<<Disclaimer: Verify this information before applying it to your situation.>>
 
This week, there were two posts about the New England Journal of Medicine
article on blood in the stools of celiacs, and elevated liver enzymes.  The
following is being forwarded with Dr. Horvath's permission:
 
From: khorvath @ umabnet.ab.umd.edu (Karoly Horvath) @ MHS
Date: 05/02/96 08:20:20 AM
 
FECAL OCCULT BLOOD
 The cited NEJM paper found occult intestinal bleeding in patients
who had some degree (partial and total) of intestinal villus atrophy.
However, this paper have certain methodological problems. The first, and
most important -as you can read in the editorial comment- that they did
not place the patient on specicific diet before collecting the stool. It
is a rule that the patients should be on a diet which eliminate all the
peroxidase containing food. So this may increase the number of false
positive cases.
 The second problem that the hemoccult test is only a screening method,
which does not give information about the degree of blood loss. The test
can be positive in the presence of small amount of blood in the stool.
 While this paper has limitations, I should accept that patients
with mucosal atrophy and inflammation have small amount of blood loss. So
I do not have any doubt regarding the final conclusion of paper, that
patients with active CD have blood loss in the stool. This is not
surprising and not a novel finding.
 To avoid any panic in the celiac community I do not recommend to
post this finding without appropriate comment to the Celiac List.
We should emphasize one sentence from this paper:
 "ALL THE PATIENTS WITH PREVIOUSLY DIAGNOSED AND TREATED CELIAC
SPRUE HAD NEGATIVE TESTS FOR FECAL OCCULT BLOOD."
 
LIVER ENZYMES
 It is well known that patient with intestinal inflammation may
have elevated liver enzymes. The well known examples are patients with
inflammatory bowel disease. Because patients with active CD have
significant accumulation of inflammatory cells in the mucosa it is not
suprising that a percentage of patients with active CD have elevated
liver enzymes. However, this is a temporary elevation, which disappears
on gluten-free diet.
 The explanation is not clear for this finding. The simplified
explanation is that there is an increased permeability in the inflammed
intestinal segments and different toxins, which normally are detoxified
by the enterocyte Cytochrom P450 enzyme system,  enter the portal
circulation and there is an increased toxin load into the liver.
 
Karoly Horvath, M.D., Ph.D.
Baltimore