Positive Faecal Calprotectin Research Articles

SP5.4 - Is Fecal Calprotectin a useful test?

Abstract Aim To identify whether there is a correlation between a positive Fecal Calprotectin level(FCP) and a diagnosis of Inflammatory Bowel Disease. Method Data was collected retrospectively from a database of all colonoscopies performed at a District General Hospital. Data was collected including patient demographics, FCP result, colonoscopy and histology report from the hospital electronic record system. Results A total of 450 patients underwent a colonoscopy for any reason with 250 male and 200 female. The average age was 63.5 years. Patients undergoing surveillance or interventional colonoscopies were excluded. 90 patients were referred for colonoscopy with a change in bowel habit and all these patients had a FCP. Out of these, 42 had a FCP greater than 99 ug/g. Only 4 had IBD confirmed on histology, 3 had non-specific bowel inflammation. Of the other 360 patients who underwent a colonoscopy for other indications, 33 had a FCP sent, with 6 being positive. Out of a total of 48 patients who had a positive FCP, 25 had a FCP result greater than 250 ug/g. however, only three of these patients had IBD confirmed on histology. Conclusion The results show no correlation between a positive FCP and a diagnosis of IBD even using a higher cut off at 250 ug/g. For most cases with altered bowel habits or rectal bleeding, a FCP should not be recommended as it will not change the need for a colonoscopy.

A Young Adult with Crohn’s Arthritis Necessitating Upper Gastrointestinal Tract Surgery - A Case Report

Upper gastrointestinal tract predominant Crohn’s Disease (CD) remains an uncommon clinical entity, manifesting limited or vague symptomatology, thus delaying clinical suspicion and subsequent diagnostic evaluation. For that reason, it has not been widely described and there is a lack of clear recommendations for diagnosis or management. Standard Inflammatory Bowel Disease (IBD) evaluation including serologic testing, imaging, and endoscopy may initially not be fruitful. Furthermore, endoscopic evaluation may be inconclusive even in patients with long standing-disease. We describe a 30-year-old male who suffered long with persistent iron-deficiency anemia (IDA) and occasional melaena along with predominant axial arthropathy. Extensive in-patient testing including multiple endoscopic evaluation with standard biopsy were unfruitful. Ultimately, long standing recurrent gastric and duodenal ulcer, suggestive colonoscopy finding, and positive fecal calprotectin in a patient along with spondyloarthropathy drove us toward the diagnosis of Crohn’s disease. We started steroid, PPI, sulfasalazine and the patient is on follow up. J MEDICINE 2024; 25: 83-86

Epstein-Barr virus-positive mucocutaneous ulcer in a patient with ulcerative colitis: a recently described entity to take into account.

Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) is a new entity recently included in the classification of B-cell lymphoproliferative disorders associated with Epstein-Barr virus (EBV). It is related to immunosuppression and it usually appears in the oropharynx or the skin, being the colon an uncommon location. We present the case of a 31-year-old man with ulcerative proctitis being treated with azathioprine (AZA) and adalimumab (ADA), who was admitted to the hospital due to suspicion of a moderate-severe flare of ulcerative proctitis. Microbiological stool analyses were negative, with a positive fecal calprotectin test (2700 mg/kg). Rectoscopy showed severe endoscopic activity, taking multiple biopsies. Intravenous steroids were started at a dose of 60 mg/day. He presented a favorable clinical and analytical evolution, being discharged from the hospital. The histological results were received at gastroenterology consultation, being compatible with EBVMCU. AZA and ADA were withdrawn, whereas descending steroid regimen and oral and topical mesalazine were continued, being the clinical response adequate.

Diagnostic value of fecal calprotectin in primary care patients with gastrointestinal symptoms: A retrospective Swedish cohort study.

To investigate the diagnostic accuracy of fecal calprotectin (FC) for inflammatory bowel disease (IBD) and organic gastrointestinal disease (OGID) in primary care. To examine the association with demographic factors, symptoms and concomitant medical therapy. A retrospective analysis of data on all semiquantitative FC tests from individuals ≥18 years conducted in primary care in Östergötland County in 2010. A 5-year follow-up with inclusion of new gastrointestinal diagnoses. A total of 1293 eligible patients were included. IBD was found in 8.8% and other OGID in 30.8% of patients with positive FC. Positive FC was associated with diarrhea, age >60 years, duration <3 months, use of nonsteroidal anti-inflammatory drug (NSAID), and proton pump inhibitor (PPI). Predictors of IBD were positive FC, diarrhea, rectal bleeding, and male sex; predictors of OGID positive FC, age >35 years, abnormal clinical findings, and duration <3 months. FC yielded the highest sensitivity and negative predictive value compared with demographic factors, symptoms, and duration. Use of NSAID and PPI showed a marginal increase in the sensitivity, positive predictive value, and decrease in the specificity of FC. Within 5 years, 4.0% had a new gastrointestinal diagnosis among patients with positive FC (0.6% IBD). FC reliably rules out IBD and contradicts the presence of other OGID in primary care patients. Positive FC test together with other predictors, such as diarrhea, rectal bleeding, short duration, or age >35 years, should encourage a prioritized investigation. Use of NSAID, PPI, and ASA may affect the diagnostic accuracy of FC for IBD and OGID.

