Intended for healthcare professionals

Practice Rational Testing

Investigating coeliac disease in adults

BMJ 2020; 369 doi: (Published 17 June 2020) Cite this as: BMJ 2020;369:m2176
  1. James J Ashton, paediatric gastroenterology research fellow1 2,
  2. Rebecca Smith, gastroenterology research fellow3,
  3. Trevor Smith, consultant gastroenterologist3,
  4. R Mark Beattie, consultant paediatric gastroenterologist1
  1. 1Department of Paediatric Gastroenterology, Southampton Children’s Hospital, Southampton SO16 6YD, UK
  2. 2Department of Human Genetics and Genomics, University of Southampton, Southampton, UK
  3. 3Department of Gastroenterology, University Hospital Southampton, Southampton, UK
  1. Correspondence to: R M Beattie Mark.beattie{at}

What you need to know

  • Coeliac disease is common and underdiagnosed, with a prevalence of around 1.4% in the general population. Presenting symptoms may be vague, and all patients with chronic gastrointestinal symptoms should be considered for screening

  • Patients should be screened with tissue transglutaminase (TTG) IgA and total IgA tests while on a gluten-containing diet

  • All patients with a positive TTG result must be referred to secondary care on a gluten-containing diet for an upper gastrointestinal endoscopy and histological diagnosis of coeliac disease

A 29 year old white woman presents to her general practitioner with a 12 month history of borderline anaemia (diagnosed when she tried to donate blood) alongside increasing bloating at the end of every day. On direct questioning, she has slightly looser stools compared with 5-10 years ago, but this has been attributed to irritable bowel syndrome by both the patient and previous GPs. She has no other medical history, including normal menarche. The GP decides to order some blood tests including a tissue transglutaminase (TTG) IgA test, which gives a result of 78.4 U/mL (normal range 0.0-4.5 U/mL), with normal total IgA (normal range 0.80-2.8 g/L).

What is coeliac disease?

Coeliac disease is a common autoimmune condition, often presenting with vague symptoms triggered by chronic gluten ingestion in genetically predisposed individuals. It is characterised by the presence of specific autoantibodies with a coexisting enteropathy.1 It is more common in females (1.5:1 predominance) and in populations with European ancestry, with an estimated prevalence of 1.4% globally.123 Despite growing recognition of coeliac disease, many cases remain undiagnosed: a North American study spanning 2006 to 2011 of over 30 000 individuals without a known coeliac disease diagnosis demonstrated coeliac-positive serology in 1.1%.4 The classic symptoms usually trigger testing, but patients with less common presentations are often not screened for coeliac disease.1 Timely diagnosis is important, …

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