Is routine surveillance endoscopy required for a patient with celiac disease who is adhering to a strict gluten‑free diet and has improving symptoms and serology?

Routine Surveillance Endoscopy Is Not Required for Patients with Established Celiac Disease on a Gluten-Free Diet

Repeat duodenal biopsy should be based on patient characteristics and clinical indications rather than performed routinely in patients with established celiac disease who are adherent to a gluten-free diet and showing clinical improvement. 1

Monitoring Strategy Without Routine Endoscopy

The most recent 2024 guidelines from Nature Reviews Gastroenterology & Hepatology provide a clear framework for monitoring celiac disease that does not include routine surveillance endoscopy for all patients. 1

Standard Monitoring Approach

Yearly monitoring should include:

• Dietician or nutritionist evaluation expert in gluten-free diet to assess adherence 1
• Serological testing with anti-TG2 IgA to evaluate for chronic gluten exposure, though negative serology cannot confirm strict adherence or predict mucosal recovery 1
• Blood tests including complete blood count, iron, folate, and other micronutrients to assess nutritional status and intestinal function 1
• Symptom assessment as improvement indicates GFD responsiveness and remission of disease activity 1
• Standardized adherence questionnaires when an expert dietician is not readily available 1

When Endoscopy IS Indicated

Duodenal histology should be reserved for specific clinical scenarios rather than routine surveillance: 1

• Non-responsiveness to gluten-free diet (persistent symptoms despite dietary adherence) 1, 2
• Suspicion of refractory celiac disease (symptoms persisting after 6-12 months of strict GFD) 1
• Suspected complications such as ulcerative jejunoileitis, lymphoma, or enteropathy-associated adenocarcinoma 1
• When performed, biopsy should generally occur >12 months after diagnosis to allow adequate time for mucosal healing 1

Timeline for Expected Recovery

The 2024 guidelines clarify that different parameters normalize at different rates: 1

• Symptoms: Improve within 1-4 weeks of starting gluten-free diet 1
• Serology (anti-TG2 IgA): Normalizes within 6 months to 1 year 1
• Histology: Takes considerably longer, often >12 months, with adults healing more slowly than children 1, 3

Why Routine Endoscopy Is Not Recommended

The 2024 guidelines explicitly state that normalization of serology (anti-TG2 IgA) should NOT be used as a marker of mucosal recovery during long-term gluten-free diet owing to poor sensitivity for identifying persistent villous atrophy. 1 This means that:

• Negative serology does not guarantee mucosal healing 1
• However, this does not justify routine surveillance biopsy in asymptomatic, adherent patients 1
• The sensitivity of anti-TG2 IgA for detecting dietary transgressions is only 52-57% 1

Special Populations Requiring Follow-Up Biopsy

Consider follow-up endoscopy with biopsy in: 1, 2

• Patients with persistent or recurrent symptoms despite reported dietary adherence 1, 2
• Those with persistently positive serology suggesting ongoing gluten exposure 1
• Patients diagnosed with severe villous atrophy initially who may benefit from confirmation of healing 1
• Individuals with additional risk factors such as refractory celiac disease type II (requiring TCR clonality and flow cytometry) 1

Additional Monitoring Considerations

Bone mineral density assessment (DXA scan) should be considered for newly diagnosed patients with additional risk factors for low bone mineral density (e.g., menopause, prolonged malabsorption) rather than routinely. 1

Enteroscopy (capsule or balloon-assisted) is reserved for suspected complications or refractory celiac disease, not routine surveillance. 1

Common Pitfalls to Avoid

• Do not perform routine surveillance endoscopy in asymptomatic patients with negative serology and good dietary adherence 1
• Do not rely solely on negative serology to confirm mucosal healing, but also do not use this as justification for routine biopsy 1
• Do not delay investigation when symptoms persist or recur—this requires systematic evaluation including dietary review, repeat serology, and consideration of follow-up biopsy 1, 2
• Do not forget that 93-94% of patients on long-term gluten-free diet (≥3 years) maintain strict adherence and achieve mucosal recovery without routine endoscopic surveillance 3

Practical Algorithm

1. At diagnosis: Confirm with endoscopy and biopsy (at least 4-6 specimens) 1
2. First year: Monitor symptoms, serology at 6 months and 12 months, dietician follow-up 1, 3
3. Ongoing (yearly): Dietician evaluation, serology, blood tests, symptom assessment 1
4. Biopsy only if: Non-responsive disease, positive serology persists, new/recurrent symptoms, or suspicion of complications 1, 2

The shift away from routine surveillance endoscopy reflects recognition that clinical response, dietary adherence assessment, and selective use of serology provide adequate monitoring for most patients with celiac disease. 1