Multiple Strictures of Small Intestine: Is It Crohn’s Disease?

Question: A previously healthy 43-year-old woman presented with epigastric pain and intermittent postprandial vomiting for 1 year. The patient denied any fever, night sweats, extraintestinal symptoms, and perianal disease. Physical examination was unremarkable. Initial laboratory values were within normal limits except for increased erythrocyte sedimentation rate (46 mm/h) and positive fecal calprotectin. Ileocolonoscopy revealed erosions in the terminal ileum. Biopsy specimens showed unspecific alterations with acute and chronic inflammation. Computed tomography enterography showed circumferential thickening and enhancement of the multiple segmental small intestinal walls, with luminal stricture and enlarged peripheral lymph nodes (Figure A). Subsequent interferon-γ release assay for Mycobacterium tuberculosis was negative and no tuberculous lesions were found on a computed tomography scan of the chest. What is the most likely diagnosis? See the Gastroenterology web site () for more information on submitting your favorite image to Clinical Challenges and Images in GI. Owing to the symptoms of mechanical obstruction and diagnostic uncertainty, a decision was made to undertake a surgical approach. Laparoscopy confirmed 8 segments of thickened intestinal wall between 5 and 200 cm proximal to the ileocecal valve, accompanied by numerous white, miliary nodules on the mesenterium and intestinal wall (Video). Focally stenosis was found (Figure B) and partial intestinal resection was obtained followed by end-to-side anastomosis. Macroscopic examination showed a circumferential ulcer (Figure C, arrows). Pathology revealed numerous caseating granulomas throughout intestinal tissue, characterized by confluent granuloma, large granuloma, and granuloma with surrounding cuffing lymphocytes (Figure D). Additionally, the results of acid-fast staining (Figure E, circle) and polymerase chain reaction testing for M tuberculosis were positive. Hence, a firm diagnose of intestinal tuberculosis was made. HIV testing was negative. The patient is on a 1-year course of antituberculosis treatment with good response. Multiple diagnostic models have been developed regarding the differentiation of intestinal tuberculosis from Crohn’s disease.1He Y. Zhu Z. Chen Y. et al.Development and validation of a novel diagnostic nomogram to differentiate between intestinal tuberculosis and Crohn's disease: a 6-year prospective multicenter study.Am J Gastroenterol. 2019; 114: 490-499Crossref PubMed Scopus (33) Google Scholar An interferon-γ release assay is the most commonly used tool. Although this assay has very high specificity (>95%), the sensitivity is only approximately 80%, as in our case.2Pai M. Zwerling A. Menzies D. Systematic review: T-cell-based assays for the diagnosis of latent tuberculosis infection: an update.Ann Intern Med. 2008; 149: 177-184Crossref PubMed Scopus (1150) Google Scholar Persons with tuberculosis in high incidence countries (like China) often have advanced disease and are likely to be malnourished or infected with HIV. Anergy owing to advanced disease (which may be applicable to our patient), malnutrition, and HIV-associated immune suppression may decrease the sensitivity of interferon-γ release assays. Hence, it is a challenge to make the differential diagnosis between intestinal tuberculosis and Crohn’s disease. Multiple segmental involvement at small intestine, especially with a normal-appearing ileocecal valve are very unusual in intestinal tuberculosis.3Bae J.H. Park S.H. Ye B.D. et al.Development and validation of a novel prediction model for differential diagnosis between Crohn's disease and intestinal tuberculosis.Inflamm Bowel Dis. 2017; 23: 1614-1623Crossref PubMed Scopus (24) Google Scholar It is frequently misdiagnosed as Crohn’s disease preoperatively. As seen in this patient, exploratory abdominal surgery was usually required for the final diagnosis. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3MmVmM2EzMDEyNjRiZGU1NmI2Y2JmZDZiZGQ5NTliOSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwOTExMjExfQ.isWS2Gk2qOguY5qIEWij4OJBJJuDXzRct5FoY4d49ZTUqfOvNyjzd1PuZwASlAVJpvWR_qEgLYpzjYhehlCMN4gTvH8mTzg_UwEDnoLexdCTsH7vGKnT_xuoZGKwhtNfM0gn4I4Egq4qkollG2UzWKHjesnMvmGKA4ConZhyqLtNlvkqdKFhWR5lW_6KLRIGLvHJqjRC6CcZlJyw1eaIBWQIyTRIqRLoQptMipd4z30ZuvX4XeDx6KNv8KIovkFSqXtDAPflPunRAUETprl6ZY0Gsakyh79bWf9_SLhN1jIiQnIqC_4AAE-EolCxqQA-zFICCCfw8QlB48Y4ITISHA Download .mp4 (16.47 MB) Help with .mp4 files Video

Specific Immunoglobulin E and G to Common Food Antigens and Increased Serum Zonulin in IBS Patients: A Single-Center Bulgarian Study.

