New 2025 ESsCD Coeliac guidelines: What patients should know

European experts have updated the framework on how doctors diagnose coeliac disease (CeD) in adults.  The changes aim to improve the diagnosis of adult patients by making testing easier, more accurate and more patient-friendly.

1. Simpler blood testing

• IgA antibodies against tissue transglutaminase 2 (IgA anti-TG2) and total IgA can be used to rule out IgA deficiency remain the first line blood tests.
• Other blood tests might be performed afterwards, if needed, but are not mandatory in all patients.

2. Non-biopsy approach

• If the level of IgA anti-TG2 antibodies is over 10 times higher than normal, and the results are confirmed with a second blood test, some adults can be diagnosed without a biopsy.
• A non-biopsy approach is only indicated for patients under the age of 45 with no significant symptoms.

3. Clearer biopsy rules

• If a biopsy is needed, at least six samples must be taken from two different locations in the small intestine. This improves accuracy and helps avoid missed diagnoses.

4. Special situations explained

• On a gluten-free diet already? A short gluten challenge may be needed.
• Negative blood test but positive intestinal damage detected by biopsy? Other causes must be evaluated.
• Unclear cases? Genetics (HLA testing) can sometimes help.

5. Patient-centered diagnostic approach: Shared decision making in the following situations:

• Non-biopsy approach option
• Gluten challenge

6. Non-coeliac wheat sensitivity

• This is indicated when symptoms improve by avoiding gluten, but coeliac blood tests and allergy tests are negative.
• This is recognised as a different gastrointestinal disorder and not coeliac disease. 

• Diagnosis may be faster and less invasive.
• Doctors aim to avoid unnecessary tests to minimize patient inconvenience while maintaining high diagnostic standards.
• Shared decision-making means patients are increasingly involved in choosing the diagnostic path in which they feel most comfortable.