Celiac disease is a common, burdensome autoimmune disease caused by the ingestion of gluten, and can develop at any age.1

On average, patients wait 10 to 13 years from onset of symptoms before receiving a correct diagnosis of celiac disease,2,3 with about 75 percent of those who have the condition not yet formally diagnosed.1,4 

Why is it important to identify patients with celiac disease?

Undiagnosed celiac disease patients often have substantially reduced quality of life,2 and may suffer from a wide range of debilitating symptoms.1

Celiac disease is treatable. When left untreated, it’s associated with increased morbidity and mortality.1

Early diagnosis and management of celiac disease with a gluten-free diet implemented in coordination with a dietitian, could:

  • Decrease the risk of delayed puberty,5 complications in type 1 diabetes,6 some cancers,5 and low birth weight of babies5
  • Improve bone mineral density,5,7 dermatitis herpetiformis,8 condition of intestinal mucosa,8 anemia,9 disease symptoms,5 and quality of life2
  • Resolve subfertility,5 spontaneous abortions,5 and menstrual problems5

Serological testing for celiac disease

The recommended first-line test for celiac disease, according to international guidelines (including NICE, ESPGHAN, and ESsCD) is tissue transglutaminase (tTG) IgA together with total IgA to check for IgA deficiency. For the tTG IgA blood test to be accurate, the patient must be consuming gluten every day for at least 6 weeks prior to testing.10-12

NICE guideline (NG20)12 
1.1.3 For people undergoing investigations for coeliac disease:
  • explain that any test is accurate only if a gluten‑containing diet is eaten during the diagnostic process and
  • advise the person not to start a gluten‑free diet until diagnosis is confirmed by a specialist, even if the results of a serological test are positive.
1.1.4 Advise people who are following a normal diet (containing gluten) to eat some gluten in more than 1 meal every day for at least 6 weeks before testing.
1.2.2 When healthcare professionals request serological tests to investigate suspected coeliac disease in young people and adults, laboratories should:
  • test for total immunoglobulin A (IgA) and IgA tissue transglutaminase (tTG) as the first choice
  • use IgA endomysial antibodies (EMA) if IgA tTG is weakly positive
  • consider using IgG EMA, IgG deamidated gliadin peptide (DGP) or IgG tTG if IgA is deficient
1.2.3 When healthcare professionals request serological tests to investigate suspected coeliac disease in children, laboratories should:
  • test for total IgA and IgA tTG as the first choice
  • consider using IgG EMA, IgG DGP or IgG tTG if IgA is deficient

Celiac serology tests may be requested through your local pathology lab who can advise if a specific algorithm needs to be followed based on the result and the age of the patient.

ESPGHAN: European Society for Paediatric Gastroenterology, Hepatology and Nutrition; ESsCD: European Society for the Study of Celiac Disease 

© NICE 2022 Coeliac disease: recognition, assessment and management. Available from https://www.nice.org.uk/guidance/ng20. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.       

1. Gujral N, Freeman H J, Thomson A B. Celiac disease: prevalence, diagnosis, pathogenesis and treatment. World J Gastroenterol 2012;18(42):6036-6059

2. Gray A M, Papanicolas I N. Impact of symptoms on quality of life before and after diagnosis of coeliac disease: results from a UK population survey. BMC Health Serv Res 2010;10:105

3. Norström F, Lindholm L et al. Delay to celiac disease diagnosis and its implications for health-related quality of life. BMC Gastroenterology 2011;11(1):118

4. West J, Fleming K M et al. Incidence and prevalence of celiac disease and dermatitis herpetiformis in the UK over two decades: population-based study. Am J Gastroenterol 2014;109(5):757-768

5. Murch S, Jenkins H et al. Joint BSPGHAN and Coeliac UK guidelines for the diagnosis and management of coeliac disease in children. Arch Dis Child 2013;98(10):806-811

6. Scaramuzza A E, Mantegazza C et al. Type 1 diabetes and celiac disease: the effects of gluten free diet on metabolic control. World J Diabetes 2013;4(4):130-134

7. Grace-Farfaglia P. Bones of contention: bone mineral density recovery in celiac disease--a systematic review. Nutrients 2015;7(5):3347-3369

8. Ciacci C, Ciclitira P et al. The gluten-free diet and its current application in coeliac disease and dermatitis herpetiformis. United European Gastroenterol J 2015;3(2):121-135

9. Annibale B, Severi C et al. Efficacy of gluten-free diet alone on recovery from iron deficiency anemia in adult celiac patients. Am J Gastroenterol 2001;96(1):132-137

10. Al-Toma A, Volta U et al. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J 2019;7(5):583-613

11. Husby S, Koletzko S et al. European Society Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for diagnosing coeliac disease 2020. J Pediatr Gastroenterol Nutr 2020;70(1):141-156

12. National Institute for Health and Care Excellence (NICE). NICE guideline 20. Coeliac disease: recognition, assessment and management, September 2015. Available at: www.nice.org.uk. Accessed June 2022