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder whose pathogenesis is considered multifactorial, including abnormal gut motility, visceral hyperreactivity, psychological factors, disturbances in the brain-gut axis, leaky gut, oxidative stress, etc. We aimed to investigate serum levels of specific immunoglobulin E and G to common food antigens and zonulin and to assess their use in clinical practice for patients with IBS. Material and methods. We included 23 participants, 15 with IBS (diagnosed according to the Rome IV criteria) and 8 healthy controls. We investigated serum levels of specific IgG antibodies to 24 food antigens, specific IgE antibodies to 20 food antigens, anti-celiac antibodies, fecal calprotectin and serum zonulin by ELISA. Results. Food-specific positive IgG antibodies were significantly higher in patients with IBS than in controls (p = 0.007). IgE-mediated allergic reactions were found in five patients with IBS; no one had anti-TG antibodies. One-third of IBS patients demonstrated a low degree of chronic inflammation (positive fecal calprotectin test > 50 ng/mL) without specific bacterial infection. Serum levels of zonulin in IBS patients were higher than in healthy controls (0.378 ± 0.13 vs. 0.250 ± 0.14 ng/mL, p = 0.0315). However, no correlations between clinical symptoms and zonulin levels were found. Conclusion. The mechanisms of IgG hypersensitivity and low degree inflammation in IBS and elevated zonulin may contribute to multifactor pathogenesis in IBS.

Faecal calprotectin increases the diagnostic yield in patients with suspected small bowel disease – a multicenter retrospective cohort study

Diagnosing small bowel pathology is challenging, and the diagnostic yield of small bowel capsule endoscopy is highly variable. Faecal calprotectin is a non-invasive intestinal inflammation marker that could be used as a selection tool to identify patients who might benefit from small bowel capsule endoscopy and increase its diagnostic yield. This study aimed to investigate the value of faecal calprotectin in detecting small bowel lesions in an unselected patient population. We performed a retrospective analysis of consecutive patients who underwent small bowel capsule endoscopy at the University Hospital Basel and the University Medical Clinic Cantonal Hospital Baselland, Switzerland, between 2010 and 2018. Patients without faecal calprotectin testing were excluded from the analysis. The primary endpoint was the presence of a clinically significant small bowel finding. Patients with positive faecal calprotectin results were more likely to have small bowel findings (66.7% vs 39.4%;P= 0.007). The optimal faecal calprotectin cut-off to identify clinically significant small bowel lesions was 63 μg/g with 78.3% (95% confidence interval: 66.7-87.9) sensitivity, 47.9% (33.3-62.8) specificity, 1.50 (1.1-2.0) positive and 0.45 (0.3-0.8) negative likelihood ratios, 68.4% (61.6-74.4) positive and 60.5% (47.3-72.4) negative predictive values, and 65.0% overall accuracy. Faecal calprotectin performed best in patients with suspected inflammatory bowel disease, with 66.7% (48.2-82.0) sensitivity, 70.6% (44.0-89.7) specificity, 2.27 (1.0-4.9) positive and 0.47 (0.3-0.8) negative likelihood ratios, 81.5% (67.0-90.5) positive and 54.5% (39.7-68.6) negative predictive values, and 71.4% overall accuracy. Faecal calprotectin testing increases the diagnostic yield of small bowel capsule endoscopy and may help identify patients at risk of small bowel disease.

Біомаркер запалення слизової оболонки при симптомах харчової гіперчутливості на шкірі у дітей

