Celiac disease (CD) is an intestinal inflammatory disease that manifests in genetically susceptible individuals when exposed to dietary gluten. It is a common chronic disorder, with a prevalence of 1% in Europe and North America. Although the disease primarily affects the gut, the clinical spectrum of CD is remarkably varied, and the disease can affect many extraintestinal organs and systems, including the liver. The hepatic dysfunction presenting in CD ranges from asymptomatic liver enzyme elevations or nonspecific reactive hepatitis (cryptogenic liver disorders), to chronic liver disease. In this article, we review the clinical presentations and possible mechanisms of CD-related liver injury to identify strategies for the diagnosis and treatment of these disorders in childhood.

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ABSTRACT. The incidence of pulmonary infections in children with cystic fibrosis caused by Pseudomonas cepacia, an organism which may possess an inducible 8-lactamase, has increased since 1978. Seven of 13 sputum isolates of P. cepacia from children with cystic fibrosis were classified as inducible by quantitative enzyme production following preincubation with 100, 200, or 400 pg/ml of cefoxitin. The recovery of inducible strains tended to be associated with recent ceftazidime therapy. Susceptibility to aztreonam, ceftazidime, and piperacillin alone or combined with the b-lactamase inhibitors. YTR 830 or sulbactam, and isoelectric focusing for /3-lactamase were performed. Inducible isolates produced significantly more /3-lactamase than noninducible strains with or wihtout the addition of cefoxitin. Noninducible isolates were more susceptible than inducible isolates to 8 pg/ml of piperacillin, a difference that was eliminated with the addition of either P-lactamase inhibitor. Twelve of 13 strains produced a Plactamase band in the pH range of 7.9-8.1; no differences in satellite patterns were noted between the two groups of organisms. Increased production of /3-lactamase in the absence of an inducer may account for piperacillin resistance in P. cepacia in children with cystic fibrosis. creased since 1978 and is now recovered from 20% of patients in some centers (3, 4).Sputum isolates of P. cepacia from children with cystic fibrosis are resistant to most P-lactam agents in vitro. In an in vitro study comparing the susceptibilities of 62 consecutive sputum isolates, concentrations of 64 pg/ml of aztreonam and piperacillin were required to inhibit 79 and 87.1 % of the bacterial population, respectively; 90% of the isolates were inhibited by 8 pg/ml of ceftazidime (5). In vitro, ceftazidime has proven more active against P. cepacia than piperacillin, aztreonam, HR-810, or BMY-28 142 (5, 6). Although the mechanism(s) of resistance of P. cepacia to Plactam agents is unclear, at least three, inducible, isoelectrically distinct p-lactamases have been identified (9-1 1). Hirai et al. (10) noted that the enzyme produced by Pseudomonas cepacia GN I 1 164 hydrolyzed cefuroxime, cefotaxime, and cefamandole. The purpose of this study was to ascertain the role played by inducible enzyme production in resistance to piperacillin, aztreonam, and ceftazidime by sputum isolates of P. cepacia from patients with cystic fibrosis. MATERIALS AND METHODSTest strains. Thirteen isolates of P. cepacia recovered from the sputum of 12 children admitted to Rainbow Babies and Children's Hospital with pulmonary exacerbations of cystic fibrosis were studied. With one exception, all of the test strains were recovered between April and December 1984. Seven of the 13 test strains were recovered during or immediately after ceftazidime therapy; two isolates were recovered following ciprofloxacin therapy, one isolate after aztreonam therapy, and three isolates were obtained prior to parenteral antibiotic therapy. Pseudomonas aeruginosa ATCC 27853 was use...