The no-biopsy pathway has arrived, and it stops at the surgery door
For the first time since 2014, adults in the UK can be diagnosed with coeliac disease without a duodenal biopsy. The British Society of Gastroenterology released its updated adult guideline on 12 July 2026. It allows a serology-only diagnosis if the IgA tissue transglutaminase level is ten times the normal limit. The details are more important than the headline. The pathway applies only to symptomatic adults assessed in secondary care, it is optional, and it rests on a conditional recommendation rather than a strong one.
The reasoning turns on prevalence. The meta-analysis behind the recommendation combined eighteen studies with 12,103 participants. It found a summary sensitivity of 51% (95% CI 42 to 60) and a specificity of 100% (95% CI 98 to 100) for the ten times threshold. Only 32% of adults with a raised tTG reached this threshold.1 Positive predictive value was 99% when disease prevalence was 40%. It was 95% at 10%, 88% at 4%, and 65% at 1%.1 The pooled prevalence across the source cohorts was 62%, showing how selected those populations were.
The guideline draws the conclusion directly, stating that the approach is neither accurate nor applicable in asymptomatic or screening settings and that all accuracy data derive from secondary care.[1] There is a laboratory constraint too. Assay performance varies by platform. Centres using the pathway must join UK NEQAS or conduct local audits. The guideline warns against setting any threshold below ten times the upper limit of normal.
For primary care, the task is therefore unchanged and stated more clearly than it has been since 2020. Test while the patient is still eating gluten, check total IgA alongside IgA-tTG, refer all newly positive serology, and do not start a gluten-free diet before confirmation.[1] A very high titre flags the referral rather than licensing a diagnosis. The same applies to children, who fall outside this guideline entirely.
That leaves NICE. NG20 dates from 2015, was last reviewed in 2019, and permits no serology-only diagnosis in any group.[3] The 2019 surveillance decision said NICE would revisit the question once the BSG published. Until it does, two national reference points disagree and local pathways will inherit the difference.
The quietest change may prove the most consequential. After two years, patients who are doing well switch to patient-initiated follow-up. This makes the practice the main contact for annual reviews, nutrient checks and vaccination status.1
Guideline comparison: serologic diagnosis of coeliac disease
BSG 2026 (adults) | NICE NG20 (children and adults) | ESsCD 2025 (adults) | ESPGHAN 2020 (children) | ACG 2023 | |
|---|---|---|---|---|---|
First-line serology | IgA-tTG | Total IgA and IgA-tTG | IgA anti-TG2 with total IgA | Total IgA and TGA-IgA, any age | tTG-IgA |
Role of EMA / DGP | tTG first line; DGP less available in UK | IgA EMA if tTG weakly positive; IgG tests if IgA deficient | Routine EMA no longer recommended for confirmation | DGP recommended against for initial testing | EMA used in paediatric confirmation |
No-biopsy diagnosis, adults | Yes, conditional. IgA-tTG ≥10× ULN, symptomatic, secondary care, shared decision-making | Not permitted | Yes, conditional. Adults <45 years, ≥10× ULN, confirmed on separate sample | Not applicable | Not endorsed in adults |
No-biopsy diagnosis, children | Not applicable | Not permitted | Not applicable | Yes. TGA-IgA ≥10× ULN plus positive EMA-IgA on second sample; HLA typing no longer required | Suggested as reliable in children |
Excluded from serology-only route | Asymptomatic or screening settings; selective IgA deficiency; recent autoimmune diagnosis including type 1 diabetes; red-flag symptoms | Not applicable | Age >45; alarm symptoms; selective IgA deficiency | Selective IgA deficiency; not endorsed in type 1 diabetes | Not applicable |
Where diagnosis is made | Secondary care | Specialist, after referral | Secondary care | Paediatric specialist | Specialist |
Action on tTG ≥10× ULN in primary care | Refer; do not diagnose or start diet | Refer for biopsy | Refer | Refer | Refer |
Action on tTG 1–10× ULN | Refer for biopsy | Refer for biopsy | Refer for biopsy | Refer | Refer for biopsy |
Patient already gluten-free | Gluten challenge 3–6 g daily for ≥6 weeks; HLA typing may avoid challenge | Continue gluten until diagnosis confirmed | Testing on gluten-containing diet required | Testing on gluten-containing diet required | Testing on gluten-containing diet required |
DXA | All newly diagnosed adults at 1 year; repeat at 2–3 years if persisting villous atrophy or refractory disease | Assessed at annual review as indicated | Not addressed in Part 1 | Not addressed | Indicated where malabsorption present |
Pneumococcal vaccination | All adults; booster at 5 years in refractory disease or immunosuppression | Recommended (2020 update) | Not addressed in Part 1 | Not addressed | Not addressed |
ULN, upper limit of normal. BSG 2026 covers adults only; paediatric UK practice follows ESPGHAN 2020 via BSPGHAN alongside NICE NG20.
References
Penny HA, Shiha MG, Raju SA, et al. The 2026 British Society of Gastroenterology guidelines on the diagnosis and management of adult coeliac disease. Gut 2026;0:1–28. doi:10.1136/gutjnl-2025-337747
Shiha MG, Nandi N, Raju SA, et al. Accuracy of the no-biopsy approach for the diagnosis of celiac disease in adults: a systematic review and meta-analysis. Gastroenterology 2024;166(4):620–630. doi:10.1053/j.gastro.2023.12.023
National Institute for Health and Care Excellence. Coeliac disease: recognition, assessment and management. NICE guideline NG20. London: NICE, 2015 (last reviewed December 2019). nice.org.uk/guidance/ng20
Further reading
Harper AM, Banks J, Elwenspoek M, et al. Navigating coeliac disease diagnosis in primary care. Br J Gen Pract 2024;74(739):52. doi:10.3399/bjgp24X736137
Husby S, Koletzko S, Korponay-Szabo IR, et al. European Society Paediatric Gastroenterology, Hepatology and Nutrition guidelines for diagnosing coeliac disease 2020. J Pediatr Gastroenterol Nutr 2020;70(1):141–156. doi:10.1097/MPG.0000000000002497
Al-Toma A, Volta U, Auricchio R, et al. European Society for the Study of Coeliac Disease 2025 updated guidelines on the diagnosis and management of coeliac disease in adults. Part 1: diagnostic approach. United European Gastroenterol J 2025;13(10):1855–1886. doi:10.1002/ueg2.70119
This article is intended for UK Healthcare Professionals only. It reports what current guidelines and published evidence state and does not constitute prescribing or clinical management advice. Content reflects evidence current at time of publication and should be read alongside local formulary and clinical guidance.
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