Quality standards for celiac disease comprehensive care units: A Spanish multidisciplinary consensus integrating professional expertise and patient perspectives

Table 5 Essential elements to be included in clinical protocols supporting Comprehensive Care Unit for patients with Celiac Disease procedures

Phase	Essential elements
Diagnosis	Coordinated and consensual approach with primary care and other specialized units, clearly defining referral criteria as well as symptoms and signs that should raise clinical suspicion of CD
	Management of biopsies deemed inadequate for histopathological assessment. Measures to be taken should be included (e.g., preparing additional tissue sections, repeating the biopsy, or applying supplementary histopathological techniques)
	Procedures for accurate differential diagnosis of seronegative enteropathies, applicable to both lymphocytic duodenosis (Marsh 1) and villous atrophy (Marsh 3a)
	Diagnosis in individuals already on a GFD. The protocol should address cases in which the patient cannot tolerate or declines the gluten challenge, acknowledging that this may preclude a definitive diagnosis of CD
Treatment and follow-up	Follow-up protocol, defining the responsibilities of different levels of care: Specify which patients should continue follow-up in the hospital setting, which in primary care, and when shared care is appropriate
	Assessment of TSH levels for early detection of autoimmune thyroid disease
	Early detection of metabolic bone disease, including evaluation of calcium-phosphate metabolism and bone densitometry
	Indications and conditions for intravenous iron replacement in patients with CD and iron deficiency
	Transition from pediatric to adult care, specifying timing, process, and participants. A standardized transfer report should be completed by pediatric gastroenterologists, including all relevant clinical information for the adult gastroenterologist (diagnostic details, nutritional deficiencies at diagnosis, response to the GFD, adherence, and unresolved issues)
	Differential diagnosis of non-responsive CD in accordance with current clinical practice guideline recommendations

CD: Celiac disease; GFD: Gluten-free diet; TSH: Thyroid-stimulating hormone.