Актуальність. Харчова гіперчутливість (ХГ) залишається актуальною медичною проблемою. Метою роботи було вивчити поширеність, кореляційно-статистичні взаємозв’язки біомаркера запалення слизової оболонки — фекального кальпротектину (ФК) із віком, статтю пацієнтів, особливостями перебігу симптомів ХГ на шкірі. Матеріали та методи. У дослідження були включені 102 пацієнти (хлопчиків — 51 (50 %), дівчаток — 51 (50 %)) із симптомами ХГ на шкірі, середній вік — 25,36 [12,00; 60,00] місяця. Рівень кальпротектину визначали якісним методом у копрофільтраті за допомогою тест-систем Calprotectin RAPIDTEST (Італія) за методикою виробника. Результати. Кількість пацієнтів із позитивним результатом аналізу копрофільтрату на наявність кальпротектину становила 45 % (n = 46). Із них 13 % (n = 6) — діти віком до 1 року, 47,82 % — від 1 до 3 років. Кількість дітей із позитивним результатом аналізу калу на ФК вірогідно не відрізнялася у різних вікових групах (Kruskal-Wallis ANOVA тест H (4, N = 102) = 4,45, p &gt; 0,05). ФК частіше виявляли у хлопчиків, проте статистично значима гендерна різниця була виявлена лише у дітей віком від 1 до 3 років (c2 = 9,09, р &lt; 0,05). Аналіз виявив відсутність зв’язку між наявністю ФК і статтю (j = 0,006, p &gt; 0,05), віком (j &lt; 0,01, p &gt; 0,05), тривалістю захворювання та віком дебюту симптомів алергії на шкірі (r = +0,06, p &gt; 0,05 та r = +0,02, p &lt; 0,05 відповідно). Висновки. У дітей із симптомами ХГ на шкірі у 45 % випадків відбуваються органічні зміни у слизовій оболонці кишечника, маркером яких визнано ФК, які не залежать від віку, статі, тривалості захворювання, віку дебюту.

A20 DIAGNOSTIC ACCURACY OF A LOW COST, WIDELY AVAILABLE TEST STRIP FOR PREDICTING A POSITIVE FECAL CALPROTECTIN TEST

Abstract Background Fecal calprotectin is a non-invasive test of colonic inflammation used for monitoring inflammatory bowel disease activity and for risk stratifying non-specific colonic symptoms. Calprotectin is a leukocyte specific enzyme. A similar test, leukocyte esterase is used to detect leukocytes in urine and is widely available as a low-cost point-of-care test strip. We hypothesize that an unmodified version of the urine test strip would be highly accurate in predicting a positive fecal calprotectin test in a real world sample of patients. Aims To explore a low cost, rapid alternative to the fecal calprotectin test Methods All inpatient and outpatient stool samples tested for calprotectin by the Vancouver General Hospital laboratory from February 2020 to November 2020 were included prospectively. Samples were simultaneously tested for fecal leukocyte esterase using an unmodified Roche Cobas Chemstrip urinalysis test strip by central lab personnel. An identical aliquot was sent to LifeLabs for calprotectin as per standard protocol. All samples were suspended in buffer using established laboratory protocols prior to testing. Fecal leukocyte esterase results were reported as 0–4+ based on visual interpretation, calprotectin results were reported as mcg/g of stool. REB review and approval was obtained prior to data collection. Sensitivity, Specificity and AUROC were calculated using Microsoft Excel and JROCFIT. Results 26 samples were collected. Using a fecal calprotectin greater than 120 mcg/g as a gold standard an AUROC of 0.89 (SE= .06) was calculated. A leukocyte esterase reading of 2+ or greater had the best test characteristics based on ROC curve analysis. Using this cutoff, 21/26 samples were concordant, giving an accuracy of 80.8%, sensitivity of 90.9% and specificity of 73.3%. Positive likelihood ratio was 8.07 and negative likelihood ratio was 0.29. Assuming an AUROC of 0.8, the sample size N=26 is 90% powered (β=0.9) to predict the true AUROC within 0.1 with a type I error rate of .05 (α&amp;lt;.05). Conclusions This study suggests application of a prepared stool sample to a urinalysis test strip gives a result highly predictive of a positive fecal calprotectin test. Further results are being collected prospectively to improve the robustness of these preliminary data. Secondary outcomes including comparison to endoscopy and biopsy results where available are planned if an adequate sample size can be accrued. Future studies justifying independent clinical use of leukocyte esterase would require a common gold standard comparator such as endoscopy. Fecal calprotectin testing is not universally insured and is not available as a rapid test strip. Use of fecal leukocyte esterase may reduce costs and shorten time to results if proven to be independently reliable. Funding Agencies None

A243 FACTORS ASSOCIATED WITH POOR QUALITY OF LIFE IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE IN CLINICAL REMISSION: A CROSS-SECTIONAL STUDY

