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Celiac disease

ACG-based case finding, serology and biopsy diagnosis, gluten-free treatment, nutritional assessment and follow-up for celiac disease.

JurisdictionUnited States
Source check2026-08-20
Clinical reviewiatroX editorial team · Clinical editorial review · reviewed 2026-08-20 · due 2027-08-20
AudienceUnited States healthcare professionals
This is an iatroX educational summary of named United States sources, not an official guideline. It does not replace the complete source documents, local policy, specialist advice or clinical judgement. Use the named authority, current FDA labeling, applicable state law, payer rules and local protocol where relevant.

Scope of this summary

Children and adults being evaluated for or living with immune-mediated celiac disease. Testing must usually occur while eating gluten. Wheat allergy, non-celiac gluten sensitivity, refractory celiac disease and dermatitis herpetiformis need condition-specific expertise; this summary does not endorse direct-to-consumer testing.
sources for this section:acg-celiac-2023

The Bottom Line

  • Test people with compatible gastrointestinal, nutritional, hepatic, bone, neurologic or autoimmune features and selected at-risk first-degree relatives rather than screening indiscriminately without context.
  • Use tissue-transglutaminase IgA with assessment for IgA deficiency as the usual first-line strategy; use IgG-based testing when IgA deficiency is present and interpret all serology while the patient consumes gluten.
  • In most adults, confirm suspected disease with upper endoscopy and multiple duodenal biopsies before prescribing lifelong treatment; a negative serology does not end evaluation when clinical suspicion remains high.
  • Treat confirmed celiac disease with a strict, lifelong gluten-free diet under a dietitian experienced in celiac care, addressing oats, cross-contact, medicines and nutritional adequacy.
  • Follow symptoms, serology, adherence and consequences such as iron, folate, vitamin B12, vitamin D and bone disease; persistent symptoms require a structured search for exposure, alternative diagnoses and refractory disease.
sources for this section:acg-celiac-2023

Practical clinical workflow

1
Record symptoms, growth or weight, anemia, fractures, liver tests, autoimmune disease, family history and prior gluten restriction; explain why self-starting a gluten-free diet can compromise diagnosis.
2
Order tTG-IgA and total IgA or a validated equivalent strategy while gluten is consumed; add appropriate IgG testing for IgA deficiency and refer serology–phenotype discordance.
3
Arrange specialist endoscopy and correctly distributed duodenal biopsies for diagnostic confirmation in the usual adult pathway; use pediatric no-biopsy criteria only within the exact specialist guideline that supports them.
4
At diagnosis, establish dietitian support, baseline nutritional and bone-risk assessment, vaccinations and associated-condition review appropriate to age and clinical findings.
5
Reassess clinical response and celiac serology, then investigate ongoing symptoms for hidden gluten, microscopic colitis, pancreatic insufficiency, IBS, small-bowel disease or refractory celiac disease as indicated.
sources for this section:acg-celiac-2023

Safety boundaries and escalation

  • Severe dehydration, major weight loss, electrolyte disturbance, bleeding, obstruction or concern for celiac crisis or malignancy requires urgent specialist assessment.
  • Do not diagnose celiac disease from HLA status, symptoms, a commercial food panel or response to diet alone; HLA testing is mainly useful when its absence can help exclude disease in selected uncertain cases.
  • Gluten challenge should be planned with gastroenterology when testing followed prior restriction; it may be inappropriate or poorly tolerated in some patients.
  • Persistent villous atrophy or symptoms despite verified adherence requires specialist review for refractory disease and complications rather than intensifying dietary restriction without evidence.
sources for this section:acg-celiac-2023

Localization

Use the 2023 ACG diagnostic framework, US food labeling and US dietetic resources. “Gluten-free” labeling, oats supply and insurance coverage vary from other countries.
sources for this section:acg-celiac-2023

Source documents

Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.

  1. American College of GastroenterologyAmerican College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac DiseaseDOI 10.14309/ajg.0000000000002075 · published 2023-01-01 · accessed 2026-08-20
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