The 2026 British Society of Gastroenterology guidelines on the diagnosis and management of adult coeliac disease

The link below will take you to the 28 page study posted on bsg.org.uk:

This document outlines an updated guideline from the British Society of Gastroenterology, detailing the standards for diagnosing and managing adult coeliac disease (CD). A multidisciplinary panel from across the UK, Sweden, Italy and Australia contributed to the development of these guidelines. This update is prompted by recent advancements in the diagnosis and treatment of adult CD. The primary goal is to emphasise evidence-based practices to enhance the management of adult CD, with the aim of improving patient care.

Here are a few highlights, but it is recommended to review the publication in its entirety.

Evidence and Recommendations: DIAGNOSIS

Recommendation 1: We recommend that patients consume a gluten-containing diet prior to testing for CD.
Recommendation 2: We recommend testing for IgA-tTG antibodies as the first-line investigation for CD.
Recommendation 3: We suggest measuring IgG-based coeliac serology and upper GI endoscopy with duodenal biopsies in individuals with sIgAD and clinical suspicion for CD.
Recommendation 4: We recommend that at least four biopsies from the second part of the duodenum (D2) and two biopsies from the duodenal bulb (D1) are sampled when biopsies are required for the investigation of suspected CD.
Recommendation 5: We recommend that a diagnosis of CD can be made in patients with positive coeliac serology and duodenal biopsies demonstrating increased intraepithelial lymphocytes (IELs) (>25/100 epithelial cells) plus crypt hyperplasia with/without villous atrophy: this equates to a Marsh 2 or 3 histology grading stage.
Recommendation 6: We suggest that in symptomatic adults being assessed in secondary-care settings, a diagnosis of CD can be made without duodenal biopsies when IgA-tTG titre ≥10× ULN. This ‘no-biopsy’ pathway is optional and should be adopted only after shared decision-making with the patient.

Box 2: Test for coeliac disease in people with any of the following (relevant to the no-biopsy pathway)

⇒ Persistent unexplained abdominal or gastrointestinal symptoms
⇒ Prolonged fatigue
⇒ Unexpected weight loss
⇒ Severe or persistent mouth ulcers
⇒ Unexplained iron, vitamin B12 or folate deficiency

Box 3: Consider testing for coeliac disease in people with any of the following

⇒ Unexplained neurological symptoms (particularly peripheral neuropathy or ataxia)
⇒ Dental enamel defects
⇒ Persistently raised liver enzymes with unknown cause
⇒ Unexplained subfertility or recurrent miscarriage
⇒ Metabolic bone disorder (reduced bone mineral density or osteomalacia)

The Gluten Challenge

Recommendation 7: For the gluten challenge, we recommend a dose of 3–6g of gluten daily for at least 6weeks (read more in the publication about the gluten challenge).

Table 4: Food portions that contain approximately 3 g of gluten that can be used for a gluten challenge

Gluten-containing food	3g gluten exchange
Sourdough spelt bread#	60 g (1.5–2 slices bread/medium bread roll)
Wheat-based breakfast cereal (e.g., Shredded wheat/Weetabix)	25 g wheat-based cereal (two Weetabix or two fist-sized portions of cereal)

Who Should Be Screened?

Box 4: Conditions where coeliac screening is recommended

Gastrointestinal diseases: Irritable bowel syndrome, inflammatory bowel disease, microscopic colitis, autoimmune atrophic gastritis
Endocrinological disorders: Type 1 diabetes mellitus, autoimmune thyroid disease (Hashimoto’s and Graves’ disease), Addison’s disease
Liver/spleen/pancreatic disorders: Autoimmune hepatitis, hyposplenism with severe bacterial infections, idiopathic pancreatitis
Skin disorders and connective tissue disorders: Dermatitis herpetiformis (biopsy needed to confirm coeliac disease), Sjögren syndrome
Gynaecological disorders: Delayed menarche, premature menopause
Genetic conditions: Down syndrome, Turner syndrome, Williams (Beuren) syndrome
Other disorders: Selective IgA deficiency, chronic fatigue syndrome, IgA nephropathy
First-degree relatives

“The gluten-free diet: the only clinically prescribed treatment for coeliac disease”

Recommendation 8: We suggest a trial of a GFD for symptomatic patients with potential CD under the guidance of a specialist dietitian.
Recommendation 9: We recommend that patients diagnosed with CD maintain a lifelong GFD to help improve symptoms, QoL and reduce the risk of complications associated with the condition.
Recommendation 10: We suggest that gluten-free oats ingestion should be discussed with patients with CD and advised as soon as the GFD is commenced in the setting of appropriate clinical follow-up.

Managing Accidental Exposure

Box 7: Management approach for acute gluten exposure

⇒ Reassurance that symptoms will settle and are highly unlikely to cause long-term damage
⇒ Help identify possible sources of gluten exposure
⇒ Ensure adequate hydration
⇒ Analgesia where required
⇒ Ondansetron for vomiting if protracted

Bottom line: refer to the statement above, “The gluten-free diet: the only clinically prescribed treatment for coeliac disease.” Carry on then…

Please read more from the publication as this is just a small portion of the information.