Elevated Poster Presentation International Celiac Disease Symposium 2026

Long-term gluten exposure without villous atrophy in adults with coeliac disease (146167)

Agostino AC Cosenza 1 , Gaia GC Cairoli 2 , Lucia LS Scaramella 3 , Matilde MT Topa 1 , Carratta AC Carratta 1 , Luca LE Elli 1
  1. Università Degli Studi La Statale di Milano / IRCCS Ca' Granda Policlinico Maggiore di Milano, Milan, ITALY, Italy
  2. Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pavia, Italy
  3. Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico Milano, Center for Prevention and Diagnosis of Celiac Disease, Milano, Italy

Background and aims: A lifelong gluten-free diet (GFD) is standard treatment for coeliac disease (CD), but responses to gluten exposure are heterogeneous. We evaluated mucosal damage and anti-transglutaminase IgA (anti-tTG IgA) status in adults with voluntary GFD non-adherence.

Methods: This retrospective single-centre cohort included adults with guideline-confirmed CD reporting intermittent gluten consumption. Gluten exposure was assessed by an expert dietitian using a validated modified food-frequency questionnaire covering 12 months. It recorded frequency, timing, meal context and quantity of gluten-containing foods and included open-ended questions to capture occasional exposure. Foods were grouped into five predefined categories. Weekly gluten intake was estimated using food-specific conversion factors and expressed as grams/week. Duodenal histology was classified according to Marsh–Oberhüber criteria: Marsh 0–2 was non-atrophic and Marsh 3a–3c atrophic. Anti-tTG IgA was classified as elevated or non-elevated.

Results: Seventy-four patients were included; 51 (68.9%) were women. Median follow-up was 20.5 years, duration of non-adherence 17 years and gluten intake 1.52 g/week. Overall, 41 patients (55.4%) were non-atrophic and 33 (44.6%) had villous atrophy. Anti-tTG IgA was elevated in 23/74 patients (31.1%) and was less frequent in non-atrophic than atrophic patients (19.5% vs 45.5%; p=0.023). Thirty-three patients (44.6%) had both non-elevated anti-tTG IgA and no villous atrophy. Non-atrophic patients had longer GFD non-adherence than atrophic patients (18 vs 14 years; p=0.048), despite comparable gluten intake. Symptoms, BMI, malabsorption-related abnormalities and bone impairment did not differ significantly.

Conclusions: More than half of adults with longstanding intermittent gluten exposure had no villous atrophy, and nearly half had both absence of villous atrophy and non-elevated anti-tTG IgA. These findings suggest a temporarily remitting or gluten-tolerant phenotype. Prospective multicentre studies should confirm its stability, identify predictors and define safe monitoring before controlled GFD liberalisation is considered.