Coeliac disease is an autoimmune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. The major predisposing genotypes are HLA-DQ2 and HLA-DQ8 found in at least 98% of patients. The widespread use of antibody screening has considerably changed the clinical spectrum of new cases seen with increasing recognition, through the testing of children with less classic symptoms and screening of children at high risk, of the varied presentation and increased prevalence of this now common condition.

Coeliac disease was previously considered to be rare, with an estimated prevalence of 1 in 2000. This was before the widespread availability of antibody screening. The prevalence of coeliac disease, based on either cross-sectional or population-based studies in Western populations, is in the order of 0.3–2%, with a higher prevalence in at-risk groups.^1–3 The vast majority of cases, however, remain undetected, with seropositivity in apparently healthy individuals when populations are screened (silent coeliac disease). This is commonly referred to as the coeliac iceberg. The potential disease burden if all cases are detected is huge.

Ravikumara et al⁴ have reported 21 years of prospectively held data on the mode of presentation of coeliac disease in a single centre, with increasing availability and progressively increasing sensitivity and specificity of antibody testing during that period. The number of new cases increased from 11 patients diagnosed between 1983 and 1989 to 50 between 1999 and 2004. This study shows that gastrointestinal manifestations are now less prominent at diagnosis with 1 in 4 patients diagnosed during 1999–2004 as a consequence of targeted screening. Median age at presentation shifted from 4 to 8 years during this period. The same group has previously reported an incidence of between 1 in 2500 and 1 in …