Abstract Background Inflammatory bowel disease (IBD) is associated with a substantial burden on quality of life (QoL). Functional gastrointestinal disorders such as irritable bowel syndrome (IBS) as well as depression and anxiety are more common in patients with IBD as compared with the general population. Although poorer QoL is correlated with IBS, depression and anxiety in individuals with IBD at times of IBD diagnosis and disease activity, it is unclear what, if any, impact these may have on overall quality of life at times of disease remission. Aims We aimed to identify factors associated with poor QoL among Canadian patients with IBD in clinical remission. Methods We conducted a prospective, cross-sectional study to determine whether fatigue, depression, anxiety and IBS were associated with lower QoL in patients with IBD in clinical remission. We enrolled patients at a single academic tertiary care center with inactive IBD. All eligible patients completed a series of questionnaires that included questions on demographics, disease activity, anxiety, depression, and the presence of irritable bowel syndrome (IBS) symptoms. Stool samples for fecal calprotectin (FC) were also collected to assess for subclinical inflammation. The primary outcome measure was QoL assessed by the short inflammatory bowel disease questionnaire (SIBDQ), with planned subgroup comparisons for fatigue, anxiety, depression and IBS symptoms. Results Ninety-three patients were eligible for inclusion in this study. The median SIBDQ scores were lower in patients with anxiety (P&amp;lt;0.001), depression (P=0.004), IBS symptoms (P&amp;lt;0.001), and fatigue (P=0.018). Conclusions In this cross-sectional study, we found that anxiety, depression, fatigue, and IBS-like symptoms were all independently associated with lower QoL among patients with inactive IBD. Importantly, subclinical inflammation as defined by a positive fecal calprotectin in the absence of clinical symptoms did not have an adverse effect on QoL. The findings of this study suggest that patients with IBD would likely benefit from screening for depression, anxiety, fatigue and IBS. Further research is warranted to determine if targeted treatment of these conditions, specifically in patients with quiescent IBD would lead to improved outcomes. Funding Agencies None

Upper Gastrointestinal Crohn’s Disease: Literature Review and Case Presentation

Upper gastrointestinal tract predominant Crohn's Disease (CD) remains an elusive clinical entity, manifesting limited or vague symptomatology, eluding clinical suspicion, and delaying subsequent diagnostic evaluation. As a result, it has not been widely described and there is a lack of clear recommendations for diagnosis or management. Standard IBD evaluation including serologic testing, imaging, and endoscopy may initially not be fruitful. Furthermore, endoscopic evaluation may be grossly normal in patients without long standing-disease. We describe an 18-year-old male who presented with only unexplained, persistent iron-deficiency anemia. Extensive outpatient testing including multiple endoscopic evaluations with standard biopsies was unfruitful. Ultimately, a positive fecal calprotectin prompted enteroscopy with endoscopic mucosal resection (EMR) in an effort to obtain a larger, deeper tissue specimen. Grossly cobblestoned mucosa along with histopathology revealing focal crypt abscesses, chronic inflammation in the lamina propria, and superficial foveolar epithelial regenerative changes were consistent with CD. This patient's case illustrates the need for a high degree of suspicion for CD in patients with unexplained or persistent iron deficiency anemias. Persistent investigation yielded an elevation in fecal calprotectin suggesting underlying gastrointestinal inflammation and prompted advanced endoscopic evaluation with EMR. Waxing and waning tissue findings are characteristic of CD and pose a unique challenge in patients with upper gastrointestinal predominant pathology. As such, diligent workup including laboratory evaluation, imaging, and serial endoscopy is critical to establish pathology and dictate subsequent management in IBD, especially upper gastrointestinal tract predominant CD.

Fecal calprotectin Level in patients with IBD and noninflammatory disease of colon: a study in Babol, Northern, Iran.

Inflammatory bowel disease (IBD) is a chronic disease with a relapsing course of inflammation in the digestive system. Endoscopy and histopathology are the golden standard methods for detection and assessment of IBD. A distinct increase of fecal calprotectin level can be a useful marker for the diagnosis of IBD. The aim of this study was to evaluate the fecal calprotectin level in patients with IBD and without inflammatory diseases of the colon. Calprotectin levels of patients referred to the Ayatollah Rouhani Hospital of Babol, northern Iran with clinical symptoms of colon disease were evaluated. After a week, colonoscopy and biopsy were performed on all patients and they were divided into two groups. The first group included patients with confirmed IBD and the second group included patients with diseases other than IBD, patients with IBS and healthy persons. Then the measured fecal calprotectin level was compared between the two groups before colonoscopy. We observed correlation between calprotection in these two groups (p<0.0001). 38 (86.8%) patients in the case group and 5 (13.2%) patients in the control group had positive fecal calprotectin test and 12 (23.1%) patients in the case group and 40 (76.9%) patients in the control group had negative results. Basad on ROC curve, the cutoff point of calprotectin was 127.65 with 73% sensitivity and 89% specificity. The area under the curve was 0.83 with 95% confidence interval, 0.74-0.91 (p<0.0001). The results pointed to this fact that fecal calprotectin can be a noninvasive marker in differentiating IBD from IBS.

