SMALL INTESTINE: Edited by Reena SidhuRefractory coeliac disease: what should we be doing different?Chetcuti Zammit, Stefania; Sanders, David S.; Sidhu, ReenaAuthor Information Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK Correspondence to Stefania Chetcuti Zammit, Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK. Mobile no: 01142261180; e-mail: Stefania.Zammit@nhs.net Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.co-gastroenterology.com). Current Opinion in Gastroenterology: May 2020 - Volume 36 - Issue 3 - p 215-222 doi: 10.1097/MOG.0000000000000628 Buy SDC Metrics Abstract Purpose of review The aim of this review is to provide insight into the diagnosis and management of patients with refractory coeliac disease (RCD) and highlight recent advances in this field. Recent findings The diagnosis of RCD can be more accurately confirmed with flow cytometry in addition to immunohistochemistry. Dietary input and excretion of gluten immunogenic peptides can help rule out gluten contamination, and therefore, substantiate a diagnosis of RCD type I. Small bowel capsule endoscopy (SBCE) is important at diagnosis and follow-up in addition to duodenal histology. Apart from ruling out complications, it can give information on extent of disease in the small bowel, and therefore, help assess response to therapy. Those patients with a poor response can have earlier intensification of therapy, which may result in an improved outcome. RCD also occurs in patients with serology negative coeliac disease but with an increased mortality compared with patients with serology-positive coeliac disease. Summary Patients with RCD can present with persistent symptoms of malnutrition but can also be completely asymptomatic. Serology is not a reliable marker to detect refractory disease. Immunostaining and flow cytometry are necessary for a diagnosis of RCD. Small bowel endoscopy enables disease extent to be assessed and allows for small bowel biopsies to be taken in case of suspicious lesions. Small bowel radiology can be complementary to small bowel endoscopy. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.