This guideline presents an update to the 2013 American College of Gastroenterology Guideline on the Diagnosis and Management of Celiac Disease with updated recommendations for the evaluation and management of patients with celiac disease (CD). CD is defined as a permanent immune-mediated response to gluten present in wheat, barley, and rye. CD has a wide spectrum of clinical manifestations that resemble a multisystemic disorder rather than an isolated intestinal disease, and is characterized by small bowel injury and the presence of specific antibodies. Detection of CD-specific antibodies (e.g., tissue transglutaminase) in the serum is very helpful for the initial screening of patients with suspicion of CD. Intestinal biopsy is required in most patients to confirm the diagnosis. A nonbiopsy strategy for the diagnosis of CD in selected children is suggested and discussed in detail. Current treatment for CD requires strict adherence to a gluten-free diet (GFD) and lifelong medical follow-up. Most patients have excellent clinical response to a GFD. Nonresponsive CD is defined by persistent or recurrent symptoms despite being on a GFD. These patients require a systematic workup to rule out specific conditions that may cause persistent or recurrent symptoms, especially unintentional gluten contamination. Refractory CD is a rare cause of nonresponsive CD often associated with poor prognosis.

For patients with celiac disease (CeD), a lifelong gluten-free diet is not a voluntary lifestyle choice—it is a necessity. The key end points in clinical follow-up are symptom resolution, the normalization of weight, prevention of overweight, seroconversion, and negation or minimization of increased long-term morbidity. For the latter, a surrogate endpoint is mucosal healing, which means the normalization of histology to Marsh 0–1. Ideally, celiac follow-up care includes a multidisciplinary approach, effective referral processes, improved access that leverages technological advances, and following guidelines with the identification of measurable quality indicators, ideally informed by evidence-based research. Face-to-face CeD care and telemedicine are considered the standards for this process, although published data are insufficient. Guidelines and statements on diagnosis are readily available. However, data are lacking on optimal clinic visit intervals and outcomes and quality indicators such as improvement of symptoms, function and quality of life, survival and disease control, and how to most effectively use healthcare resources. The results of future research should provide the basis for general recommendations for evidence-based standards of quality of care in CeD.

Objectives: Limited data suggest complete mucosal healing in treated children with celiac disease (CD), but recent data from adult endoscopic biopsies have shown substantial numbers with persistent mucosal injury. We aimed to assess the rate of mucosal healing and indications for repeat small bowel (SB) biopsy in children with CD.Methods: We retrospectively reviewed records of children (ages 1–18 years) with CD who underwent a second SB biopsy. All of the children were seen at Mayo Clinic (Rochester, MN) from January 1997 through June 2013.Results: Forty children were identified (14 boys); average age at diagnosis was 8.5 years. Indications for second SB biopsy were abdominal pain (n = 20), diarrhea (n = 7), constipation (n = 5), non–celiac‐related concern (n = 2), follow‐up (n = 5), and persistent serology (n = 1). Average time between biopsies was 24 months (range 4–120 months). Histology on the second biopsy showed complete healing (n = 25), intraepithelial lymphocytes (n = 9), and persistent villous atrophy (n = 6). Of these, 3 patients had partial villous atrophy and 3 had with complete villous atrophy. Persistent villous atrophy was observed in 2 of 20 patients with abdominal pain and 1 of 7 with diarrhea. All of the patients with persistent constipation (n = 5) had complete resolution.Conclusions: Mucosal healing in children with CD may not be complete as previously assumed. Abdominal pain was the most common indication for repeating the SB biopsy. Persistence of abdominal pain, diarrhea, and constipation was poorly associated with persistence of mucosal injury.

Background Non-coeliac gluten/wheat sensitivity (NCGWS) is characterised by gastrointestinal and extraintestinal symptoms related to gluten or wheat ingestion in individuals without coeliac disease or wheat allergy. Objective A systematic review and meta-analysis was conducted to estimate the global burden and clinical characteristics of self-reported NCGWS. Design We searched for studies evaluating the prevalence of self-reported NCGWS in the general population. Pooled prevalence estimates and odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated using random-effects meta-analysis. Results Twenty-five studies comprising 49 476 participants from 16 countries were included in the analysis. The pooled prevalence of self-reported NCGWS was 10.3% (95% CI 7.0% to 14.0%), with marked variations between countries. Among individuals reporting NCGWS, 40% (95% CI 25.2% to 55.0%) adhered to a gluten-free diet. The most common symptoms were bloating (71.0%; 95% CI 62.8% to 79.1%), abdominal discomfort (46.0%; 95% CI 39.0% to 52.7%), abdominal pain (36.0%; 95% CI 28.6% to 43.2%) and fatigue (32.1%; 95% CI 25.3% to 39.0%). Self-reported NCGWS was significantly more common in females than in males (OR 2.29; 95% CI 1.80 to 2.90; p<0.001). Individuals who self-reported NCGWS were significantly more likely to report anxiety (OR 2.95; 95% CI 1.56 to 5.57; p<0.001), depression (OR 2.42; 95% CI 1.80 to 3.24; p<0.001) and irritable bowel syndrome (OR 4.78; 95% CI 3.48 to 6.57; p<0.001) than controls. Conclusion Approximately one in 10 people worldwide self-report NCGWS, with a female predominance and a significant association with psychological distress and irritable bowel syndrome. Our findings suggest positioning NCGWS within the spectrum of disorders of gut–brain interaction once organic pathologies have been excluded.