Celiac Disease

Primary Author: Tebo, Anne E., PhD, D(ABMLI).

  • Key Points
  • Diagnosis
  • Algorithms
  • Screening
  • Monitoring
  • Background
  • Lab Tests
  • References
  • Related Topics
  • Videos

Celiac Disease in Children and Adolescents

Guidelines from the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) discuss serology testing for celiac disease (CD) evaluation and use of HLA-DQ2/HLA-DQ8 typing.

Recommendations for Celiac Disease (CD) Testing in Children and Adolescents (ESPGHAN 2012)*

ESPGHAN recommends testing for CD in children and adolescents

  • Who have unexplained
    • Gastroenterological symptoms
    • Poor growth
    • Delayed puberty
    • Iron deficiency anemia
    • Abnormal liver testing
  • Who have one of the following risks for CD (even if asymptomatic)

Laboratory Testing Options

Recommended antibody tests

*Individual must be on gluten-containing diet when tested and IgA status must be known

  • Tissue transglutaminase (tTG) or endomysial antibody (EMA) IgA testing – both tests highly sensitive
  • In children <2 yrs with high suspicion of CD – further testing may increase sensitivity if tTG and/or EMA IgA is negative
    • Consider anti-deamidated gliadin peptide (DGP) antibody test
  • Anti-gliadin antibody (AGA) testing is not useful

HLA genotyping

  • Should not be routinely performed
  • Absence of HLA-DQ2/HLA-DQ8 virtually excludes CD
  • Uses
    • Strong serologic evidence and clinical suspicion AND the desire is to avoid small bowel biopsy
    • Negative CD specific antibodies with mild changes on proximal small intestinal biopsy

Available recommended ARUP tests

*Husby S et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of coeliac disease. J Pediatr Gastroenterol Nutr. 2012 Jan;54(1):136-60

Indications for Testing

  • Symptomatic patient
    • Typical gastrointestinal manifestations of celiac disease (CD)
      • Chronic or intermittent diarrhea (in the absence of infectious etiology)
      • Failure to thrive (in children)
    • Atypical extraintestinal symptoms
  • Asymptomatic (at-risk) patient
    • Family history of CD
    • Syndromes associated with risk for CD (eg, Down syndrome, Turner syndrome)
    • Autoimmune disease associated with CD (eg, diabetes mellitus type 1, thyroid or adrenal disease)

Criteria for Diagnosis

  • Positive tTG IgA and/or EMA IgA serologic test and biopsy consistent with CD in individuals with normal serum IgA levels
    • CD may be confirmed without the need for biopsy in symptomatic individuals with high levels of CD-specific antibodies who are HLA-DQ2/DQ8 positive
  • Complete resolution of clinical symptoms and/or a seronegative response following a gluten-free diet
    • Gluten rechallenge not necessary except in patients who did not have initial biopsy or had an uncharacteristic biopsy

Laboratory Testing

  • Initial testing
    • Serum IgA level by nephelometry – determination of IgA levels prior to antibody testing is recommended; if patient is IgA deficient, all serologic testing must be performed using IgG tests to prevent false-negative antibody results
      • IgA level ≥7.0 mg/dL but below age-matched range – order Celiac Dual Antigen Screen with Reflex (see table above for components and characteristics)
      • IgA <7.0 mg/dL – order tTG IgG and DGP IgG
        • Consider evaluation for immunoglobulin deficiency if IgG is normal – IgA deficiency may accompany other immunoglobulin deficiencies
        • Note: infants may present with transient suboptimal levels of IgA and/or IgG levels, which may not be related to immune deficiency
      • IgA level normal (age-matched range) – order tTG IgA
  • Genetic testing – HLA genotyping
    • HLA-DQ2 (encoded by HLA-DQA1*05 and HLA-DQB1*02) and HLA-DQ8 (encoded by HLA-DQB1*03:02)
      • DQ2
        • Present in >90% of individuals with CD; presence does not confirm CD
        • Found in 20-30% of general population
      • DQ8
        • Present in ~5-10% of individuals with CD
        • Found in 10% of general population
      • Absence virtually excludes CD
      • Not necessary for routine laboratory evaluation of CD due to low positive predictive value
      • May be indicated in individuals at risk for CD or individuals who are repeatedly seropositive but biopsy-negative
      • Wheat allergy testing – not relevant; do not order
      • Biopsy can be avoided if IgA anti-tTg >10x manufacturer's cutoff, confirmed by EMA in a different blood sample, and HLA testing is positive (ESPGHAN, 2012)
    •  Results
      • HLA positive – CD confirmed
        • Not necessary to confirm by biopsy; may consider biopsy for atypical presentation
      • HLA negative – likely false-positive tTG test
  • Other testing
    • F-actin IgA antibody by ELISA
      • Presence of anti-actin antibodies in biopsy-confirmed CD patients may indicate intestinal villus atrophy – more severe form of disease expected
      • Should be ordered only in patients with confirmed CD by biopsy
  • Histology

