From the Guidelines
Diagnosing celiac disease requires a combination of serologic testing and intestinal biopsy confirmation, with initial screening including tissue transglutaminase antibody (TG2Ab) and duodenal biopsy showing villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes, as supported by the most recent guidelines 1.
Diagnostic Steps
The diagnostic process for celiac disease involves several key steps:
- Initial screening with serologic testing, specifically tissue transglutaminase antibody (TG2Ab), which has high sensitivity (93%) and specificity (98%) 1
- Duodenal biopsy to confirm the presence of villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes
- Genetic testing for HLA-DQ2 and HLA-DQ8 can help rule out celiac disease if negative, as nearly 100% of individuals diagnosed with celiac disease exhibit this specific genetic profile 1
Management Options
Management of celiac disease centers on a strict, lifelong gluten-free diet, eliminating wheat, barley, and rye, as well as:
- Nutritional counseling to ensure adequate intake of fiber, iron, calcium, and B vitamins
- Monitoring for symptom improvement and normalization of antibody levels, typically within 6-12 months of diet adherence
- Correction of nutritional deficiencies like iron, folate, vitamin D, and B12 with supplements as needed
- Regular follow-up to assess dietary compliance and screen for associated conditions like osteoporosis, thyroid disease, and other autoimmune disorders
Key Considerations
It is essential to note that patients should remain on a gluten-containing diet during testing to avoid false negatives, and that seronegative celiac disease can occur, in which case the diagnosis can be established by a clinical and histologic response to the gluten-free diet in patients with consistent pathology and compatible HLA haplotypes 1.
From the Research
Diagnostic Steps for Celiac Disease
- The diagnosis of celiac disease involves a combination of serologic testing and intestinal biopsy 2, 3, 4, 5.
- Serologic tests, such as tissue transglutaminase immunoglobulin antibody and endomysial immunoglobulin antibody, are used to identify individuals who need to undergo an intestinal biopsy 2, 5.
- The gold standard for the diagnosis of celiac disease is a small bowel biopsy showing villous atrophy 2, 3.
- Intestinal biopsy should be pursued even if serologic tests are negative if the suspicion of celiac disease is high 2.
Management Options for Celiac Disease
- The treatment for celiac disease is lifelong adherence to a gluten-free diet (GFD) 2, 3, 4.
- A gluten-free diet can help to resolve symptoms and prevent complications associated with celiac disease 2, 3, 4.
- Non-responsive celiac disease occurs frequently, particularly in those diagnosed in adulthood, and may require further evaluation and management 3.
- Newer therapeutic modalities are being studied in clinical trials, but are not yet approved for use in practice 3.
Factors Associated with Progression to Villous Atrophy
- Factors associated with the development of villous atrophy in children with potential celiac disease include the number of γδ intraepithelial lymphocyte cells, age, and homozygosity for the HLA DQB1*02 allele 6.
- The cumulative incidence of progression to villous atrophy was 43% at 12 years in a study of children with suspected celiac disease 6.
- Identifying factors that can be used to identify children at highest risk for villous atrophy may help determine whether children with suspected celiac disease should immediately start a gluten-free diet or be monitored on their regular diet 6.
Serologic Testing for Celiac Disease
- IgA antitissue transglutaminase antibodies and IgA antiendomysial antibodies have high sensitivity and specificity for diagnosing celiac disease 5.
- The sensitivity and specificity of serologic tests for celiac disease can vary depending on the population being tested and the specific test used 5.
- Serologic testing should be performed on a gluten-containing diet to ensure accurate results 3, 4.