Background In 2020 ESPGHAN updated guidelines for the evaluation of suspected coeliac disease. Significant changes to diagnostic pathways have been recommended. The aim of this study is to audit how these recommendations have been implemented in a large tertiary children’s hospital, as part of a service evaluation optimising coeliac diagnostic pathways.

Methods Children between September 2020 and August 2021 who underwent evaluation and diagnosed with coeliac disease were retrospectively identified. Their indication for evaluation (such as symptom profile, high risk co-morbidities and family history), serology and genetic testing and subsequent biopsy or non-biopsy pathways were reviewed against ESPGHAN guidelines.

Results 24 children (8 male, 16 female) with an average age 8 years (range 2–16) were identified with an elevated (>6.9 U/ml) IgA tissue transglutaminase antibody (IgA TTG). Endomysial antibody testing (EMA) was sent in 11/24. Patients were screened for co-existing IgA deficiency. 5/24 underwent HLA testing. The median IgA TTG in this cohort was 21.2U/ml, with 7 having a IgA TTG ≥ 10 times the upper limit of normal. Those with an IgA TTG level that allowed a non-biopsy pathway, 2 children underwent endoscopic assessment. Those children with a IgA TTG <10 times the upper limit of normal, the biopsy pathway for assessment was recommended. 3 children has deferred endoscopic assessment, as families had opted for a gluten free diet prior to endoscopy.

All children who underwent the biopsy-pathway, during endoscopy had at ≥4 biopsies from the D2/D3 duodenum and ≥1 from the duodenal bulb, as per the guideline recommendations

Conclusions The non-biopsy pathway for the assessment and diagnosis of Coeliac disease has been successfully adopted, with (71%) of those appropriate for this approach, avoiding the need for endoscopy. Challenges in adopting these pathways were seen with clear documentation around shared decision making about choice of pathway, families adopting a gluten free diet prior to formal diagnosis and ongoing HLA testing for those with elevated IgA TTG at assessment.