Background Red cell distribution width (RDW) has been shown as a distinctive marker of mortality and morbidity in a wide spectrum of conditions related to systemic inflammation or deficiency of antioxidant nutrients. Objective We aimed to investigate the predictive value of RDW in detection of intestinal atrophy in celiac disease (CD). Methods Iron indices and RDW were studied in 49 patients with CD to evaluate the utilization of RDW as a predictive marker for presence of intestinal atrophy. Results Sixty-nine percent of patients had iron deficiency at initial presentation and 89% had abnormal RDW defined as >14. Receiver operating characteristics curves of RDW has been found to be a predictive of intestinal atrophy at levels higher than 17.25 (68% sensitivity and 85% specificity). In patients with transglutaminase antibody IgA titers >200 U/l, RDW level >17.75 showed 76% sensitivity and 100% specificity for intestinal atrophy. Conclusions We suggest that RDW can be used as a surrogate marker of atrophy in patients with iron deficiency and suspected CD. In addition, the sensitivity, specificity, negative and positive predictive values of RDW increases when used in combination with high levels of transglutaminase IgA antibody. J. Clin. Lab. Anal. 26:497-502, 2012. (C) 2012 Wiley Periodicals, Inc.