The Role of Endoscopy in the Diagnosis of Coeliac Disease

Coeliac disease is a common autoimmune condition triggered by gluten in genetically predisposed individuals. While endoscopy with duodenal biopsies has traditionally been the diagnostic gold standard, this work demonstrates that serology-based diagnosis is a highly accurate, cost-effective, and environmentally sustainable alternative. A meta-analysis of 18 studies involving >12,000 adults revealed that tissue transglutaminase levels ≥10 times the upper limit of normal have 100% specificity and 98% positive predictive value, enabling a no-biopsy approach that could save the NHS over £2.5 million annually and reduce the carbon footprint by 87 tonnes of CO2. Patient preference study confirmed favourability for serology-based diagnosis over endoscopy and biopsies, emphasising diagnostic accuracy, reduced procedural discomfort, and shorter wait times as the main factors influencing patient choices. Interviews with primary and secondary care physicians identified confidence in serological tests and concerns about missed diagnoses as key factors influencing adoption. Additionally, patients with potential coeliac disease, positive serology and normal biopsies showed mixed outcomes, with some developing overt disease while others normalised serology; most symptomatic individuals benefited from a gluten-free diet. Narrow-band imaging during endoscopy was shown to accurately identify duodenal villous atrophy, reducing the need for random biopsies in patients with a low pre-test probability of coeliac disease. These findings underscore the evolving role of endoscopy, integrating advanced imaging and selective biopsy strategies. Serology-based diagnosis aligns with patient preferences, reduces healthcare burden, and promotes sustainability.