No-biopsy pathway following the interim BSG guidance reliably diagnoses adult coeliac disease

Abstract

Recent interim guidance from the British Society of Gastroenterology, aligned to historical paediatric practice, advises a no-biopsy protocol (NBP) for adults with high anti-tissue transglutaminase (tTG-IgA) titres and other clinical factors. A 7-year retrospective review identified 433 patients with positive tTG-IgA. Of these 433, 98 (23%) fulfilled the high titre criteria for an NBP which may have reduced endoscopic burden on the service. A high titre versus low titre translated in a 95% versus 75% histological confirmation of coeliac disease (p<0.01). The addition of anti-endomysial antibody analyses impacted minimally on these predictive rates. Our data support an NBP approach for selected patients. Of concern, however, was the finding that a third of patients with positive titres were not referred for a biopsy despite national guidance at the time advocating it. A clear message needs to be transmitted that the NBP is only for those with high titre, as opposed to any tTG-IgA positivity.

Keywords: coeliac disease; small intestinal biopsy.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1

Flow chart showing tTG-IgA positivity and subsequent histological findings for adult patients with suspected CD. CD, coeliac disease; GFD, gluten free diet; tTG-IgA, IgA-based anti-tissue transglutaminase antibody; ULN, upper limit of normal.

Figure 2

Manifestations leading to tTG-IgA testing and subsequent diagnosis of CD (n=213). CD, coeliac disease; GI, gastrointestinal symptoms; EIM, extraintestinal manifestations; HRG, high risk groups; tTG-IgA, IgA-based anti-tissue transglutaminase antibody; ULN, upper limit of normal.