32 Does faecal calprotectin measurement have an impact on patient management

Background Faecal calprotectin (FC) is recommended to support the differential diagnosis of IBD or IBS in adults with recent onset lower gastrointestinal symptoms. FC can assess IBD activity in those with known disease, as a rising level is an early marker of potential relapse. There is presently no formal funding for FC within Northern Ireland. Aim To assess if FC measurement directs an immediate modification in patient management within two out-patient groups: 1) new patients with differential diagnosis of IBS or IBD; 2) review patients with known IBD. Method A random selection of FC results from secondary care patients over 12 months were analysed. Patient outcomes following the FC result stratified patients into one of four groups: Discharged, colonoscopy performed, clinic review or escalation of medical therapy. Results Group 1 (n=28): 8 positive FC, all proceeding to endoscopy. In the 14 negative FC, 12 patients were discharged, 2 had clinic review. For indeterminate result: one patient with 2 indeterminate results underwent colonoscopy; 4 had clinic review; 1 was discharged. Group 2 (n=28): of the 20 positive results, 11/20 (55%) had medical management escalated, 5/20 (25%) underwent colonoscopy and 20% had clinic review. In the negative and indeterminate results: 7/8 had clinic review. Conclusions For patients with suspected IBS, a negative FC avoided unnecessary colonoscopy. In patients with known IBD, a raised FC led to an escalation in therapy in the majority of patients to minimise the risk of relapse and potential hospital admission. This study supports the need for a Northern Ireland FC service.

Diagnosing colorectal cancer and inflammatory bowel disease in primary care: The usefulness of tests for faecal haemoglobin, faecal calprotectin, anaemia and iron deficiency. A prospective study

Objective: Abdominal complaints are common reasons to consult primary care but they are seldom caused by colorectal cancer (CRC), high-risk adenomas (HRAs), or inflammatory bowel disease (IBD). Reliable diagnostic aids would be helpful in deciding which patients to refer for bowel imaging. Our aim was to assess the value of a faecal immunochemical test (FIT) and a faecal calprotectin (FC) test in detecting CRC, HRAs and IBD in primary care, and the value of combining these tests with anaemia and iron-deficiency tests.Materials and methods: This prospective study included 373 consecutive patients that received a FIT or a FC test ordered by a primary care physician. We collected samples for FITs, FC tests, full blood counts and iron-deficiency tests. Physicians were instructed to refer patients with a positive FIT or FC test (cut-off ≥100μg/g) for bowel imaging. The patients’ presenting symptoms were recorded. Patients were followed for 2 years.Results: The best test for detecting CRC and IBD was the combination of the FIT and haemoglobin concentration. This test had a sensitivity, specificity, positive predictive value and negative predictive value of 100%, 61.7%, 11.7% and 100%, respectively. The FIT detected a significantly larger proportion of CRC, HRAs and IBD than the FC test (0.92 versus 0.46, 95% confidence interval 0.22–0.67).Conclusion: A negative FIT combined with a normal haemoglobin concentration could rule out CRC and IBD with a high degree of safety. This could be useful in prioritising referrals for bowel imaging from primary care.

PTH-059 The Absence of Clear Pathways Leads to Poor Utilisation of Faecal Calprotectin in Primary Care and Failure to Comply with Nice Guidance

Introduction Irritable bowel syndrome (IBS) has a prevalence of around 15% in the UK and up to 20% are referred to secondary care. Current practice shows that GPs are excellent at identifying and referring cases of inflammatory bowel disease (IBD) but due to the high prevalence of IBS, 60% of outpatient colonoscopies performed are normal. Faecal Calprotectin (FCP) is recommended by NICE to assist differentiating IBD from IBS in patients where cancer isn’t suspected. This was expected to speed the time to diagnosis, reduce referrals and unnecessary endoscopies. Implementation across the UK is patchy. Locally the test was instituted for primary care without the development of an agreed care pathway as recommended by NICE. Methods A retrospective audit of 193 consecutive patients with primary care initiated FCP tests from 01/02/15-02/02/15 were reviewed. Referral information, demographics, blood results, endoscopy and histology reports as well as patient outcomes were extracted from hospital and primary care IT systems using a standardised proforma. 10 paediatric cases were excluded. We aimed to assess the outcomes of testing in the absence of agreed clinical guidelines. Results Complete data was available for 183 adult patients. 29.5% did not meet NICE criteria for FCP testing. 20% met criteria for suspected colorectal cancer referral. 91.2% of patients with negative results (FCP 100) were referred for further investigation. 28.6% of patients with indeterminate results (50–100) had a repeat test, of which 70% were persistently abnormal but only 20% were subsequently referred. No patients were assessed for factors which may cause false positive results. 82% of endoscopies were performed in patients with a positive FCP. 14% of the patients scoped were diagnosed with IBD, all had a positive FCP but only 37% had abnormal blood tests. Conclusion Use of FCP testing in the absence of a clear pathway leads to poor compliance with NICE guidance and is inappropriate in nearly 1/3rd of patients. There is clear reliance on the negative predictive value to avoid referral but this approach does not account for the highly variable pre-test probability and consequent detrimental effect on reliability. FCP is used too often in patients with unclear indications: upper GI symptoms; short symptom duration or suspected cancer criteria. False positive confounders do not appear to be considered, resulting in inconsistent retesting of indeterminate results. The results suggest that without a clear pathway FCP is commonly misused and misinterpreted, with the potential to delay or even fail to diagnose major GI pathology. This supports the use of a clear pathway for testing which we have now developed. Disclosure of Interest None Declared

Clinical outcomes at 12 months and risk of inflammatory bowel disease in patients with an intermediate raised fecal calprotectin: a ‘real-world’ view

ObjectivesA recent systematic review confirmed the usefulness of fecal calprotectin (FC) in distinguishing organic (inflammatory bowel disease (IBD)) from non-organic gastrointestinal disease (irritable bowel syndrome (IBS)). FC levels <50 μg/g...

