Background: Accurate coeliac disease (CeD) assessment requires adequate duodenal biopsy sampling and handling, histopathological interpretation, and effective gastroenterologist-pathologist communication. We assessed variation across self-reported gastroenterology and pathology practice and real-world duodenal biopsy report documentation.
Methods: Two anonymous online surveys assessed respondent characteristics, biopsy handling and reporting practices, perceived barriers, follow-up approaches and clinicopathological communication. A complementary audit of 141 CeD duodenal histology reports (2004-2025) assessed reporting detail and terminology against best practice.
Results: Survey responses were obtained from n=196 (105 gastroenterologists/endoscopists, 91 pathologists). Endoscopists reported high adherence to recommended biopsy sites, with 94.3% sampling the duodenal bulb and 99.0% sampling the second part of the duodenum. However, 34.3% submitted all duodenal biopsies in a single specimen pot, limiting site-specific interpretation, and 81.7% used two bites per pass despite guidance favouring single-bite sampling. Routine follow-up gastroscopy was most common in mixed public–private practice (68.5%) and occurred at 12 months (64.8%) on a gluten-free diet. Confounders to villous atrophy such as poor biopsy orientation were less acknowledged by endoscopists on clinical questioning.
Among pathologists, 79.5% did not use structured CeD reports and only 6.7% were aware of best-practice reporting guidance. Villous architecture was predominantly described qualitatively (83.5%); Marsh staging, villous height:crypt depth ratios and quantitative intraepithelial lymphocyte assessment were infrequently used. Histological case assessment demonstrated concordant Marsh grading but substantial interobserver variability in intraepithelial lymphocyte and villous architecture estimates.
Complementing survey findings, audit scores averaged 4.71/8 (range: 1-8), highlighting substantial variation in real-world reporting practice. Orientation (5.7%), quantitative villous height:crypt depth ratio (26.9%) and Marsh staging/classification (9.9%) were inconsistently reported. Villous terminology, diagnostic nomenclature and the extent of interpretive guidance varied widely across reports.
Conclusion: Variation across self-reported practice and real-world histopathology documentation may compromise CeD assessment. These findings support the need for visible, evidence-based standards and joint gastroenterology-pathology education.