schiavon, MD, PhD, Associate Professor, Gastroenterology Division, Internal Medicine Department, Federal University of Santa Catarina, R Maria Flora Pasewang S/N, Florianopolis 88040-900, SC, Brazil. janaina.narciso@uol.com.br
Received: October 27, 2022
Peer-review started: October 27, 2022
First decision: November 26, 2022
Revised: November 26, 2022
Accepted: December 21, 2022
Article in press: December 21, 2022
Published online: January 14, 2023


We write a letter to the editor commenting the article “Who to screen and how to screen for celiac disease”. We discuss the present literature on cirrhosis and celiac disease (CD) and recommend screening and treating CD in individuals with cryptogenic cirrhosis.

Key Words: Celiac disease, Liver cirrhosis, Liver failure, Aspartate aminotransferase, Alanine aminotransferase

Core Tip: We discuss reasons for recommendation of celiac disease screening in patients with cryptogenic cirrhosis.


We read with interest the article by Singh et al[1]. Liver cirrhosis is a disease with potential morbidity, which can progress to decompensation, hepatocellular carcinoma and death. A high proportion (9.15%) of patients with cryptogenic hypertransaminasemia is affected by asymptomatic celiac disease (CD)[2]. It has been proposed that the hepatic manifestation of CD is a nonspecific chronic hepatitis[3], called by some authors celiac hepatitis[4]. A higher prevalence of CD has been demonstrated in individuals with autoimmune hepatitis[5], and anti-actin antibodies may be present in both diseases, as they are reliable for the diagnosis of type-1 autoimmune hepatitis[6] and can also be associated with severe intestinal mucosa damage in CD patients[7]. This could support an immunological link between CD and liver injury. Despite these findings, it is not known for sure whether liver disease associated with celiac has the potential to progress to liver cirrhosis, although CD is twice as common in individuals with cirrhosis of the liver as in the general population[8,9]. In this sense, studies suggest that CD can be a cause of cryptogenic cirrhosis[10,11]. Most importantly, it has been reported that a gluten-free diet (GFD) treatment can reverse the decompensation of cirrhosis and remove the patient from liver transplantation waiting list[12-14]. Joshi et al[9] evaluated 84 patients with chronic liver disease, and 13% were diagnosed with CD. An improvement in liver function tests and Child-Pugh score was observed after GFD treatment. Demir et al[10] reported five cases of children with cryptogenic cirrhosis and CD. Treatment with GFD leaded to clinical and biochemical improvement, followed by a decrease in liver and spleen size. The most important sample was reported by Wakim-Fleming et al[8]. They have evaluated 204 patients with biopsy proven cirrhosis of different causes, and 2.5% were diagnosed with CD. After a GFD, patients with CD showed a return to normal levels of their celiac antibodies, small bowel biopsy and liver enzymes, and none received a liver transplant[8]. The European Society for the Study of Celiac Disease states that patients with unexplained elevation of liver enzymes should be assessed for CD and recognizes that CD can be associated with severe liver disease and even liver failure[15].

For the aforementioned reasons, and because liver cirrhosis has a high potential for morbidity and mortality, we recommend screening and treating CD in individuals with cryptogenic cirrhosis[16]. And one should consider screening for celiac antibodies in patients with decompensated cirrhosis on the liver transplantation waiting list, whatever are the mechanisms involved in the deterioration of liver function.


Provenance and peer review: Unsolicited article; Externally peer reviewed.

Peer-review model: Single blind

Corresponding Author's Membership in Professional Societies: Sociedade Brasileira de Hepatologia; Associação Latinoamericana para Estudo do Fígado; and Associação Catarinense para Estudo do Fígado.

Specialty type: Gastroenterology and hepatology

Country/Territory of origin: Brazil

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): B

Grade C (Good): C

Grade D (Fair): 0

Grade E (Poor): 0

P-Reviewer: Beenet L, United States; Taavela J, Finland S-Editor: Gong ZM L-Editor: A P-Editor: Gong ZM

