Celiac Disease Follow-up: Complementary Measures to a Gluten-Free Diet

Evaluation and Monitoring

The American Gastroenterological Association recommends routine serological evaluation with serum levels of anti-transglutaminase type 2 IgA antibodies in patients with celiac disease on a gluten-free diet; a positive value suggests poor dietary adherence or gluten contamination, while a negative value does not confirm strict adherence or absence of gluten exposure 1, 2
The normalization of serology (anti-TG2 IgA) should not be considered a marker of mucosal recovery during long-term gluten-free diet due to its low sensitivity for identifying persistent villous atrophy 1
The analysis of clinical chemistry, including complete blood count, iron, folate, and other micronutrients, is recommended for the evaluation of malabsorption and nutritional status 1, 3
The follow-up of hemoglobin and serum ferritin levels is especially important in premenopausal women, considering iron supplementation when the gluten-free diet alone does not improve the deficiency 4
The evaluation of lipid profile and liver enzymes is recommended, as celiac disease patients have a higher risk of developing fatty liver and cardiovascular disease 4

The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition recommends dietary evaluation by a specialist to assess adherence to the gluten-free diet 1
Dietary evaluation is fundamental for monitoring the nutritional balance of the gluten-free diet during follow-up 1
The use of standardized patient-reported adherence questionnaires is recommended as a reasonable method of evaluation when an expert dietitian is not readily available 1
The determination of gluten immunogenic peptides (GIP) in urine or stool is recommended in cases of non-responsive celiac disease when gluten ingestion is suspected 1

The British Society of Gastroenterology does not recommend routine re-biopsy strategy in patients with celiac disease on a gluten-free diet 1
Repeating duodenal biopsy between 12-24 months after starting the gluten-free diet is considered reasonable in treated patients, unless in cases of severe clinical course where it would be indicated at a shorter interval 1
When a follow-up biopsy is performed, four oriented biopsies in the second portion of the duodenum, plus two oriented biopsies in the bulb, are recommended 1

The American College of Gastroenterology recommends the use of capsule endoscopy and/or device-assisted enteroscopy in the follow-up of celiac disease in cases of suspected complications and refractory celiac disease 1
The evaluation of bone mineral density using DXA is recommended in most adult patients after celiac disease diagnosis, especially when approaching premenopause or andropause 5
The analysis of T-cell receptor clonality is recommended to subtype refractory celiac disease when this complication is suspected 1

The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition suggests annual follow-up for most patients, with shorter intervals in case of non-responsive celiac disease 2
Follow-up should include clinical, serological, and dietary evaluation at each visit 6, 7

Adolescents are often less satisfied with the impact of celiac disease on their lives and are less adherent to the gluten-free diet, requiring closer follow-up 7
Promoting adherence to the gluten-free diet improves quality of life, but dietary hypervigilance that could decrease it should be monitored 1