CLINICAL

Interpreting tests for coeliac disease

Tips, pitfalls and updates

Jason A Tye-Din COELIAC DISEASE is an immune illness, coeliac disease serology, but this is
triggered by dietary gluten, that causes a uncommon and excluding other causes of
broad range of gastrointestinal and extra- villous atrophy (see below) is important.
This article is the second in a series intestinal manifestations.1 Untreated Testing at-risk individuals is strongly
on pathology testing. Articles in this disease reduces quality of life, increases recommended to detect cases before
series aim to provide information about
healthcare use and is associated with substantial morbidity develops.3,6 An
emerging laboratory tests that general
practitioners (GPs) may encounter. substantial morbidity.2–4 Mortality is active case-finding approach can improve
increased because of lymphoproliferative detection of coeliac disease by more than
Background malignancy, sepsis and refractory 40-fold,7 but this only works when doctors
Coeliac disease is one of most prevalent disease.3 As 1.5% of Australians have are mindful of the disease. Approximately
autoimmune illnesses encountered
coeliac disease, it is one of the most 30 at-risk individuals need to be tested
in general practice, and GPs have a
common autoimmune illnesses that to find a positive case of coeliac disease.7
central role in its diagnosis and follow-
up. Key challenges are improving its general practitioners (GPs) will encounter. There is insufficient evidence to support
poor rate of detection, distinguishing it However, its broad and often subtle population screening.8 Figure 2 provides
from ‘gluten sensitivity’, and monitoring presentation makes detection challenging, an outline of a recommended diagnostic
and optimising treatment to enhance and means 80% of Australians with pathway.
long‑term outcomes. coeliac disease remain undetected.5 As
Objective
expeditious diagnosis and treatment with When to test for coeliac disease
The objective of this article is to review a strict, lifelong gluten-free diet (GFD)
the evidence-based use of serology, minimises long-term complications,3 Symptoms and clinical features that
histology and genetic testing in the application of the appropriate tests to identify patients who might benefit
diagnosis and follow-up care of adults ensure accurate diagnosis and follow-up from testing are shown in Table 1.9
and children with coeliac disease. is crucial. ‘Classical’ symptoms caused by intestinal
Discussion inflammation, such as diarrhoea and
Recognition and testing of at-risk Making the diagnosis weight loss, are frequent, but the ‘non-
patients are keys to expediting classical’, extra-intestinal manifestations
the diagnosis of coeliac disease. In clinical practice, suspected patients are even more common. These non-
Knowing when and how to use are generally screened with coeliac classical features include lethargy,
serology, histology, human leukocyte
disease serology. In patients with headaches, osteoporosis, iron deficiency,
antigen typing and gluten challenge
positive coeliac disease serology, the transaminase elevation, infertility, other
will increase the accuracy of both
diagnosis and disease monitoring. diagnosis is confirmed by the presence autoimmune disease and dermatitis
of characteristic small intestinal mucosal herpetiformis. A positive family history
changes. The key diagnostic features are: of coeliac disease carries the strongest
• intestinal histology showing raised predictive value for the disease.
intraepithelial lymphocytes (>25 per
100 enterocytes), crypt hyperplasia and Tips and pitfalls
villous atrophy (Figure 1) • Coeliac disease can develop at any age.
• disease remission confirmed by The median age of diagnosis is 40 years,
symptom resolution, normalised coeliac but do not discount coeliac disease in
disease serology and, most reliably and the young and elderly.
importantly, mucosal healing following • Coeliac disease affects both sexes,
treatment with a GFD.3,6 with a modest female predominance.
Correlation of histology and serology Men with coeliac disease are often
with clinical history is important. Coeliac overlooked.5
disease can be present despite negative • Coeliac disease is a global disorder that

28 | REPRINTED FROM AJGP VOL. 4 7, NO. 1–2, JAN–FEB 2018 © The Royal Australian College of General Practitioners 2018
INTERPRETING TESTS FOR COELIAC DISEASE CLINICAL

is common in Western populations, Coeliac serology is typically performed with intravenous

