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Coeliac Disease

NICE guideline [NG20] Coeliac disease: recognition, assessment and management. Published: Sep 2015. NICE CKS Coeliac disease. Last revised: Jun 2025.

Guidelines

NICE recommends offering testing in any of the following:
  • 1st degree relative with coeliac disease
 
  • Possible coeliac features
    • Persistent unexplained abdominal or gastrointestinal symptoms
    • Faltering growth
    • Prolonged fatigue
    • Unexpected weight loss
    • Severe or persistent mouth ulcers
    • Unexplained iron, vitamin B12 or folate deficiency
    • Irritable bowel syndrome (in adults)
 
  • Possible autoimmune association
    • Type 1 diabetes, at diagnosis
    • Autoimmune thyroid disease, at diagnosis
 

  • 1st line test: serological testing
  • If serological testing +ve → refer all patients for endoscopic intestinal biopsy for definitive testing

The patient must follow a gluten-containing diet (>1 meal every day) for at least 6 weeks before testing
  • Explain that the test is only accurate if a gluten-containing diet is eaten during the process, otherwise may result in false negative
  • If the patient has already restricted their gluten intake or excluded gluten, advise re-introducing gluten into their diet before testing


Choice of serology testing:
  • 1st line: IgA tTGTissue transglutaminase + total IgA
  • If IgA tTGTissue transglutaminase is weakly +ve → test for IgA EMAEndomysial antibodies
 
  • If there is IgA deficiency → test for IgG tTGTissue transglutaminase or IgG DGPDeamidated gliadin peptide

Refer all patients with +ve serological test results to secondary care for definitive testing.

 

IgA deficiency is the most common primary antibody deficiency in the UK, and is often asymptomatic in most patients. IgA deficiency can result in false negatives in IgA tTG, therefore IgA tTG should always be tested together with total IgA levels to exclude underlying IgA deficiency.

Do not use HLA DQ2/DQ8 in initial testing in non-specialist settings.

Endoscopic duodenal biopsy is the definitive test of choice for ALL suspected cases to confirm or exclude coeliac disease.

Biopsy findings:
  • Villous atrophy
  • Crypt hyperplasia
  • Intraepithelial lymphocytic infiltration

Long-term gluten-free diet - only effective treatment
  • Consider supplements (e.g. calcium, vitamin D) if insufficient dietary intake
  • Assess risk of osteoporosis

Consider annual blood monitoring:
 
Test Purpose
Coeliac serology
  • To assess adherence to gluten-free diet (in addition to dietary review)
FBC and ferritin
  • Screen for anaemia and iron deficiency
  • Marked thrombocytosis may suggest hyposplenism
TFT
  • Screen for concurrent autoimmune thyroid disease
LFT
  • Screen for concurrent autoimmune liver disease
Calcium, vitamin D, vitamin B12, folate
  • Screen for deficiency due to malabsorption and dietary changes

 

For those with hyposplenism, offer the following vaccinations:

  • Influenza (yearly)
  • Pneumococcal
  • Meningococcal

References

Author: Adams Lau
Reviewer:
Last edited: 08/08/25