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PostPosted: 09 Jun 2013 01:27 
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GPs should use faecal calprotectin testing to confirm a diagnosis of irritable bowel syndrome (IBS) and rule out more serious inflammatory bowel diseases, NICE has recommended


Draft guidance from NICE advocates the use of the stool test that it said could reduce the misdiagnosis of bowel disorders in adults and children - such as such as ulcerative colitis and Crohn’s disease.

The test should be used to help diagnose inflammatory bowel diseases, and indicate whether a referral to a specialist for further investigation is needed.
However, the guidance does not apply to people who are being considered for referral for suspected cancer as inflammatory markers are also present in bowel cancer.

NICE said that the test could help pick up inflammatory bowel disease (IBD) that can lead to serious complications such as surgery and a reduced life expectancy.


The guidance said: ‘Faecal calprotectin testing is recommended as an option in adults with lower gastrointestinal symptoms for whom specialist investigations are being considered, if cancer is not suspected, it is used to support a diagnosis of IBD or IBS, and appropriate quality assurance processes are in place for the testing.’

It added that the test is recommended in children with suspected IBD who have been referred for specialist investigation, to support a diagnosis of IBD.

NICE’s evaluation looked at the different technologies to diagnose IBD and found that faecal calprotectin test was estimated to cost £22.79 per patient, while a colonoscopy- an invasive surgery which can also help diagnose inflammatory bowel disease- was estimated to cost £741.68 per person.

Cost included the cost of the different tests, treatment costs, resource costs such as staff time and the costs of adverse effects associated with colonoscopy.

NICE Health Technology Evaluation Centre director Professor Carole Longson said distinguishing between IBS and more serious bowel disorders will allow patients to be better monitored and managed.

She said: ‘Faecal calprotectin testing helps doctors to distinguish between non-inflammatory disorders like IBS where sufferers will not come to serious harm and inflammatory bowel diseases such as Ulcerative Colitis or Crohn’s Disease – which need to be quickly referred to specialists.

‘Currently a number of tests are carried out in both hospitals and GPs’ surgeries to rule out conditions rather than to diagnose. This means people often face uncertainty, lots of visits to hospitals and their GP and repeated tests – some of them invasive and uncomfortable. Many people with IBD, particularly children with Crohn’s disease, sometimes have to wait for several years for confirmation of their condition.’

She added the tests could also reduce demands on colonoscopy departments: ‘The test is also likely to reduce the demands on colonoscopy departments which will be able to focus on people thought to have more serious conditions such as bowel cancer.’

Dr Jamie Dalrymple, chair of the Primary Care Society for Gastroenterology and a GP in Norwich said he welcomed the recommendation but advised caution when using the test on children: ‘It will be very useful to exclude IBD, especially Crohn’s disease. I would advise caution at the moment in children as the sensitivity and specificity are not as good as adults.

ref: NATIONAL INSTITUTE OF CLINICAL EXCELLENCE, ENGLAND- 5TH JUNE 2013.

G.MOHAN.


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PostPosted: 09 Jun 2013 17:11 
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Mohan thanks for this post.

This is an important message for all doctors treating patients with "problem bowels".

The message is very clear:

The main diseases that cause an increased excretion of faecal calprotectin are Crohn's disease, ulcerative colitis and neoplasms (cancer). Levels of faecal calprotectin are normal in patients with irritable bowel syndrome (IBS).

Faecal calprotectin testing should be used as an indicator for IBD during treatment and as diagnostic marker. The test would distinguish between inflammatory bowel disease (IBD) and functional bowel disease (IBS).


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PostPosted: 10 Jun 2013 01:05 
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Hi Mohan & Badri,

Thank you for the post. About 3 years ago BMJ published an article citing their conclusions of meta-analysis of 13 prospective studies that compared fecal calprotectin testing with endoscopy as the reference test. 6 were done in adults and 7 in children and teenagers. Their conclusion was that this test would reduce the need for endoscopy in adults and children by 67% and 35% respectively. However the downside of such screening would be a delayed diagnosis of 6% adults and 8% in children because of false negatives. A false negative test would lead to delayed treatment and continuation of symptoms, where as a false positive would lead to an unnecessary endoscopy with possible complications of perforation,tear or anesthesia. They also pointed out methodological limitations, i.e. two of the included studies did not sample intestinal mucosa. None of the studies used a well defined set of clinical findings or flow chart to identify patients with a high probability of IBD. The meta analysis was limited to studies in English and did not include world literature.
Despite these limitations measuring fecal calprotectin is a useful tool in identifying patients who may need endoscopy. Their conclusion was that the test cannot be recommended as a diagnostic test for IBD in primary care because the results of the study apply to patients referred to secondary care.


Calprotectin is a calcium and zinc binding protein and accounts for 30 to 40% of neutrophils' cytosol. It has bacteriostatic and fungistatic properties and is resistant to enzymatic degradation, hence can be easily measured in feces stored at room temperature for up to 7 days.

IBD is a condition that causes a pathological inflammation of the bowel wall. Neutrophils influx into the bowel lumen as a result of the inflammatory process. Measurement of faecal calprotectin has been shown to be strongly correlated with 111-indium-labelled leucocytes - considered the gold standard measurement of intestinal inflammation.

The main diseases that cause an increased excretion of faecal calprotectin are IBD and neoplasms . Levels of faecal calprotectin are normal in patients with irritable bowel syndrome (IBS).

Specific indications for measuring calprotectin are as follows.

1) Distinguishing inflammatory bowel disease (IBD) from functional bowel disease (IBS), and avoid the need for invasive tests such as colonoscopy.
2) Assessing efficacy of IBD treatments.
3) Predicting relapses or flares of IBD.
4) Offer an alternate diagnostic test for patients phobic of needles or endoscopy.

_________________
Raghuthaman


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