Celiac disease laboratory tests

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: : Iqra Qamar M.D.[2]


Laboratory findings consistent with the diagnosis of celiac disease include electrolyte abnormalities such as hypokalemia, hypocalcemia, hypomagnesemia, metabolic acidosis, hypoalbuminemia, hypoproteinemia, hypocholesterolemia and low serum carotene level. Hematologic findings include low folate and vitamin B-12 levels, low serum iron level and prothrombin time (PT) prolongation. Stool examination may show fat droplets on Sudan stain and a 72-hour fecal fat collection may be used for documentation of steatorrhea. Genetic testing is usually positive for HLA-DQ2 and HLA-DQ8. Serologic markers include IgA endomysial antibody (IgA EMA), IgA tissue transglutaminase antibody (IgA tTG), IgG tissue transglutaminase antibody (IgG tTG), IgA deamidated gliadin peptide (IgA DGP), and IgG deamidated gliadin peptide (IgG DGP). Serum IgA EMA and IgA tTG have the highest diagnostic accuracy. The IgA and IgG anti-gliadin antibodies (AGA) are not recommended for establishing diagnosis because of a high rate of false positive results as compared to IgA tTG and IgA DGP assays.

Laboratory Findings

Laboratory findings consistent with the diagnosis of Celiac disease include:[1]

Electrolyte abnormalities:

Hematologic findings:

Stool examination:

Oral tolerance tests:

  • Breath hydrogen excretion- increased in celiac disease
  • Oral D-xylose tolerance test
    • Decreased urinary D-xylose excretion
    • Decreased peak blood xylose levels

Genetic testing:

Serologic Markers

Serological testing may be divided into 3 groups based on antibodies against respective antigens:

  • IgA endomysial antibody (IgA EMA)
  • Anti-TTG antibody tests
    • IgA tissue transglutaminase antibody (IgA tTG)
    • IgG tissue transglutaminase antibody (IgG tTG)
  • Anti-gliadin antibody tests 
    • IgA deamidated gliadin peptide (IgA DGP)
    • IgG deamidated gliadin peptide (IgG DGP)

IgA endomysial assay:

Anti-tissue transglutaminase antibodies:

  • These antibodies are directed against the tissue transglutaminase-2 (tTG) antigen.[14]
  • They can be easily detected by ELISA[15]
  • Anti-tTG antibodies have high diagnostic accuracy.[16][17][18][19][20]

Antigliadin antibody assays

  • Anti-gliadin antibody (AGA) tests have low positive predictive value and are not recommended generally.[21]
  • The anti-deamidated gliadin peptide [DGP] assays have higher specificity and are thus preferred over antigliadin antibody (AGA) tests.[22][23]


  • Serum IgA EMA and IgA tTG have the highest diagnostic accuracy.
  • The IgA and IgG antigliadin antibodies (AGA) are not recommended for establishing the diagnosis as they have low accuracy and give a high rate of false positive results when compared with IgA tTG and IgA DGP assays.
  • The anti-deamidated gliadin peptide (DGP) assays also have high diagnostic accuracy.

Sensitivity and Specificity of Antibody testing:

IgA endomysial and IgA tissue transglutaminase antibodies have a sensitivity of more than 95% and a specificity almost 100%. However, variations in results are seen among different laboratories.[2][24][25][22][23][26][27]

Blood antibody tests for coeliac disease
Test sensitivity specificity
IgA enomysial antibody 85 to 98% 97 to 100%
IgA tissue transglutaminase antibody 90 to 98% 95 to 97%
IgA deamidated gliadin peptide 94% 99%
IgG deamidated gliadin peptide 92% 100%
Blood HLA tests for coeliac disease
Test sensitivity specificity
HLA-DQ2 94% 73%
HLA-DQ8 12% 81%

Algorithm for diagnostic testing of Celiac disease

Abbreviations: DGP: deamidated gliadin peptide; HLA: human leukocyte antigen; Ig: immunoglobulin; TTGA: tissue transglutaminase antibody.

Diagnostic testing in low probability celiac disease patients

Low Probability (<5%)
TTGA IgA ± IgA level
Positive TTGA
Negative TTGA
↓ IgA
Negative TTGA
Normal IgA
If any positive
All negative
Celiac disease unlikely

Diagnostic testing in high probability celiac disease patients

High probability
• Duodenal biopsy
Both negative
Both positive
Serology/biopsy disagreement
Celiac disease unlikely
Celiac disease
• HLA DQ2 and DQ8 genotyping
•IgA level ± TTGA/DGP IgG
•work up for other causes of villous atrophy


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