1.  Singh P, Singh AD, Ahuja V, Makharia GK. Who to screen and how to screen for celiac disease. World J Gastroenterol. 2022;28:4493-4507.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 2]  [Cited by in F6Publishing: 2]  [Article Influence: 2.0]  [Reference Citation Analysis (3)]
2.  Volta U, Granito A, De Franceschi L, Petrolini N, Bianchi FB. Anti tissue transglutaminase antibodies as predictors of silent coeliac disease in patients with hypertransaminasaemia of unknown origin. Dig Liver Dis. 2001;33:420-425.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 40]  [Cited by in F6Publishing: 43]  [Article Influence: 1.8]  [Reference Citation Analysis (0)]
3.  Nehra V, Angulo P, Buchman AL, Lindor KD. Nutritional and metabolic considerations in the etiology of nonalcoholic steatohepatitis. Dig Dis Sci. 2001;46:2347-2352.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 114]  [Cited by in F6Publishing: 120]  [Article Influence: 5.2]  [Reference Citation Analysis (0)]
4.  Rubio-Tapia A, Murray JA. The Liver and Celiac Disease. Clin Liver Dis. 2019;23:167-176.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 17]  [Cited by in F6Publishing: 18]  [Article Influence: 4.3]  [Reference Citation Analysis (0)]
5.  Haggård L, Glimberg I, Lebwohl B, Sharma R, Verna EC, Green PHR, Ludvigsson JF. High prevalence of celiac disease in autoimmune hepatitis: Systematic review and meta-analysis. Liver Int. 2021;41:2693-2702.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 8]  [Article Influence: 4.0]  [Reference Citation Analysis (0)]
6.  Granito A, Muratori L, Muratori P, Pappas G, Guidi M, Cassani F, Volta U, Ferri A, Lenzi M, Bianchi FB. Antibodies to filamentous actin (F-actin) in type 1 autoimmune hepatitis. J Clin Pathol. 2006;59:280-284.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 69]  [Cited by in F6Publishing: 70]  [Article Influence: 4.1]  [Reference Citation Analysis (0)]
7.  Carroccio A, Brusca I, Iacono G, Alessio MG, Sonzogni A, Di Prima L, Barrale M, Ottomano C, Ambrosiano G, Teresi S, D'Angelo A, Pirrone G, Cefalù B, Scalici C, La Chiusa SM. IgA anti-actin antibodies ELISA in coeliac disease: a multicentre study. Dig Liver Dis. 2007;39:818-823.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 19]  [Cited by in F6Publishing: 21]  [Article Influence: 1.2]  [Reference Citation Analysis (0)]
8.  Wakim-Fleming J, Pagadala MR, McCullough AJ, Lopez R, Bennett AE, Barnes DS, Carey WD. Prevalence of celiac disease in cirrhosis and outcome of cirrhosis on a gluten free diet: a prospective study. J Hepatol. 2014;61:558-563.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 20]  [Cited by in F6Publishing: 20]  [Article Influence: 2.2]  [Reference Citation Analysis (0)]
9.  Joshi A, Falodia S, Kumar N, Gupta P, Khatri PC. Prevalence of celiac disease among pediatric patients with cryptogenic cirrhosis and effect of gluten-free-diet. Indian J Gastroenterol. 2018;37:243-247.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9]  [Cited by in F6Publishing: 9]  [Article Influence: 1.8]  [Reference Citation Analysis (0)]
10.  Demir H, Yüce A, Caglar M, Kale G, Kocak N, Ozen H, Gürakan F, Saltik-Temizel IN. Cirrhosis in children with celiac disease. J Clin Gastroenterol. 2005;39:630-633.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 16]  [Cited by in F6Publishing: 12]  [Article Influence: 0.9]  [Reference Citation Analysis (0)]
11.  Duman AE, Oğütmen Koç D, Korkmaz U, Tohumcu A, Celebi A, Sentürk O, Hülagü S, Erçin C. Cirrhosis and intestinal B-cell lymphoma: two entities that are rarely associated with celiac disease. Turk J Gastroenterol. 2013;24:192-194.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 2]  [Article Influence: 0.2]  [Reference Citation Analysis (0)]
12.  Roumeliotis N, Hosking M, Guttman O. Celiac disease and cardiomyopathy in an adolescent with occult cirrhosis. Paediatr Child Health. 2012;17:437-439.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 5]  [Cited by in F6Publishing: 5]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]
13.  Ratziu V, Nourani M, Poynard T. Discussion on celiac disease in patients with severe liver disease: gluten-free diet may reverse hepatic failure. Gastroenterology. 2002;123:2158-9; author reply 2159.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 6]  [Cited by in F6Publishing: 6]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
14.  Al-Hussaini A, Basheer A, Czaja AJ. Liver failure unmasks celiac disease in a child. Ann Hepatol. 2013;12:501-505.  [PubMed]  [DOI]  [Cited in This Article: ]
15.  Al-Toma A, Volta U, Auricchio R, Castillejo G, Sanders DS, Cellier C, Mulder CJ, Lundin KEA. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J. 2019;7:583-613.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 293]  [Cited by in F6Publishing: 308]  [Article Influence: 73.3]  [Reference Citation Analysis (1)]
16.  Narciso-Schiavon JL, Schiavon LL. To screen or not to screen? World J Gastroenterol. 2017;23:776-791.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 14]  [Cited by in F6Publishing: 14]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]