North Africa, the Middle East, India sedation, is simple and safe, and takes
and Pakistan.10 Reports from Asian Currently, serologic testing for coeliac as little as 10 minutes. As coeliac disease
countries, such as China, are on the rise. disease consists of the transglutaminase causes patchy involvement of the proximal
Coeliac disease should not be excluded (tTG) and deamidated gliadin peptide small intestine, multiple biopsies are
on the basis of a patient’s ethnicity or (DGP) antibody tests. In practice, both recommended (eg two from the first
appearance. tests have >85% sensitivity and >90% and four from the second part of the
• Clinical heterogeneity is substantial. specificity.12 The DGP assay has replaced duodenum).3,6 Endoscopic changes of
Some patients have minimal or the whole-protein anti-gliadin antibody coeliac disease, such as mucosal scalloping,
no obvious symptoms, or only (AGA) assay because of improved are occasionally seen, but diagnosis rests
extra‑intestinal issues. One-third specificity; however, many labs will on the microscopic appearance.
of patients with coeliac disease are report the DGP result as the ‘anti-gliadin
overweight or obese at diagnosis.11 antibody’. The anti-endomysial antibody Tips and pitfalls
(EMA) test measures tTG antibodies, but is • Villous atrophy is suggestive but
labour-intensive, user-dependent and less not pathognomonic of coeliac
widely performed. Testing approaches are disease. Other causes to consider,
shown in Table 2. especially if coeliac disease serology
is negative, include Giardia, common
Tips and pitfalls variable immunodeficiency, Crohn’s
• Positive coeliac disease serology in disease, tropical sprue, autoimmune
isolation is insufficient for the diagnosis enteropathy, cow’s milk protein
of coeliac disease. intolerance and some medications
• The higher the titre of serology, the (eg olmesartan).
greater the positive predictive value for • A GFD or immunosuppression can
coeliac disease.13 obscure changes of villous atrophy.
• Coeliac disease serology has a false • Correct biopsy processing and
negative rate of 10–15%.14 Check if interpretation by a skilled pathologist
your patient is on a GFD or taking is vital. When there is diagnostic
immunosuppressants. uncertainty, review of the pathology
• The tTG normal range varies can be informative.
by manufacturer as there is no
A
international standard. Comparing Human leukocyte antigen
titres is not possible if different labs or
DQ2/8 genotyping
tTG assays are used.
• In patients with risk factors for coeliac The strong association between coeliac
disease, negative coeliac disease disease and specific human leukocyte
serology has lower negative predictive antigen (HLA) genes makes HLA
value, so further work-up should be genotyping a useful tool in specific
considered.15 situations (Table 3).16 The main
• Point-of-care tests to detect coeliac susceptibility genes are HLA-DQ2
disease antibodies have not been (specifically HLA-DQ2.5 and HLA-DQ2.2)
validated in primary practice, so cannot and HLA-DQ8, which are collectively
currently be recommended.11 seen in almost all (99%) patients with
• Patients with persistently positive coeliac disease, compared with 40–50%
B coeliac disease serology but normal of the Australian community.5 Although
small intestinal histology may have these genes, especially HLA-DQ2.5,
Figure 1. Healthy small intestine, compared ‘potential’ (or ‘latent’) coeliac disease, impart substantial relative risk for coeliac
with villous atrophy in coeliac disease.
and follow-up is recommended.3,6 disease, the absolute risk is low, and most
A. Normal small intestinal mucosa in
adequately treated coeliac disease patients with one or more of these genes
B. Untreated coeliac disease showing the Gastroscopy and small bowel will not develop coeliac disease. HLA-DQ7
classic triad of infiltration of the epithelium (composed of half the DQ2.5 allele,
with lymphocytes, crypt hyperplasia and biopsies
DQA1*05) may impart a very low risk for
villous atrophy
Magnification ×100, haematoxylin and
Histological evaluation of biopsies from coeliac disease but this remains unclear.16
eosin stain. the small intestine is the cornerstone of The main benefit of HLA typing is its
coeliac disease diagnosis.3,6 Gastroscopy ability to exclude coeliac disease diagnosis

