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Statement on Best Practices in the Use of Pathology as a Diagnostic Tool for Celiac Disease: A Guide for Clinicians and Pathologists

Robert, Marie E., MD*,†; Crowe, Sheila E., MD‡,§; Burgart, Lawrence, MD*,∥; Yantiss, Rhonda K., MD*,¶; Lebwohl, Benjamin, MD‡,#; Greenson, Joel K., MD*,**; Guandalini, Stefano, MD‡,††; Murray, Joseph A., MD‡,‡‡

The American Journal of Surgical Pathology: September 2018 - Volume 42 - Issue 9 - p e44–e58
doi: 10.1097/PAS.0000000000001107
Special Article

Small intestinal biopsy interpretation has been the cornerstone for the diagnosis of celiac disease for over 50 years. Despite the existence of sensitive and specific serological tests, duodenal mucosal biopsies continue to be obtained in the vast majority of patients in whom a diagnosis of celiac disease is being considered. The accurate evaluation of these biopsies requires coordination and information sharing between the gastroenterologist, laboratory, and pathologist in order to optimize tissue sampling, preparation and interpretation. This document, a collaboration between the Rodger C. Haggitt Gastrointestinal Pathology Society and the North American Association for the Study of Celiac Disease, is intended to provide clinicians and pathologists with a summary of best practices in the use of endoscopy and biopsy for patients with suspected celiac disease. The authors present a comprehensive and critical appraisal of the literature with respect to the topics of endoscopic findings, best methods for the obtaining biopsies, completing the pathology form and pathologic assessment, including evaluating intraepithelial lymphocytes and villous architecture. A discussion of conditions with overlapping pathologic findings in duodenal mucosal biopsies is presented. In order to provide additional guidance for challenging situations, the authors include an appendix containing practical suggestions. This review may be utilized in interdisciplinary discussions to optimize care for patients with possible celiac disease.

*Rodger C. Haggitt Gastrointestinal Pathology Society (GIPS)

North American Society for the Study of Celiac Disease (NASSCD)

**Department of Pathology, University of Michigan Hospitals, Ann Arbor, MI

§Division of Gastroenterology, University of California San Diego, San Diego, CA

Department of Pathology, University of Minnesota, Minneapolis

‡‡Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN

Department of Pathology and Laboratory Medicine, Weill Cornell Medicine

#Celiac Disease Center, Columbia University, New York, NY

Department of Pathology, Yale University School of Medicine, New Haven, CT

††Section of Pediatric Gastroenterology, University of Chicago, Chicago, IL

Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Correspondence: Marie E. Robert, MD, Yale University School of Medicine, 310 Cedar Street, PO Box 208023, New Haven, CT 06520 (e-mail:

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