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Coeliac Disease — RACP Adult Medicine MCQ

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HardGastroenterology & HepatologyCoeliac DiseaseRACP Adult Medicine

A 42-year-old woman with coeliac disease on a strict gluten-free diet presents with ongoing diarrhoea and weight loss after 12 months of dietary compliance. Anti-tTG antibodies are now negative. Duodenal biopsies show persistent villous atrophy. What is the most appropriate next step?

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Correct answer: C — Check for refractory coeliac disease with CD3/CD8 immunohistochemistry

Persistent villous atrophy despite a strict gluten-free diet (confirmed by negative serology) raises concern for refractory coeliac disease (RCD). Immunohistochemistry and flow cytometry for aberrant intraepithelial lymphocytes (CD3+/CD8-) distinguishes RCD type I (normal IELs, good prognosis) from RCD type II (aberrant IELs, risk of enteropathy-associated T-cell lymphoma).

Reference: eTG – 2025 – Gastrointestinal; BSGHAN/Coeliac UK – 2024 – Coeliac Disease Guidelines