Persisting Villous Atrophy and Adherence in Celiac Disease: What Does the Patient Want? What Should a Clinician Advise?

ABSTRACT: Adherence to a gluten-free diet in celiac disease remains challenging. Clinicians may view mucosal healing as crucial. From the patient's perspective, avoidance of an invasive upper endoscopy may be desirable. A fundamental misconception is that noninvasive tools including symptoms, serology, dietary adherence questionnaires, and novel gluten immunogenic peptides may detect ongoing villous atrophy rather than assess adherence. Duodenal biopsies are the only reliable method for assessment of mucosal healing-however, we as clinicians should provide patients with the uncertainties of this approach allowing them to make an informed decision on an individual basis.