World Gastroenterology Organisation Global Guidelines Celiac Disease February 2017

The World Gastroenterology Organisation aims to guide health providers in the best management of celiac disease by providing a concise document with recommendations based on the latest evidence and resulting from our global expert consensus process on best current practices. In this guideline, a review team consisting of experts from 4 continents provides an updating with concepts that have been developed since the publication of the earlier guideline (2013). The guideline explores the epidemiology of the disorder from a global perspective and updates the diagnostic work-up as well as therapeutic and follow-up aspects of celiac disease. As a novelty in celiac disease, the team also provides cascades that represent a hierarchical set of diagnostic and management options to deal with the disease, ranked by available resources. The aim in presenting cascades is to highlight appropriate, context-sensitive, and resource-sensitive management options for all geographic regions, regardless of whether they are considered as "developing," "semideveloped," or "developed." World Gastroenterology Organisation cascades are context-sensitive, and the context is not necessarily defined solely by resource availability. As first-line tests for symptomatic and asymptomatic patients, the experts suggest antitissue transglutaminase (anti-tTG) immunoglobulin A (IgA)+total IgA. However, to confirm a positive initial test, or in case of borderline tissue tests should be added, such as IgA antiendomysium, which is strongly recommended in most other guidelines. Other immunoassays regarded as good tests include the antiendomysium antibody (EMA) and immunoglobulin G-deamidated gliadin peptide (IgG-DGP) tests. A combination of IgG-DGP and IgA-tTG is particularly useful for detecting patients with celiac disease who are IgA-deficient. IgG-DGP is reported to be able to detect a few more IgA-sufficient patients who are missed on IgA-transglutaminase (IgA-tTG) tests. For some authors, performing IgA-tTG+IgG-DGP-2 tests addressing different antigens-is better than if 2 tests addressing the same autoantigen (IgA-tTG+IgA-EMA) are carried out. There was intense debate in the review team regarding the most appropriate serological strategy for diagnosing celiac disease, and we present readers with all of the various strategies here.