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BSG Coeliac Disease Guidelines 2026: Key Changes in Diagnosis, Dietetic Support and Follow-Up

The 2026 BSG coeliac disease guidelines introduce new adult no-biopsy diagnosis pathways, personalised follow-up strategies, and a greater role for specialist dietitians. Discover the key updates for healthcare professionals.

BSG Coeliac Disease Guidelines 2026: What Healthcare Professionals Need to Know

The British Society of Gastroenterology (BSG) has published its first major update to the diagnosis and management of adult coeliac disease in more than a decade. The new 2026 guidelines reflect advances in diagnostic testing, a growing understanding of the diverse presentations of coeliac disease, and a stronger focus on personalised care.

Here, we summarise the key updates most relevant to healthcare professionals involved in the diagnosis and management of adults with coeliac disease.

1. New Diagnostic Pathways for Some Adults with Coeliac Disease

One of the most significant updates is the introduction of an optional no-biopsy diagnostic pathway for selected adults.

The guideline suggests that symptomatic adults assessed in secondary care may be diagnosed with coeliac disease without undergoing duodenal biopsy if:

  • They are consuming a gluten-containing diet.
  • Their tissue transglutaminase IgA (tTG-IgA) level is at least 10 times the upper limit of normal.
  • Shared decision-making takes place between the patient and clinician.

This marks a major shift in adult coeliac disease diagnosis, bringing practice closer to established paediatric pathways. For appropriate patients, this approach could reduce waiting times, avoid invasive procedures, and improve access to diagnosis. However, the guideline emphasises that the no-biopsy pathway should be considered an option rather than the default approach, with clinical judgement remaining essential.

Gluten Challenge Guidance Clarified

The guideline also provides clearer recommendations for patients who have already commenced a gluten-free diet before testing.

For diagnostic purposes, individuals should consume approximately 3-6g of gluten per day for at least six weeks before investigation.

2. Improved Recognition of Different Presentations of Coeliac Disease

The updated guidance acknowledges that coeliac disease does not always present in a "classic" way and provides clearer definitions for less straightforward clinical scenarios.

Potential Coeliac Disease

The guideline formally recognises potential coeliac disease, defined by:

  • Positive coeliac serology
  • HLA-DQ2 and/or HLA-DQ8 positivity
  • Normal duodenal histology or isolated intraepithelial lymphocytosis (Marsh 0-1)

For symptomatic patients, a specialist dietitian-guided trial of a gluten-free diet may be considered. Those who choose to continue consuming gluten should be monitored due to the risk of progression to overt coeliac disease.

Seronegative Coeliac Disease

The guideline also provides clearer diagnostic criteria for seronegative coeliac disease, recognising that some individuals may have characteristic villous atrophy despite negative antibody testing. Diagnosis requires careful exclusion of alternative causes and evidence of clinical improvement on a gluten-free diet. These recommendations may help improve recognition and management of patients who do not fit traditional diagnostic patterns.

3. Greater Emphasis on Specialist Dietetic Support

A recurring theme throughout the guideline is the importance of specialist dietetic input, one of the most important changes within the updated guidance. The guideline recommends ongoing access to specialist dietetic support for:

  • Gluten-free diet education
  • Nutritional assessment
  • Dietary adherence monitoring
  • Management of complex cases such as potential or refractory coeliac disease

Monitoring Adherence Requires More Than Serology

The guideline recognises that no single test can reliably assess gluten-free diet adherence. Instead, clinicians should adopt a combined approach that includes: specialist dietetic review, symptom assessment, serological testing and histological assessment where clinically indicated

This reinforces the value of specialist dietitians in supporting long-term disease management and improving patient outcomes.

Gluten-Free Oats Can Be Introduced Earlier

Another notable update is the recommendation that discussions around certified gluten-free oats should take place as soon as the gluten-free diet is commenced, alongside appropriate follow-up.

This reflects growing evidence supporting their safety in most individuals with coeliac disease and recognises their potential contribution to dietary quality and fibre intake.

4. A More Personalised Approach to Follow-Up Care

The 2026 guideline moves away from a universal follow-up model and instead recommends a more personalised, risk-based approach.

Structured Follow-Up After Diagnosis

All patients diagnosed with coeliac disease should receive regular follow-up during the first two years after diagnosis. This period should focus on:

  • Assessing symptom response
  • Supporting dietary adherence
  • Monitoring nutritional status
  • Identifying complications early

Patient-Initiated Follow-Up

For some patients who are clinically stable and managing well, the guideline introduces the option of patient-initiated follow-up (PIFU). This reflects a more patient-centred approach while allowing healthcare resources to be focused on those who need more intensive support.

Ongoing Follow-Up for Higher-Risk Patients

Longer-term follow-up should be prioritised for individuals who:

  • Have persistent symptoms
  • Struggle with gluten-free diet adherence
  • Have ongoing villous atrophy
  • Develop complications such as refractory coeliac disease

Additional Updates for Clinical Practice

Several other important recommendations are included within the guideline:

Key Takeaways

The 2026 BSG guideline represents a significant evolution in adult coeliac disease care. The most notable changes include:

  • Introduction of a no-biopsy diagnostic pathway for selected adults.
  • Greater recognition of potential and seronegative coeliac disease.
  • Increased emphasis on specialist dietetic support throughout the patient journey.
  • More personalised and flexible follow-up pathways.
  • Greater focus on nutritional monitoring, bone health and long-term outcomes.

Ultimately, the guideline reinforces the importance of multidisciplinary care, shared decision-making, and specialist dietary support to help optimise outcomes for adults living with coeliac disease.

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Sources

Penny HA, Shiha MG, Raju SA, et al. The 2026 British Society of Gastroenterology Guidelines on the Diagnosis and Management of Adult Coeliac Disease. Gut. 2026.