© The Royal Australian College of General Practitioners 2018 REPRINTED FROM AJGP VOL. 47, NO. 1–2, JAN–FEB 2018 | 29
CLINICAL INTERPRETING TESTS FOR COELIAC DISEASE

Option 1: HLA-DQ2/8 genotyping

Table 1. When to test for coeliac disease9 The absence of HLA susceptibility
Offer serological testing for coeliac disease to people with any of the following: means that coeliac disease is unlikely
and further investigations can focus on
• Persistent unexplained abdominal or gastrointestinal symptoms other diagnoses. The presence of HLA
• Faltering growth susceptibility genes is not diagnostic of
• Prolonged fatigue coeliac disease, so option 2 is required.
• Unexpected weight loss
• Severe or persistent mouth ulcers Option 2: Gluten challenge, then testing
• Unexplained iron, vitamin B12 or folate deficiency The amount and duration of gluten
• Type 1 diabetes, at diagnosis required to consistently trigger diagnostic
• Autoimmune thyroid disease, at diagnosis changes of coeliac disease appears highly
• Irritable bowel syndrome (in adults) variable and more research is required.
• First-degree relatives of people with coeliac disease Approximately 3–6 g of gluten consumed
Consider serological testing for coeliac disease in people with any of the following: daily for two weeks will cause intestinal
changes of coeliac disease in 50–70% of
• Metabolic bone disorder (reduced bone mineral density or osteomalacia) affected adults, with the development
• Unexplained neurological symptoms (particularly peripheral neuropathy or ataxia of positive serology after four weeks in
• Unexplained subfertility or recurrent miscarriage 10–55%.19,20 To optimise the diagnostic
• Persistently raised liver enzymes with unknown cause yield, patients should be encouraged to
• Dental enamel defects return to consuming 3–6 g or more of gluten
• Down syndrome each day for, ideally, six or more weeks.
• Turner syndrome This daily amount of gluten can be found
Reproduced with permission from the National Institute for Health and Care Excellence. Coeliac disease: Recognition, in two to four slices of wheat bread, two to
assessment and management. London: NICE, 2015. Available at www.nice.org.uk/guidance/ng20 four Weet-Bix or 0.5–1 cup of cooked pasta.

Tips and pitfalls

when the susceptibility genotypes are Gluten-sensitive or • Symptomatic relapse with a gluten
absent (likelihood of coeliac disease <1%). wheat‑sensitive patients challenge is common, but has poor
A positive HLA test does not diagnose predictive value for coeliac disease.
coeliac disease, but indicates that Many Australians adopt a GFD without Gluten challenge is informative only if
further investigation may be warranted. assessment for coeliac disease. This accompanied by objective testing.
Genotyping is widely available through poses a diagnostic dilemma as coeliac • The tolerability of a gluten challenge
commercial labs in Australia with a disease serology and intestinal histology may be improved by commencing with
request for ‘HLA-DQ2/8 genotyping’. It can become falsely negative if the patient a small amount of gluten and slowly
is performed on a blood sample, but can has been on a GFD for more than a increasing over subsequent days, and
be done on a buccal scrape through some few months. Many Australians remove consuming it in divided doses over the
collection centres (patients can check gluten from their diet because they feel course of the day (eg breakfast and
in advance). HLA typing reports can be it helps improve gastrointestinal or other lunch). Fermented breads with lower
difficult to interpret, so Australasian symptoms.17 For these people, a definitive FODMAP content (that still contain
guidelines have been developed to simplify diagnosis is desirable as: gluten) are commercially available and
and standardise reporting.16 • a formal diagnosis of coeliac disease will may also improve challenge tolerability.
ensure strict treatment and follow-up of
Tips and pitfalls a serious medical illness Family screening
• LA typing is expensive (Medicare
H • many people who self-report ‘gluten
Benefits Schedule item number 71151; sensitivity’ are not actually sensitive The risk of coeliac disease in patients who
$118.85), so it is important to use it to gluten. These patients, instead of have an affected family member with the
prudently (Table 3).16 excluding gluten, may benefit more disease is 10%, but increases up to 20%
• HLA typing is a ‘once only’ test as a from excluding other symptom-inducing if multiple family members are affected.
person’s genotype does not change. wheat components, such as fermentable Screening patients with a family history of
• HLA typing results are not adversely carbohydrates (FODMAPs).18 coeliac disease is important and strongly
affected by a GFD. There are two diagnostic approaches – indicated when there are suggestive
• Most patients with HLA susceptibility option 1 may be appropriate if the patient symptoms or signs.3,6 As it is increasingly
for coeliac disease will not have the is unwilling to undertake the gluten recognised that many ‘asymptomatic’
disease or ever develop it. challenge; however, option 2 is definitive. patients with coeliac disease have

