Recognition and assessment of coeliac disease in children and adults: summary of NICE guidance

Who should be offered serological testing for coeliac disease?

• Offer testing to children and adults with any of the following signs and symptoms:

  • -Chronic or intermittent diarrhoea

  • -Failure to thrive or faltering growth (in children)

  • -Persistent and unexplained gastrointestinal symptoms including nausea or vomiting

  • -Prolonged fatigue

  • -Recurrent abdominal pain, cramping, or distension

  • -Sudden or unexpected weight loss

  • -Unexplained iron deficiency anaemia or other unspecified anaemia.

[Based on moderate quality evidence from cohort studies]

• Offer testing to children and adults with any of the following conditions:

  • -Autoimmune thyroid disease

  • -Dermatitis herpetiformis

  • -Irritable bowel syndrome

  • -Type 1 diabetes.

• Offer testing to children and adults who have first degree relatives with coeliac disease.

[Based on moderate quality evidence from cohort studies]

• Consider offering testing to children or adults with any of the following:

  • -Addison’s disease

  • -Amenorrhoea

  • -Aphthous stomatitis

  • -Autoimmune liver conditions

  • -Autoimmune myocarditis

  • -Chronic thrombocytopenia purpura

  • -Dental enamel defects

  • -Depression or bipolar disorder

  • -Down’s syndrome

  • -Epilepsy

  • -Low trauma fracture

  • -Lymphoma

  • -Metabolic bone disease (such as rickets or osteomalacia)

  • -Microscopic colitis

  • -Persistent or unexplained constipation

  • -Persistently raised liver enzymes with unknown cause

  • -Polyneuropathy

  • -Recurrent miscarriage

  • -Reduced bone mineral density

  • -Sarcoidosis

  • -Sjögren’s syndrome

  • -Turner’s syndrome

  • -Unexplained alopecia

  • -Unexplained subfertility.

[Based on moderate quality evidence from cohort studies and case control studies and the experience and opinion of the Guideline Development Group (GDG)]

• Do not use serological testing for coeliac disease in infants before gluten has been introduced into the diet. [Based on the experience and opinion of the GDG]

Advice to patients

• Inform people that testing for coeliac disease is accurate only if the person is eating a diet that contains gluten at the time of testing.

• Inform people that when following a normal gluten containing diet they should eat some gluten (for example, bread, chapattis, pasta, biscuits, or cakes) in more than one meal every day for a minimum of six weeks before testing.

• If a person is reluctant or unable to reintroduce gluten into their diet before testing refer them to a gastrointestinal specialist and inform them that it may be difficult to confirm a diagnosis of coeliac disease on intestinal biopsy.

• Inform people and their parents or carers that a delayed diagnosis of coeliac disease, or undiagnosed coeliac disease, can result in:

  • -Continuing ill health

  • -Long term complications, including osteoporosis and increased risk of fracture, unfavourable pregnancy outcomes, and a modest increased risk of intestinal malignancy

  • -In children, growth failure, delayed puberty, and dental problems.

  • [Based on moderate quality evidence from observational studies and on the experience and opinion of the GDG]

Serological tests

• All tests should be undertaken in laboratories with clinical pathology accreditation. [Based on the experience and opinion of the GDG]

• Do not use IgG or IgA antigliadin antibody (AGA) tests in the diagnosis of coeliac disease. [Based on good quality evidence from cohort studies and health economic evidence]

• When clinicians request serology, laboratories should:

  • -Use IgA tissue transglutaminase antibody (tTGA) testing as the first choice of test

  • -Use IgA endomysial antibody (EMA) testing if the result of the IgA tissue transglutaminase antibody test is equivocal

  • -Check for IgA deficiency if serology is negative (if the laboratory detects a low optical density on the IgA tTGA test, very low IgA tTGA results, or low background on the IgA EMA test)

  • -Use IgG tissue transglutaminase antibody or IgG endomysial antibody tests (or both) for people with confirmed IgA deficiency

  • Communicate clearly the results in terms of values, interpretation, and recommended action.

[Based on good quality evidence from cohort studies and on a health economic analysis]

Referral for intestinal biopsy

• Offer anybody with positive serological results a referral to a gastrointestinal specialist for intestinal biopsy to confirm or exclude coeliac disease.

• If serology tests are negative but coeliac disease is still clinically suspected, offer referral to a gastrointestinal specialist for further assessment.

[Based on the experience and opinion of the GDG]