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ESPGHAN 2020 guidelines permit a no-biopsy diagnosis of coeliac disease in children when tissue transglutaminase IgA (TTG-IgA) is ≥10× the local upper limit of normal (ULN), endomysial antibodies (EMA) are positive, total IgA is sufficient, the child is <18 years and consuming gluten and families agree to this pathway. 1 Real-world uptake varies and laboratory ULN differences materially alter eligibility.A retrospective review was conducted of 80 paediatric patients who underwent endoscopic evaluation for suspected coeliac disease over 6 years (2020 to November 2025) at a single tertiary centre. Data was collected for eligibility for ESPGHAN no-biopsy pathway. This included age, sex, TTG-IgA, EMA, IgA deficiency markers, endoscopy/histology, diet status at testing/scope, diagnosis, and management. No-biopsy eligibility was defined as: age <18 y, TTG-IgA ≥70 U/mL (≥10× ULN), EMA positive, no IgA deficiency, and on a gluten containing diet at testing/scope. Modified Marsh classification was used to grade the severity of intestinal damage seen on biopsy. This was categorised into stages 0, 1, 2, and 3, with the most severe forms (3a, 3b, and 3c) being consistent with coeliac disease.Coeliac disease was diagnosed in patients with histology-proven enteropathy (Marsh type ≥2) or in those with Marsh type 1 changes accompanied by elevated TTG and initiation of a gluten-free diet.Among the 80 children evaluated, 10 (12%) fulfilled strict ESPGHAN no-biopsy criteria.1 2 of these patients were also being evaluated for inflammatory bowel disease so warranted endoscopic evaluation. 1 of the patient’s parents wanted endoscopic evaluation despite raised TTG IgA levels . IgA deficiency was present in 4 patients (5%); however, EMA-IgG was only performed in 3 of the 4 patients (2 IgG positive, 1 IgG-negative)EMA was not measured in 15 patients (24%) with elevated TTG, limiting assessment of eligibility for biopsy avoidance. There was one patient with a TTG of 1.18 whose biopsy confirmed coeliac disease. Among the 80 patients evaluated, coeliac disease was diagnosed in 62 patients. 6 patients diagnosed with coeliac disease had Marsh type 1 changes on histology, elevated TTGs and were started on a gluten-free diet.10 (12%) patients required gluten challenges prior to endoscopy 8 of whom were diagnosed with coeliac disease and started on gluten free diets.Marsh type changes were identified on histology in 24 patients despite macroscopically normal endoscopic findings.Figure 1 showing patients with higher TTG titres were more likely to have histology changes (Marsh type 3 changes).A total of 12% of patients fulfilled the ESPGHAN coeliac disease no-biopsy diagnostic criteria but nonetheless underwent endoscopy, representing procedures that might have been avoidable. EMA testing was omitted in 24% of cases, limiting adherence to the no-biopsy diagnostic pathway. This quality improvement project has highlighted areas for optimizing patient selection for endoscopy. As a result, all suspected coeliac disease cases are now discussed in our endoscopy MDT, and more stringent criteria have been implemented to improve diagnostic efficiency and compliance with ESPGHAN guidance.Reference Husby S, Koletzko S, Korponay-Szabó I, et al. European society paediatric gastroenterology, hepatology and nutrition guidelines for diagnosing coeliac disease 2020. J Pediatr Gastroenterol Nutr. 2020;70(1):141–156.Abstract OC67 Figure 1Distribution of Marsh classification (Histology) with tTG levels