30 | REPRINTED FROM AJGP VOL. 4 7, NO. 1–2, JAN–FEB 2018 © The Royal Australian College of General Practitioners 2018
INTERPRETING TESTS FOR COELIAC DISEASE CLINICAL

Doctor considers
coeliac disease
(Table 1)
Following a gluten-free diet

Option 1: If initially Option 2

Consuming
gluten in diet unwilling to do
gluten challenge

Coeliac serology HLA DQ2/8 genotyping Gluten

(Table 2) (Box 1) challenge
At-risk or
Low-risk patient clinical suspicion

Positive
tTG and/or DGP
Coeliac disease unlikely

Specialist review

Not coeliac May benefit from further

Gastroscopy + small
investigation such as HLA
disease intestinal biopsies
DQ2/8 genotyping and
CD serology can also be performed
gastroscopy and biopsies

Characteristic Normal
coeliac histology histology Equivocal

Coeliac disease
Specialist review
Not coeliac disease Needs further investigation
Note: If CD serology is such as review of pathology,
consistently positive consider HLA DQ2/8 genotyping, and
Follow-up to confirm ‘potential coeliac disease’ possibly gluten challenge and
improvement on GFD repeat biopsies

Figure 2. Recommended diagnostic pathway for coeliac disease

CD, coeliac disease; DGP, deamidated gliadin peptide antibody; tTG, tissue transglutaminase antibody

underlying nutrient deficiencies, disease. If HLA susceptibility is present the age of four years if they are well
reduced bone density, or have symptom but coeliac disease serology is normal, the and symptom-free.
improvement following a GFD (indicating individual is at risk for future development • Remind your patients with coeliac
they were never asymptomatic), this of the disease. Repeat coeliac disease disease that their relatives are at
means all relatives, irrespective of serology would be recommended if increased risk of the disease and
symptom status, should be considered for they develop suggestive symptoms. If should be considered for testing.
screening.21 First-degree relatives should asymptomatic, some experts recommend
be screened, and if there are several screening every two to three years during Paediatric testing
affected family members second-degree childhood to avoid the detrimental effects
relatives should also be tested. of unrecognised coeliac disease on growth Although similar to adults, there are
Family screening using HLA DQ2/8 and bone health.13 additional considerations when assessing
genotyping with coeliac disease serology children for coeliac disease.22 New
is more informative than serology alone.16 Tips and pitfalls European guidelines, based on evidence
A relative without HLA susceptibility • Screening children with a family history that high-titre tTG is strongly predictive
does not require monitoring for coeliac of coeliac disease can be delayed until of coeliac disease in children, suggest

