NICE clinical guidelines
Issued: May 2009

Coeliac disease: Recognition and assessment of coeliac disease

This is an extract from the guidance. The complete guidance is available at

1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

1.1 Recommendations

When to offer testing

1.1.1 Offer serological testing for coeliac disease 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 or unexplained gastrointestinal symptoms including nausea and vomiting

  • prolonged fatigue ('tired all the time')

  • recurrent abdominal pain, cramping or distension

  • sudden or unexpected weight loss

  • unexplained iron-deficiency anaemia, or other unspecified anaemia.

1.1.2 Offer serological testing for coeliac disease to children and adults with:

  • any of the following conditions:

    • autoimmune thyroid disease

    • dermatitis herpetiformis

    • irritable bowel syndrome

    • type 1 diabetes


  • first-degree relatives (parents, siblings or children) with coeliac disease.

1.1.3 Consider offering serological testing for coeliac disease to children and adults with any of the following:

  • Addison's disease

  • amenorrhoea

  • aphthous stomatitis (mouth ulcers)

  • 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 syndrome

  • unexplained alopecia

  • unexplained subfertility.

Dietary considerations before testing for coeliac disease

1.1.4 Do not use serological testing for coeliac disease in infants before gluten has been introduced to the diet.

1.1.5 Inform people (and their parents or carers, as appropriate) that any testing for coeliac disease is accurate only if the person continues to follow a gluten-containing diet during the diagnostic process (serological tests and biopsy if required).

1.1.6 Inform people that they should not start a gluten-free diet until diagnosis is confirmed by intestinal biopsy, even if a self-test or other serological test is positive.

1.1.7 Inform people that when they are following a normal diet (containing gluten) they should eat some gluten (for example, bread, chapattis, pasta, biscuits, or cakes) in more than one meal every day for a minimum of 6 weeks before testing; however, it is not possible to say exactly how much gluten they should eat.

1.1.8 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, and that this may have implications for the prescribing of gluten-free foods.

Other information before serological testing

1.1.9 Inform people who are considering, or have undertaken, self-testing for coeliac disease (and their parents or carers) that any result from self-testing needs to be discussed with a healthcare professional and confirmed by laboratory-based tests.

1.1.10 Before seeking consent to take blood for serological tests, explain:

  • what coeliac disease is

  • that serological tests do not diagnose coeliac disease, but indicate whether further testing is needed

  • the implications of a positive test (including referral for intestinal biopsy and implications for other family members)

  • the implications of a negative test (that coeliac disease is unlikely but it could be present or could arise in the future).

1.1.11 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 fracture risk, unfavourable pregnancy outcomes and a modest increased risk of intestinal malignancy

  • growth failure, delayed puberty and dental problems (in children).

Serological tests

1.1.12 All tests should be undertaken in laboratories with clinical pathology accreditation (CPA).

1.1.13 Do not use immunoglobulin G (IgG) or immunoglobulin A (IgA) anti‑gliadin antibody (AGA) tests in the diagnosis of coeliac disease.

1.1.14 Do not use of self-tests and/or point-of-care tests for coeliac disease as a substitute for laboratory-based testing.

1.1.15 When clinicians request serology, laboratories should:

  • use IgA tissue transglutaminase (tTGA) as the first choice test

  • use IgA endomysial antibodies (EMA) testing if the result of the tTGA test is equivocal

  • check for IgA deficiency if the serology is negative[1]

  • use IgG tTGA and/or IgG EMA serological tests for people with confirmed IgA deficiency

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

1.1.16 Do not use human leukocyte antigen (HLA) DQ2/DQ8 testing in the initial diagnosis of coeliac disease. (However, its high negative predictive value may be of use to gastrointestinal specialists in specific clinical situations.)

After serological testing

1.1.17 Offer referral to a gastrointestinal specialist for intestinal biopsy to confirm or exclude coeliac disease to people with positive serological results from any tTGA or EMA test.

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

[1] Investigation for IgA deficiency should be done if the laboratory detects a low or very low optical density on IgA tTGA test or low background on IgA EMA test.