<<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