    • Duodenal biopsy – gold standard for CD diagnosis
      • 4-5 samples preferred to increase probability
      • Patient should not be on a gluten-free diet at time of biopsy
      • Intestinal damage is assessed by a modified Marsh score
        • Scores range from 0, 1, 2, 3a to 3c
        • Marsh 0-1
          • Consider early phase disease or false-positive result
          • Follow-up testing on normal diet
        • Marsh ≥2
          • CD confirmed

    Prognosis

    • Anti-actin IgA (F-actin) levels correlate with severity of mucosa damage – may indicate moderate to severe disease
      • Lacks specificity

    Differential Diagnosis

     

    • Serologic and/or genetic (HLA-DQ2 and HLA-DQ8) screening is not recommended for the general population
    • Serologic screening for celiac disease (CD) is recommended for specific at-risk groups, including first degree relatives of CD patients and individuals who have the following
    • For asymptomatic at-risk children (groups referred to above) screening  should begin after 2 years and when child has been on wheat diet for ≥1 year or when suggestive signs and symptoms are present
    • HLA-DQ2 and HLA-DQ8 testing is generally recommended for exclusion of CD when serologic and biopsy results are equivocal
      • In rare cases, some patients with CD have been reported to have only DQA1*05 or DQB1*02, the latter usually associated with HLA-DR7 heterozygosity or homozygosity
    • Monitoring adherence to gluten-free diet (GFD) or disease activity (American Gastroenterological Association [AGA] guidelines, 2006)
      • tTG and/or DGP IgA or IgG assay, EMA assay
        • Assay should be chosen (IgA or IgG) based on IgA levels
        • Either tTG, DGP, or EMA assays can be used depending on previous results in monitoring adherence to GFD
        • Typically ordered every 3-6 months – if levels remain elevated after >12 months of GFD, consider rebiopsy
        • Decline in antibody levels may correlate with normalization of the intestinal villi
      • F-actin IgA antibody
        • Strict adherence to GFD and normalization of the intestinal villi correlate with declining levels of F-actin IgA antibodies in some patients with celiac disease

    Celiac disease (CD), or gluten sensitive enteropathy, is a nonallergic, immune-mediated sensitivity (in genetically susceptible individuals) to gluten in wheat or related proteins found in barley and rye.

    Epidemiology

    • Incidence – 1/100-300 in western countries (Brusca, 2015)
    • Age – three peaks
      • Infancy
      • Second to third decade of life
      • Fifth to sixth decade of life
    • Sex – M>F, (2-3:1)
    • Ethnicity – mainly affects Caucasians of European origin

    Genetics

    • HLA-DQ2 (encoded by HLA-DQA1*05 and HLA-DQB1*02) – 90-95% of CD patients have HLA-DQ2
    • HLA-DQ8 (encoded by HLA-DQB1*03:02) – 5-10% of CD patients have HLA-DQ8
    • 75-90% concordance in monozygotic twins; 10-20% in dizygotic twins

    Risk Factors

    Pathophysiology

    • T-cell mediated inflammatory response in proximal small bowel
      • Celiac lesion may be characterized by increased intraepithelial lymphocytes with crypt hyperplasia and partial, subtotal, or total atrophy
    • tTG (tissue transglutaminase) has been identified as the major target autoantigen of the endomysial antibody (EMA)
      • tTG is an enzyme that catalyzes the replacement of amide groups of protein and peptide-bound glutamine residues by primary amines (cross-linking) as well as by hydrolysis (deamidation)
    • Gliadin, a glutamine-rich protein, has been identified as a specific substrate for tTG
      • Deamidation of gliadin has been reported to improve the overall diagnostic performance of conventional antigliadin antibody assays

