Introduction British Society of Gastroenterology guidance on repeating the intestinal biopsy in coeliac patients on diet is ambiguous and suggests that dietary advice is the same irrespective of the follow-up biopsy results. Addenbrooke's Coeliac Disease Clinic has a policy of routine re-biopsy at 9–12 months after commencing gluten withdrawal. The following graded dietary interventions are introduced if villous atrophy is present on repeat biopsy—interview and dietary history; food diary; withdrawal of oats; withdrawal of “Codex” products, barley malt extract, (“supersensitive diet”—SSD); liquid diet. Response is assessed by re-biopsy as we have shown serology to be unreliable in this setting.

Methods Information was retrieved from the Addenbrooke's Adult Coeliac Disease database of over 600 patients with coeliac disease (30% male, 70% female, average age at diagnosis 48 yrs and 44 yrs respectively). 170 patients with persisting villous atrophy on follow-up biopsy were identified. Dietetic interventions and outcomes based on subsequent biopsy results were reported.

Results Of 170 patients with persisting villous atrophy, 84 did not undergo re-biopsy after dietitian intervention and were therefore excluded from further analysis. In 57 patients interview or food diary analysis revealed a likely source of gluten ingestion as the cause of persistent villous atrophy and advice was given to eliminate the likely source (Dietary Advice—DA). In 29 patients, no potential gluten source was identified and a “supersensitive diet” was recommended (SSD). Further biopsy revealed complete normalisation of the duodenal mucosa (Marsh 0) in 14 (24.5%) of the DA group and 8 (27.5%) of the SSD group. Normal or minor changes (Marsh 0, 1, or 2) were seen in 31 (54%) of the DA group and 18 (62%) of the SSD group. Intensive dietary intervention revealed two additional patients who concealed deliberate gluten ingestion. 11 patients who remained persistently seronegative, had no identifiable source of gluten and showed no response to SSD were deemed to be histologically refractory and assigned to careful clinical follow-up.

Conclusion Contrary to current BSG guidance, dietary advice is not irrespective of the outcome of the follow-up biopsy on gluten free diet. Dietitian intervention is effective in over half of the patients who showed persistent villous atrophy despite following a gluten free diet. This strategy also identifies patients who are histologically refractory and at high risk of subsequent complications. These results strongly support a policy of assessment by follow-up biopsy and appropriate specialist dietitian intervention in the management of coeliac disease.

Competing interests None declared.