Last updated January 17, 2023

Diagnosis and Management of Celiac Disease

Summary of Recommendations

1A. We recommend EGD with multiple duodenal biopsies for confirmation of diagnosis in both children and adults with suspicion of CD (strong recommendation, moderate quality of evidence; dissent).

1B. We suggest a combination of high-level TTG IgA (>10× upper limit of normal) with a positive endomysial antibody (EMA) in a second blood sample as reliable tests for diagnosis of CD in children. In symptomatic adults unwilling or unable to undergo upper GI endoscopy, the same criteria may be considered after the fact, as a diagnosis of likely CD (conditional recommendation, moderate quality of evidence; dissent).
1. Multiple biopsies of the duodenum (1 or 2 from bulb and 4 from distal duodenum) are necessary for diagnosis of CD.
2. EGD and duodenal biopsies can also be useful for the differential diagnosis of other malabsorptive disorders or enteropathies.
3. Lymphocytic duodenosis (≥25 intraepithelial lymphocytes per 100 epithelial cells) in the absence of villous atrophy is not specific for CD, and other causes should be considered.

2. We suggest setting a goal of intestinal healing as an end point of GFD therapy. We advocate for individualized discussion of goals of the GFD with the patient beyond clinical and serological remission (conditional recommendation, low quality of evidence; dissent).
1. Upper endoscopy with intestinal biopsies is helpful for monitoring in cases with a lack of clinical response or relapse of symptoms despite a GFD.
2. Follow-up biopsy could be considered for assessment of mucosal healing in adults in the absence of symptoms after 2 years of starting a GFD after shared decision-making between patient and provider.

3. We suggest against routine use of gluten detection devices in food or biospecimens among patients with CD (conditional recommendation, low quality of evidence; dissent).
1. The standard of care in assessing diet adherence involves interview with a dietitian with expertise in GFD.
2. Technologies to qualitatively detect gluten in food or biospecimens may not distinguish between clinically significant and trivial gluten exposure.
3. There is a paucity of evidence to suggest that using gluten detection technology enhances diet adherence or quality of life.
4. Studies are needed to evaluate the utility of gluten detection technologies to improve GFD adherence and clinical outcomes in CD.

4. There is insufficient evidence to recommend for or against the use of probiotics for the treatment of CD (evidence gap in recommendation; very low quality of evidence; dissent).
1. Dysbiosis is a feature of CD, but its role in disease pathogenesis and symptomatology is uncertain.
2. Despite the widespread use of probiotics, a benefit in the management of CD is not established.

5. We recommend consumption of gluten-free oats in the diet of those with CD. Gluten contamination of oats, variable toxicity in different varieties of oats, and the small risk for an immune reaction to the oat protein avenin require monitoring for oat tolerance (strong recommendation, moderate quality of evidence; dissent).
1. Oat consumption seems to be safe for most individuals with CD, but may be immunogenic in a subset of patients.
2. Heterogeneity in the tolerance of oats may be related to differences in the origin/harvesting and quantity of oats consumed.
3. Intervals for monitoring symptoms and serology after gluten-free oats are introduced into the diet are not known.

6. We suggest vaccination to prevent pneumococcal disease in patients with CD (conditional recommendation, low quality of evidence; dissent).
1. Vaccination against pneumococcal infection is safe and effective.
2. Vaccination is widely recommended for all adults older than 65 years and smokers aged 19–64 years or adults with certain underlying conditions.

7A. We recommend case finding to increase detection of CD in clinical practice (strong recommendation, low quality of evidence; dissent).
7B. We recommend against mass screening for CD in the community (strong recommendation, low quality of evidence; dissent).
1. Patients with symptoms, signs, or laboratory evidence suggestive of malabsorption, such as chronic diarrhea with weight loss, steatorrhea, abdominal pain, and bloating, should be tested for CD.
2. Patients with symptoms, signs, or laboratory evidence for which CD is a treatable cause should be considered for testing for CD.
3. Patients with a first-degree family member who has a confirmed diagnosis of CD should be tested whether they show possible signs or symptoms or laboratory evidence of CD.
4. Consider testing of asymptomatic relatives with a first-degree family member who has a confirmed diagnosis of CD.

8A. We recommend the immunoglobulin IgA anti-TTG antibody (TTG-IgA) as the preferred single test for the detection of CD in children younger than 2 years who are not IgA-deficient (strong recommendation, moderate quality of evidence; dissent).
8B. We recommend that testing for CD in children with IgA deficiency be performed using IgG-based antibodies (DGP-IgG or TTG-IgG) (strong recommendation; moderate quality of evidence; dissent)
1. TTG-IgA and EMA-IgA are reported to be less accurate in children younger than 2 years.
2. Current guidelines recommend that testing for CD in children younger than 2 years include both TTG-IgA and DGP-IgG.

Recommendation Grading

Overview

Title

Diagnosis and Management of Celiac Disease

Authoring Organization

Publication Month/Year

January 5, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This guideline presents recommendations for the diagnosis and management of patients with celiac disease. 

Target Patient Population

Patients with celiac disease

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D002446 - Celiac Disease, D055050 - Diet, Gluten-Free, D005983 - Glutens

Keywords

gastrointestinal, celiac disease, gluten

Source Citation

Rubio-Tapia A, Hill ID, Semrad C, Kelly CP, Lebwohl B. American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease. Am J Gastroenterol. 2023 Jan 1;118(1):59-76. doi: 10.14309/ajg.0000000000002075. Epub 2022 Sep 21. PMID: 36602836.