    Clinical Presentation

    • Clinical presentation – varied, tends to differ by age group
      • General symptoms – fatigue, weight loss
      • Pediatric symptoms – diarrhea, abdominal distention, pain, malnutrition
      • Adult symptoms
        • Intestinal symptoms
          • Abdominal pain
          • Flatulence
          • Diarrhea
        • Extraintestinal symptoms
          • Anemia
          • Fatigue and malaise – may occur independently of anemia
          • Neurologic or psychiatric disorders – epilepsy, depression, migraines
          • Musculoskeletal disorders – osteopenia, osteoporosis,  joint pain/inflammation
          • Infertility/recurrent fetal loss
          • Mouth ulcers/dermatitis herpetiformis
    • Associated conditions
    Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

    Celiac Disease Reflexive Cascade 2008114
    Method: Quantitative Nephelometry/Semi-Quantitative Enzyme-Linked Immunosorbent Assay//Semi-Quantitative Indirect Fluorescent Antibody

    Limitations 

    ​Correlation between celiac disease serologic tests may be variable at low antibody titers, early disease or treatment with GFD; strong clinical correlation is recommended

    At screening dilution, EMA may show prozone phenomenon; if suspicion for disease is strong, consider testing for tTg and/or DGP antibodies

    False-negative results

    • Early disease
    • Individuals on GFD
    • Use of immunosuppression

    False-positive results

    • Consider early disease and or specific risk for CD
    • Small bowel biopsy and/or HLA DQ typing may be important in establishing a diagnosis CD based on patient’s age, clinical symptoms and/or risk for disease 

    Tissue Transglutaminase (tTG) Antibody, IgA 0097709
    Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay

    Limitations 

    Correlation between celiac disease serologic tests may be variable at low antibody titers, early disease or treatment with GFD; strong clinical correlation is recommended

    False-negative results

    • Early disease
    • Individuals on GFD
    • Use of immunosuppression

    False-positive results

    • Consider early disease and or specific risk for CD
    • Small bowel biopsy and/or HLA DQ typing may be important in establishing a diagnosis CD based on patient’s age, clinical symptoms and/or risk for disease 

    Tissue Transglutaminase Antibody, IgG 0056009
    Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay

    Limitations 

    Correlation between celiac disease serologic tests may be variable at low antibody titers, early disease or treatment with GFD; strong clinical correlation is recommended

    False-negative results

    • Early disease
    • Individuals on GFD
    • Use of immunosuppression

    False-positive results

    • Consider early disease and or specific risk for CD
    • Small bowel biopsy and/or HLA DQ typing may be important in establishing a diagnosis CD based on patient’s age, clinical symptoms and/or risk for disease 

    Deamidated Gliadin Peptide (DGP) Antibody, IgA 0051357
    Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay

    Limitations 

    Correlation between celiac disease serologic tests may be variable at low antibody titers, early disease or treatment with GFD; strong clinical correlation is recommended

    False-negative results

    • Early disease
    • Individuals on GFD
    • Use of immunosuppression

    False-positive results

    • Consider early disease and or specific risk for CD
    • Small bowel biopsy and/or HLA DQ typing may be important in establishing a diagnosis CD based on patient’s age, clinical symptoms and/or risk for disease

    Deamidated Gliadin Peptide (DGP) Antibody, IgG 0051359
    Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay

    Limitations 

    Correlation between celiac disease serologic tests may be variable at low antibody titers, early disease or treatment with GFD; strong clinical correlation is recommended

    False-negative results

    • Early disease
    • Individuals on GFD
    • Use of immunosuppression

    False-positive results

    • Consider early disease and or specific risk for CD
    • Small bowel biopsy and/or HLA DQ typing may be important in establishing a diagnosis CD based on patient’s age, clinical symptoms and/or risk for disease

    Endomysial Antibody, IgA by IFA 0050736
    Method: Semi-Quantitative Indirect Fluorescent Antibody

