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Celiac Disease Clinical Diagnosis

The main diagnostic criteria still rest on duodenal biopsy fi ndings while the patient is following a normal diet and whether signifi cant clinical and analytical improvement is seen while the patient is on a strict GFD.

Patients usually undergo hematological and biochemical tests along with the determination of serological celiac disease markers (usually tTG-IgA class) by ELISA, when this disease is suspected. If serology results are negative, but clinical suspicion is high, intestinal biopsy should be performed.

These biopsies must be oriented correctly in order to determine the degree of villous atrophy and to assess the presence and quantify the number of IELs, epithelial disarray, crypts hyperplasia and the degree of chronic infl ammation present at the lamina propria. A clear clinical improvement while the patient is following the gluten-free diet yields a defi nitive diagnosis.

The serum antibodies generally disappear by 6 to 12 mo, although they are not necessarily a reliable indication of the mucosal response[25]. When patients do not present with the classic clinical symptoms of CD, a second biopsy that shows histologic improvement will confi rm the diagnosis. An algorithm for a possible diagnosis of celiac disease, consisting of several consecutive steps, is shown (Figure 1).

For diagnostic confirmation in uncertain cases, several potential strategies may be agreed upon according to patient and family preferences. Amongst them, we shall quote the following: (a) repeat serology and laboratory tests periodically (b) perform a full family exploration, searching the presence of new potential cases (c) perform a new endoscopy with biopsy samples (less accepted) (d) try a gluten-free diet for 6 mo, monitoring the clinical response as well as the serologic and analytical changes.

†Gluten challenge is not considered necessary for diagnosis, except in patients for whom no initial diagnostic biopsy was done, or results of biopsy are unclear or uncharacteristic of CD. Patients should be informed that they may have a severe reaction with the gluten challenge

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