How to test - adults
Diagnosis in adults
Coeliac disease in adults is traditionally diagnosed by serological testing and endoscopic intestinal biopsy, but in response to the Covid-19 pandemic, interim guidelines for a no-biopsy diagnosis in adults have been published by the British Society of Gastroenterology.
People with coeliac disease produce tissue transglutaminase antibodies (tTGA) and endomysial antibodies (EMA) when gluten is ingested. When requesting tests for adults, NICE recommends:
- test for total immunological immunoglobin A (IgA) and IgA tissue transglutaminase as a first choice test
- use IgA endomysial antibodies (EMA) if IgA tTG is weakly positive
- consider using IgG EMA, IgG deamidated gliadin peptide (DGP) or IgG tTG in cases of IgA deficiency.
Adults with a positive blood test and those with negative antibodies where coeliac disease is suspected should be referred to a gastroenterologist, even if they may be eligible for a no-biopsy diagnosis.
No-biopsy diagnosis in adults
In response to the Covid-19 pandemic, the British Society of Gastroenterology have published interim guidance on diagnosis of coeliac disease in adults. The diagnosis of coeliac disease should be made by a gastroenterologist.
The guidance suggests that a no-biopsy diagnosis can be made in adults who:
- are 55 years of age or younger
- do not have red flag symptoms
- have symptoms of coeliac disease
- have IgA tTG ≥10 upper limit of normal (ULN) for the assay
- have a second positive antibody blood test (EMA or IgA tTG if EMA is not available)
Alongside the launch of this pathway, a prospective service evaluation is being carried out to assess the appropriateness and impact of this approach. Details of how to participate in the evaluation are available on the BSG website.
After diagnosis, adults with coeliac disease should be referred to dietetic services for information and support on the gluten free diet.
Total IgA should be measured when testing for coeliac disease. This is because IgA deficiency is more common in people with coeliac disease than the general population. People with IgA deficiency will have a false negative serological result when tested for IgA antibody, which may lead to a missed diagnosis of coeliac disease.
In individuals with IgA deficiency, IgG antibodies are recommended in place of IgA antibodies.
People with IgA deficiency should not be diagnosed without a biopsy. The no-biopsy pathway is based on IgA antibodies and there isn’t enough evidence to support the use of IgG antibodies for a no-biopsy diagnosis.
Advice before testing
It is important to inform people undergoing testing for coeliac disease that in order to get accurate test results, they should continue to eat a gluten containing diet before and during the diagnosis process. NICE recommends including gluten in more than one meal a day for at least six weeks before testing.
A gluten free diet should not be initiated until diagnosis is confirmed by a specialist, even if the results of a serological test are positive.
If people who have restricted their gluten intake or excluded gluten from their diet are unable to reintroduce gluten into their diet before testing, refer the patient to a gastroenterologist and explain that it may be difficult to confirm their diagnosis.