The Utility of Fecal Calprotectin in the Real-World Clinical Care of Patients with Inflammatory Bowel Disease.

Objectives. To determine the relationship between fecal calprotectin (FCAL) and imaging studies and other biochemical inflammatory markers and the impact of FCAL measurements on decision-making in IBD patient management in usual clinical practice. Methods. 240 persons with IBD were enrolled. The correlation between FCAL values and other markers for disease activity such as serum albumin (alb), hemoglobin (Hg), and C-reactive protein (CRP) and diagnostic imaging or colonoscopy was examined. FCAL ≥ 250 mcg/g of stool was considered a positive result indicating active IBD. Results. 183 stool samples (76.3%) were returned. The return rate in the pediatric and adult cohorts was 91% (n = 82) and 67.3% (n = 101), respectively (P < 0.0001). Positive FCAL was associated with colonoscopy findings of active IBD (P < 0.05), low albumin (P < 0.05), anemia (P < 0.01), and elevated CRP (P < 0.01). There was no significant difference for FCAL results by outcomes on small bowel evaluation among the 21 persons with small bowel CD. Most persons (87.5%) with normal FCAL and no change in therapy remained in remission during subsequent 3 months. Conclusions. FCAL is a useful marker of disease activity and a valuable tool in managing persons with IBD in clinical practice. Clinicians have to be cautious in interpreting FCAL results in small bowel CD.

PTU-326 A positive faecal calprotectin does not predict bile acid diarrhoea

<h3>Introduction</h3> Bile acid diarrhoea (BAD) is a common disorder which in the primary, idiopathic form may affect up to 1% of the population. ⁷⁵Selenium Homocholic Acid Taurate (SeHCAT) 7 day retention is used in diagnosis, predicting faecal bile acid loss but is not available to primary care practitioners. The condition is chronic, causes significant morbidity and is easily treatable with bile acid sequestrants. Calprotectin is released into the intestinal lumen during neutrophil activation and apoptosis. A Faecal Calprotectin (FC) of &gt;50 µg/g in the primary care setting has been reported to have a sensitivity and specificity of 82% and 77% respectively for organic GI disease.¹In 2013 NICE recommended its use in primary care as a decision aid.²Since primary BAD does not have an inflammatory pathogenesis, we hypothesised that the faecal calprotectin test was not sensitive for bile acid diarrhoea. <h3>Method</h3> Faecal calprotectin was measured in patients attending for SeHCAT testing at Imperial Healthcare NHS trust between March 2014 and July 2014. Patients with known bile acid diarrhoea, or inflammatory bowel disease were also recruited from the gastroenterology clinic during the same period. All patients had undergone lower GI endoscopy previously. Faecal samples were analysed in the Imperial Healthcare Biochemistry Laboratory using a commercially available ELISA kit (EliA, Phadia AB, Uppsala, Sweden). <h3>Results</h3> 55 patients were recruited. Of these 32 (58%) were female, the mean age was 53 (range 23–88) and 41 (75%) had a SeHCAT scan, of which 25 (61%) were positive (&lt;15% 7d retention). Overall 23 (42%) had a positive FC (&gt;50 µg/g); 21 (38%) were known, or subsequently found to have traditional organic GI disease (14 Crohn’s, 3 ulcerative colitis, 1 radiation colitis, 3 hepatobiliary). 9 (22%) patients with a positive SeHCAT had a positive FC, all patients (n = 5, 12%) with IBD and a positive SeHCAT had a positive FC. If primary bile acid diarrhoea was excluded in the definition of organic disease, FC had a negative predictive value of 88% (95% CI: 71–96%) and a sensitivity and specificity of 83% (95% CI: 61–95%) and 88% (95% CI: 71–96%) respectively. However, if primary bile acid diarrhoea was included in the definition of organic disease, then FC has a negative predictive value of 43% (95% CI: 26–62%) and a sensitivity and specificity of 54% (35% CI: 37–70%) and 88% (95% CI: 62–98%) respectively. <h3>Conclusion</h3> By including primary bile acid diarrhoea in the definition of organic disease the sensitivity of FC falls to 54%, which is unacceptable for a screening test. Patients with undiagnosed BAD are likely to be denied referral to secondary care for diagnosis and subsequent treatment due to the current guidance. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Polychronis P, <i>et al</i>. Scand J Gastroenterol. 2013;48:1048–1054 NICE diagnostics guidance 11, Issued Oct 2013

PWE-060 Is a false positive faecal calprotectin as false as you think?

