Purpose: Celiac disease is a common disorder and its association with other immunologically mediated diseases has been well described. Patients with celiac disease often have an increase in liver enzymes. We report a case of acute autoimmune hepatitis in a patient with celiac disease. Case Report: 67 y/o woman with a PMH of HTN, OA, hyperlipidemia, and hypothyroidism presented to her PCP complaining of nausea, diarrhea, RUQ pain. Initial evaluation revealed elevated liver enzymes (ALT 269 IU/L and AST 156 IU/L), gallbladder sludge on RUQ ultrasound, and chronic cholecystitis on a HIDA scan. Patient underwent laparoscopic cholecystectomy and had normal intraoperative cholangiograms. Subsequently the abdominal pain resolved but the nausea and diarrhea persisted. Over the next 2 months, she had unintentional 30 lbs. weight loss and was referred to the GI clinic. At her initial visit she complained of fatigue, weight loss, a new diffuse abdominal pain, diarrhea, belching, flatulence, and heart burn. Physical exam was unremarkable. Significant findings included: ALP 311 IU/L, ALT 272 IU/L, AST 257 IU/L, INR 1.2, ANA 1:160, ASMA 30 units, and unremarkable MRCP and CT scan of the abdomen and pelvis. Complete serologic and metabolic evaluation was otherwise negative. Duodenal biopsies were consistent with celiac disease. Serum IgA level and Endomysial antibody IgA were normal, but tissue transglutaminase IgA was elevated (21 units). The patient was started on a gluten free diet and her symptoms improved. Repeat liver enzymes however had acutely worsened (ALT 1109 IU/L, AST 980 IU/L, ALP 270 IU/L, and total bilirubin 4.2 mg/dL). Review of data suggested acute autoimmune hepatitis (AIH). The patient had an AIH pretreatment score of 20 (>15 definite AIH). Liver biopsy revealed acute hepatitis with diffuse parenchymal injury, bridging fibrosis with areas of hepatocellular necrosis. The patient was started on Prednisone 20mg QD orally. Over the next few weeks, the liver enzymes improved (ALT 164 IU/L, AST 68 IU/L, ALP 118 IU/L, and total bilirubin 1.6 mg/dL). She is maintained on Prednisone 5 mg QD. Symptoms attributed to celiac disease have resolved on a gluten free diet. Discussion: Celiac disease is a common disorder affecting approximately 1% of the population. Treatment of celiac disease is life-long gluten free diet. Celiac disease is associated with elevated liver enzymes in approximately 15-60% of patients. These usually improve on a gluten free diet within 6-12 months, in approximately 70-95% of patients. If liver enzymes significantly increase on a gluten free diet, it is imperative to search for a concomitant liver disease and commence treatment as indicated.