© The Royal Australian College of General Practitioners 2018 REPRINTED FROM AJGP VOL. 47, NO. 1–2, JAN–FEB 2018 | 31
CLINICAL INTERPRETING TESTS FOR COELIAC DISEASE

small intestinal biopsies can be avoided

Table 2. How to test for coeliac disease
if children meet the following criteria:13
• characteristic symptoms of coeliac 1. Confirm your patient is consuming a normal, gluten-containing diet
disease
2. Request coeliac serology as follows:
• tTG-IgA levels >10× upper limit of
Option 1: Transglutaminase-IgA (tTG-IgA) + Deamidated gliadin peptide-IgG (DGP-IgG)
normal
– Medicare Benefits Schedule (MBS) item number 71164, double antibody test
• a positive endomysial antibody (EMA) ($39.90) is the preferred* one-step approach.
on a different blood sample Or
• positive HLA susceptibility for coeliac Option 2: Transglutaminase-IgA (tTG-IgA) + Total IgA level† – If the IgA level is low,
disease. perform the deamidated gliadin peptide-IgG (DGP-IgG). MBS item number
The utility of this approach in Australia 71163, single antibody test ($24.75).
is uncertain because of the limited
3. If tTG-IgA and/or DGP-IgG is positive, irrespective of titre, refer for confirmatory small
availability of the EMA test, as well
intestinal biopsy
as intra-lab variation and lack of
standardisation of the tTG assay. Further *Option 1 overcomes the need to assess the total IgA level by performing DGP-IgG, which is not adversely affected
by IgA deficiency. Further, DGP-IgG enhances the pick-up of coeliac disease by 15% compared to tTG-IgA alone. 25
validation is warranted. The decision to Positive tTG-IgA and DGP-IgG together provides greater predictive value for coeliac disease than either alone. 26
make a non-biopsy diagnosis should only †Total IgA level detects the 3% of people with coeliac disease with selective IgA deficiency that can cause false
negative results.
be made with specialist paediatric input.

Tips and pitfalls

• The tTG assay has lower sensitivity in small dietary indiscretions, and intestinal • Distinguishing coeliac disease from
children under three years of age. Ensure biopsies are recommended when disease ‘gluten sensitivity’ has important
DGP-IgG testing is performed alongside activity needs to be accurately assessed. implications for the patient and their
tTG-IgA to overcome this issue. family’s medical care.
• Children with coeliac disease may Conclusion • Do not forget family screening given the
present with more ‘classical’ complaints insidious nature and adverse outcomes
than adults,22 but be mindful of extra- Coeliac disease is highly prevalent in of undiagnosed coeliac disease.26,27
intestinal issues. Anxiety, depression, general practice. Good patient care
aggressive behaviour and sleep depends on knowing when and how to Authors
problems can be a presenting feature.23 test for it and how to monitor progress. Jason A Tye-Din MBBS, FRACP, PhD, Consultant
Awareness of the strengths and limitations Gastroenterologist and Laboratory Head,
Immunology Division, The Walter and Eliza Hall
Clinical follow-up of each testing approach is vital for optimal Institute Parkville, and Gastroenterology Department,
diagnosis and follow-up. The Royal Melbourne Hospital, Parkville, Vic. tyedin@
wehi.edu.au
Confirming successful treatment of
Competing interests: JT-D is a co-inventor of patents
coeliac disease with the GFD is important Key points pertaining to the use of gluten peptides in diagnostic
as the risk of complications is higher in applications and therapeutics, and non-toxic
patients not achieving mucosal remission.3 • Recognition and testing at-risk patients gluten for the management of coeliac disease. He
is a shareholder of Nexpep Pty Ltd and a scientific
Yearly follow-up to review medical and are keys to expediting coeliac disease advisor to ImmusanT Inc, companies developing
dietary progress is recommended.9 A diagnosis. novel diagnostic and therapeutic approaches for
repeat gastroscopy may be considered in • Coeliac disease serology and histology coeliac disease.
Provenance and peer review: Commissioned,
adults after two years of starting a GFD are not accurate in people following a externally peer reviewed.
to assess for mucosal healing.3 Coeliac GFD. Ask about diet when testing.
disease serology is frequently used as a • Positive coeliac disease serology
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© The Royal Australian College of General Practitioners 2018 REPRINTED FROM AJGP VOL. 47, NO. 1–2, JAN–FEB 2018 | 33