Introduction There is a clear need for a simple unambiguous test to differentiate between functional and true organic disease. This would have the effect of reducing the number of unnecessary investigations such as colonoscopies, whist reducing health service costs. Faecal calprotectin is a well validated non-invasive faecal inflammatory marker capable of differentiating functional (e.g. Irritable Bowel Syndrome) from organic (e.g. Inflammatory Bowel Disease). A recent BMJ meta-analysis suggested that it had 93% sensitivity and 96% specificity, with a false positive rate of 9%. The false positives were labelled as patients with a high faecal calprotectin who had subsequently undergone normal gastroscopy and colonoscopy. We decided to investigate this further. Method All the patients who had undergone a small bowel capsular endoscopy in our unit from 2011 to 2014 were indentified. Patients with an unexplained positive faecal calprotectin were selected (regardless of their referral indication). A retrospective analysis of the capsule findings was then made in those patients who had undergone normal endoscopic investigation. We excluded those with a positive endoscopy. This left us with 21 patients with a positive faecal calprotectin who had negative endoscopies. Results A total of 206 patients underwent capsule endoscopy between 2011 and 2014. Of these 46 had raised faecal calprotectin levels. 160 were excluded because of positive endoscopic findings. This lead to a total of 21 patients with raised faecal calprotectin and normal endoscopic investigations, labelled as false positives. Within this group 71.4% were found to have small bowel pathology including 12 (57.14%) patients with enteropathy, 2 (9.52%) patients had angiodysplasia and 1 (4.76%) with small bowel malignancy. Conclusion The documented false positive rate of 9% may not be as accurate as we previously thought. In our unit capsule endoscopy highlighted a pathological explanation in 71.4% and possible small bowel Crohn’s Disease in 57.14% of patients. Disclosure of interest None Declared. Reference van Rheenen PF, Van de Vijver E, Fidler V. Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis. BMJ. 2010; 341 :c3369

OC-048 Does the performance of faecal calprotectin testing in primary care differentiate patients with inflammatory bowel disease?: Abstract OC-048 Table 1

Introduction Measurement of faecal calprotectin (FC) may identify those harbouring inflammatory bowel disease (IBD). Use of the test is supported by NICE guidance (DG11) but evidence of its performance, in “real-life”, in patients presenting to primary care, is limited. Aim To assess the yield of IBD from FC testing in primary care. Method FC testing (Immunodiagnostics Phical Calprotectin ELISA) was made available to clinicians in October 2013. The results of all FC assays from 1.10.13 to 28.2.14 were reviewed retrospectively with results of GI investigations. Results Of FC measurements undertaken in 526 patients, 26 could not be identified on the local patient administration system, 57 were initiated in secondary care, 23 had known IBD and outcomes were not available for 22 patients with a raised FC (median 90 μg/g); range 54–995). These were excluded. 398 patients had FC requested in primary care (158 male; median age 42; range 6–91). FC was “positive” (>50 μg/g) in 132/398 (33.2%; median age 44 (range 6–91); median FC 128.5 μg/g (51–1770). 122/132 with positive FC underwent further investigation; 94 (77%) had lower GI endoscopy: IBD (7), colorectal cancer (2), adenoma (8), nil significant (77). 87/94 had lower GI endoscopy for a false positive FC (no IBD). 49/266 FC-negative patients also underwent lower GI endoscopy (median age 47; range 19–76) finding IBD (2), diverticulitis (1), adenomas (2), nil significant (43). 3/266 FC negative patients had IBD. IBD was diagnosed in 11/398 (2.3%; 4 ulcerative colitis (UC), 3 Crohn’s disease (CD), 2 collagenous colitis, 2 lymphocytic colitis (Table 1)). 8/11 were FC positive (range 67–1170); 3 were FC negative. At a 50 μg/g threshold, sensitivity for detecting IBD was 72.7%, specificity 68%, positive predictive value (PPV) 6.1%, negative predictive value 98.9%. Conclusion FC testing in primary care has lower sensitivity and specificity than in secondary care and poor PPV for detecting IBD. False positive FC is associated with more lower GI investigation than previously estimated. This experience differs from data used to inform NICE DG11. Strategies to target use to those with higher pre-test probability of IBD are needed. Disclosure of interest S. Conroy: None Declared, M. Hale: None Declared, S. Cross: None Declared, K. Swallow: None Declared, R. Sidhu: None Declared, R. Sargur: None Declared, A. Lobo Consultant for: Takeda UK and Vifor Pharma.