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No-biopsy approach to the diagnosis of coeliac disease
  1. Geoffrey Holmes
  1. Department of Gastroenterology, Royal Derby Hospital, Derby, UK
  1. Correspondence to Dr Geoffrey Holmes, Royal Derby Hospital, Derby DE22 3NE, UK; geoffreyholmes31{at}

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In 1983, endomysial antibodies (EMAs) were found in the serum of patients with coeliac disease (CD) and dermatitis herpetiformis and with high sensitivity and specificity proved an almost ideal diagnostic test. The enzyme tissue transglutaminase (TTG) was identified as the endomysial antigen in 1997 and led to a further test that could be quantified and also exhibited high diagnostic accuracy. These tests allowed large scale screening studies that showed CD to be one of the most common chronic disorders in the western world with a prevalence of about 1%.1

Upper gastrointestinal endoscopy is invasive and for many patients requires sedation or occasionally general anaesthetic, is uncomfortable and interpretation of small intestinal biopsy specimens obtained is not always straightforward.1 The procedure is expensive and time consuming for patients and endoscopists. It was estimated that the cost of diagnosing CD in children could be reduced by 95% if endoscopies were omitted.2 Similar savings are likely to apply in adult practice. Therefore, the next step was to ask whether serological tests could be used to establish the diagnosis of CD without recourse to small intestinal biopsy. Studies based on a defined level of TTG antibodies indicated that this was the case and about 50% of paediatric and adult patients could be diagnosed without biopsy.1 The case was so compelling that the principle was incorporated into the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines for the diagnosis of CD in children in 2012 and modified in 2020. However, gastroenterologists in adult practice …

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  • Contributors I was invited to write this Commentary on a paper that I refereed and will be published in the journal.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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