    Limitations 

    Correlation between celiac disease serologic tests may be variable at low antibody titers, early disease or treatment with GFD; strong clinical correlation is recommended

    At screening dilution, EMA may show prozone phenomenon; if suspicion for disease is strong, consider testing for tTg and/or DGP antibodies

    False-negative results

    • Early disease
    • Individuals on GFD
    • Use of immunosuppression

    False-positive results

    • Consider early disease and or specific risk for CD
    • Small bowel biopsy and/or HLA DQ typing may be important in establishing a diagnosis CD based on patient’s age, clinical symptoms and/or risk for disease

    Endomysial Antibody, IgG 2005501
    Method: Semi-Quantitative Indirect Fluorescent Antibody

    Limitations 

    Correlation between celiac disease serologic tests may be variable at low antibody titers, early disease or treatment with GFD; strong clinical correlation is recommended

    At screening dilution, EMA may show prozone phenomenon; if suspicion for disease is strong, consider testing for tTg and/or DGP antibodies

    Sera containing anti-smooth muscle antibodies (ASMA) will interfere with the detection of EMA IgG

    Sera should be further tested at higher dilutions

    False-negative results

    • Early disease
    • Individuals on GFD
    • Use of immunosuppression

    False-positive results

    • Consider early disease and or specific risk for CD
    • Small bowel biopsy and/or HLA DQ typing may be important in establishing a diagnosis CD based on patient’s age, clinical symptoms and/or risk for disease 

    Celiac Disease Dual Antigen Screen with Reflex 2002026
    Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay

    Limitations 

    Correlation between celiac disease serologic tests may be variable at low antibody titers, early disease or treatment with GFD; strong clinical correlation is recommended

    False-negative results

    • Early disease
    • Individuals on GFD
    • Use of immunosuppression

    False-positive results

    • Consider early disease and or specific risk for CD
    • Small bowel biopsy and/or HLA DQ typing may be important in establishing a diagnosis CD based on patient’s age, clinical symptoms and/or risk for disease

    Celiac Disease Dual Antigen Screen 0051689
    Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay

    Limitations 

    Correlation between celiac disease serologic tests may be variable at low antibody titers, early disease or treatment with GFD; strong clinical correlation is recommended

    False-negative results

    • Early disease
    • Individuals on GFD
    • Use of immunosuppression

    False-positive results

    • Consider early disease and or specific risk for CD
    • Small bowel biopsy and/or HLA DQ typing may be important in establishing a diagnosis CD based on patient’s age, clinical symptoms and/or risk for disease

    F-Actin (Smooth Muscle) Antibody, IgA 0051724
    Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay

    Limitations 

    Not specific for CD

    Does not replace intestinal biopsy for confirming CD

    Celiac Disease (HLA-DQ2, and HLA-DQ8) Genotyping 2005018
    Method: Polymerase Chain Reaction/Fluorescence Monitoring

    Limitations 

    Other HLA types will not be detected

    Copy of each detected allele will not be determined

    Rare diagnostic errors can occur due to probe-site mutations

    Guidelines

    Giersiepen K, Lelgemann M, Stuhldreher N, Ronfani L, Husby S, Koletzko S, Korponay-Szabó IR, ESPGHAN Working Group on Coeliac Disease Diagnosis. Accuracy of diagnostic antibody tests for coeliac disease in children: summary of an evidence report. J Pediatr Gastroenterol Nutr. 2012; 54(2): 229-41. PubMed

    Hill ID, Dirks MH, Liptak GS, Colletti RB, Fasano A, Guandalini S, Hoffenberg EJ, Horvath K, Murray JA, Pivor M, Seidman EG, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2005; 40(1): 1-19. PubMed

    Husby S, Koletzko S, Korponay-Szabó IR, Mearin ML, Phillips A, Shamir R, Troncone R, Giersiepen K, Branski D, Catassi C, Lelgeman M, Mäki M, Ribes-Koninckx C, Ventura A, Zimmer KP, ESPGHAN Working Group on Coeliac Disease Diagnosis, ESPGHAN Gastroenterology Committee, European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of coeliac disease. J Pediatr Gastroenterol Nutr. 2012; 54(1): 136-60. PubMed

