AGA Clinical Practice Update on the Evaluation and Management of Seronegative Enteropathies

Abstract Description We aim to provide a consensus statement for the best approaches for diagnosis and management of patients with suspected enteropathy but negative results from serologic tests for celiac disease (seronegative enteropathy). Methods We collected findings from published cohort, case–control, and cross-sectional studies of diagnosis and case series and descriptive studies of management of patients believed to have celiac disease or other enteropathies unrelated to gluten but negative results from serologic tests. Best Practice Advice Best practice advice 1: review histologic findings with experienced pathologists who specialize in gastroenterology. Best practice advice 2: serologic tests are essential for an accurate diagnosis of celiac disease. For patients with suspected celiac disease but negative results from serologic tests, total immunoglobulin A (IgA) level should be measured; patients should also be tested for anti-tissue transglutaminase, IgA against deamidated gliadin peptide, and endomysial antibody (IgA). Patients with total IgA levels below the lower limit of detection and IgG against tissue transglutaminase or deamidated gliadin peptide, or endomysial antibody, should be considered to have celiac disease with selective IgA deficiency rather than seronegative celiac disease. Best practice advice 3: patients’ diets should be carefully reviewed and duodenal biopsies should be collected and analyzed at the time of serologic testing, to determine exposure to gluten and accuracy of test results. Best practice advice 4: thorough medication histories should be collected from patients, with attention to angiotensin II receptor blockers such as olmesartan, along with travel histories to identify potential etiologies of villous atrophy. This will guide additional testing. Best practice advice 5: patients should be analyzed for disease-associated variants in human leukocyte antigen genes; results must be carefully interpreted. Negative results can be used to rule out celiac disease in seronegative patients. Best practice advice 6: patients with suspected celiac disease who are seronegative but have villous atrophy and genetic risk factors for celiac disease must undergo endoscopic evaluation after 1–3 years on a gluten-free diet, to evaluate improvements in villous atrophy. A diagnosis of seronegative celiac disease can then be confirmed, based on clinical and histologic markers of improvement on the gluten-free diet. Best practice advice 7: seronegative patients with an identified cause for enteropathy should be treated accordingly; a follow-up biopsy may or may not be necessary. Best practice advice 8: patients with persistent signs and symptoms who do not respond to a gluten-free diet, and for whom no etiology of enteropathy is ultimately identified, should be treated with budesonide. Conclusions These best practice guidelines will aide in diagnosis and management of patients with suspected celiac disease but negative results from serologic tests.