Against the Grain: Navigating Challenges in Celiac Disease Pathology.

The diagnosis of celiac disease requires integration of clinical features, serologic testing, and histopathologic findings. Duodenal biopsy remains essential, with characteristic findings that include villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis. This article outlines key considerations in the assessment of each histologic feature and examines ongoing controversies in pathologic interpretation, including the value of formal classification systems and the role of immunohistochemistry in routine practice. It also discusses issues with the evaluation of follow-up biopsies after treatment, reinforcing the pathologist's critical role in guiding accurate diagnosis and optimal patient care.