    Rostom A, Murray JA, Kagnoff MF. American Gastroenterological Association (AGA) Institute technical review on the diagnosis and management of celiac disease. Gastroenterology. 2006; 131(6): 1981-2002. PubMed

    Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA, American College of Gastroenterology. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol. 2013; 108(5): 656-76; quiz 677. PubMed

    General References

    Brusca I. Overview of biomarkers for diagnosis and monitoring of celiac disease. Adv Clin Chem. 2015; 68: 1-55. PubMed

    Caja S, Mäki M, Kaukinen K, Lindfors K. Antibodies in celiac disease: implications beyond diagnostics. Cell Mol Immunol. 2011; 8(2): 103-9. PubMed

    Crowe SE. In the clinic. Celiac disease. Ann Intern Med. 2011; 154(9): ITC5-1-ITC5-15; quiz ITC5-16. PubMed

    Ensari A. Gluten-sensitive enteropathy (celiac disease): controversies in diagnosis and classification. Arch Pathol Lab Med. 2010; 134(6): 826-36. PubMed

    Harrison MS, Wehbi M, Obideen K. Celiac disease: more common than you think. Cleve Clin J Med. 2007; 74(3): 209-15. PubMed

    Jenkins HR, Murch SH, Beattie RM, Coeliac Disease Working Group of British Society of Paediatric Gastroenterology, Hepatology and Nutrition. Diagnosing coeliac disease. Arch Dis Child. 2012; 97(5): 393-4. PubMed

    Lebwohl B, Ludvigsson JF, Green PH. Celiac disease and non-celiac gluten sensitivity. BMJ. 2015 Oct 5;351:h4347. Review. PubMed

    Plebani M, Basso D. Diagnostic testing for celiac disease. JAMA. 2010; 304(6): 639; author reply 639-40. PubMed

    Prause C, Richter T, Koletzko S, Uhlig H, Hauer AC, Stern M, Zimmer K, Laass MW, Probst C, Schlumberger W, Mothes T. New developments in serodiagnosis of childhood celiac disease: assay of antibodies against deamidated gliadin. Ann N Y Acad Sci. 2009; 1173: 28-35. PubMed

    Sugai E, Hwang HJ, Vázquez H, Smecuol E, Niveloni S, Mazure R, Mauriño E, Aeschlimann P, Binder W, Aeschlimann D, Bai JC. New serology assays can detect gluten sensitivity among enteropathy patients seronegative for anti-tissue transglutaminase. Clin Chem. 2010; 56(4): 661-5. PubMed

    van der Windt DA, Jellema P, Mulder CJ, Kneepkens CM, van der Horst HE. Diagnostic testing for celiac disease among patients with abdominal symptoms: a systematic review. JAMA. 2010; 303(17): 1738-46. PubMed

    Vermeersch P, Coenen D, Geboes K, Mariën G, Hiele M, Bossuyt X. Use of likelihood ratios improves clinical interpretation of IgA anti-tTG antibody testing for celiac disease. Clin Chim Acta. 2010; 411(1-2): 13-7. PubMed

    References from the ARUP Institute for Clinical and Experimental Pathology

    Jaskowski TD, Hamblin T, Wilson AR, Hill HR, Book LS, Meyer LJ, Zone JJ, Hull CM. IgA anti-epidermal transglutaminase antibodies in dermatitis herpetiformis and pediatric celiac disease. J Invest Dermatol. 2009; 129(11): 2728-30. PubMed

    Jaskowski TD, Schroder C, Martins TB, Litwin CM, Hill HR. IgA antibodies against endomysium and transglutaminase: a comparison of methods. J Clin Lab Anal. 2001; 15(3): 108-11. PubMed

    Nandiwada SL, Tebo AE. Testing for antireticulin antibodies in patients with celiac disease is obsolete: a review of recommendations for serologic screening and the literature. Clin Vaccine Immunol. 2013; 20(4): 447-51. PubMed

    Patil DT, Bennett AE, Mahajan D, Bronner MP. Distinguishing Barrett gastric foveolar dysplasia from reactive cardiac mucosa in gastroesophageal reflux disease. Hum Pathol. 2013; 44(6): 1146-53. PubMed

    Medical Reviewers

    Last Update: August 2016