Faecal calprotectin is not necessarily required as a screen for significant bowel disease in primary care

Objective NICE recommends measurement of faecal haemoglobin (f-Hb) using faecal immunochemical test (FIT) when colorectal cancer is suspected and calprotectin (f-Cal) in the context of inflammatory bowel disease, though neither is disease specific. During the COVID-19 pandemic, f-Hb has been a requirement prior to referral for endoscopy in England; f-Cal is often performed simultaneously. The aim of this study was to investigate test performance of both tests for significant bowel disease in those patients referred. Design All adult patients with simultaneous measurements of f-Hb and f-Cal between April 2019 and September 2020 were included. For those referred, outcomes were determined from clinical records. Results 650 patients with simultaneous samples for f-Hb an f-Cal were managed in Primary Care; 319 patients were referred to hospital; SBD was found in 32 (10.0%) (CRC 5, high risk adenomas 5, IBD 22). At a cut-off of 10 μg/g for f-Hb and 200 μg/g for f-Cal, the sensitivity, specificity and negative predictive value for diagnosis of SBD were 84.4%, 58.2% and 96.7% and 68.8%, 89.6% and 95.7%, respectively. Performance of both tests would have enabled diagnosis of two more cases of significant, but non-malignant, bowel disease but required over 4% more referrals for investigation. Conclusion Use of FIT has become established to assist prioritisation of patients for referral from Primary Care. Whilst introduced specifically for CRC, FIT performs well as a rule out for IBD in Primary Care and the use of f-Cal is not required.

Dietary triggers of gut inflammation following exclusive enteral nutrition in children with Crohn’s disease: a pilot study

Background The anti-inflammatory effect of exclusive enteral nutrition on the gut of children with Crohn’s disease is rapidly lost after food reintroduction. This study assessed disease dietary triggers following successful treatment with exclusive enteral nutrition. Methods Nutrient intake, dietary patterns and dietary biomarkers in faeces (gluten immunogenic peptides, undigestible starch, short chain fatty acids) were assessed in 14 children with Crohn’s disease during early food reintroduction, following exclusive enteral nutrition. Groups above (Group A) and below (Group B) the median levels of faecal calprotectin after food reintroduction were assigned for comparative analysis. Results Intakes of fibre, gluten-containing cereals and red and processed meat were significantly higher in Group A than Group B; (median [Q1, Q3], g/day; Fibre: 12.1 [11.2, 19.9] vs. 9.9 [7.6, 12.1], p = 0.03; Red and processed meat: 151 [66.7, 190] vs. 63.3 [21.7, 67], p = 0.02; gluten-containing cereals: 289 [207, 402] vs. 203 [61, 232], p = 0.035). A diet consisting of cereals and meat products was predictive (92% accuracy) of higher faecal calprotectin levels after food reintroduction. In faeces, butyrate levels, expressed as absolute concentration and relative abundance, were higher in Group A than Group B by 28.4 µmol/g (p = 0.015) and 6.4% (p = 0.008), respectively. Levels of gluten immunogenic peptide and starch in faeces did not differ between the two groups. Conclusions This pilot study identified potential dietary triggers of gut inflammation in children with Crohn’s disease after food reintroduction following treatment with exclusive enteral nutrition. Trial registration: Clinical trials.gov registration number: NCT02341248; Clinical trials.gov URL: https://clinicaltrials.gov/ct2/show/NCT02341248 (retrospectively registered).

Faecal calprotectin testing in UK general practice: a retrospective cohort study using The Health Improvement Network database

BackgroundFaecal calprotectin (FC) testing to detect inflammatory bowel disease (IBD) was recommended for use in UK general practice in 2013. The actual use of FC testing following the national recommendations is unknown.AimTo characterise the use of FC testing for IBD in UK general practice.Design and settingA retrospective cohort study of routine electronic patient records from The Health Improvement Network database from UK general practice.MethodThe study included 6 965 853 adult patients (aged ≥18 years), between 2006 and 2016. FC test uptake, the patients tested, and patient management following testing were characterised.ResultsA total of 17 027 patients had 19 840 FC tests recorded. The mean age of tested patients was 44.2 years. The first FC tests were documented in 2009. FC test use was still increasing in 2016. By 2016, 66.8% (n = 493/738) of practices had started FC testing. About one-fifth (20.7%, n = 1253/6051) of tests were carried out in patients aged ≥60 years. Only 7.8% (n = 473/6051) of the FC test records were preceded by symptoms eligible for FC testing. Only 3.1% (n = 1720/55 477) of patients with eligible symptoms have received FC testing since the national recommendations were published. There was only a small number of patients with symptoms, FC test, and a IBD diagnosis. In total, 71.3% (n = 1416/1987) of patients with a positive and 47.7% (n = 1337/2805) with a negative FC test were referred or further investigated.ConclusionUptake of FC testing in clinical practice has been slow and inconsistent. The indication of non-compliance with national recommendations may suggest that these recommendations lack applicability to the general practice context.

Diagnostic Performance of Faecal Calprotectin among People with Chronic Inflammatory Diseases of the Bowel in Cameroon: A Pilot Study in Sub-Saharan Africa

Background: Inflammatory bowel diseases (IBDs) are relatively common in African countries. The use of faecal markers, Calprotectin in particular, is presently of considerable interest to IBD patients. The high faecal calprotectin level has a good diagnostic accuracy in discriminating intestinal organic and functional diseases and enables the selection of patients in need of other invasive diagnosis such as endoscopy. Aim: To evaluate the diagnostic performance of faecal calprotectin as a useful diagnostic tool for IBD patients in Cameroon. Study design: This was a case control cross-sectional multicentre study conducted in major gastroenterology units of the towns of Yaoundé and Douala involving 64 participants grouped as 32 IBD positive subjects and 32 IBD negative subjects. Methods: Stool sample collected from participants at various recruitment sites were collected, conditioned and transported to the CIAB laboratory for analysis using a direct ELISA method. The R software was used for data analysis. Results: The calprotectin levels of IBD patients were significantly higher than those of the control subjects (P < .001.) The area under the curve (AUC) was 0.96 [95%CI: 0.92 – 1.00; P < .001]. A threshold value of 2.51µg/g was chosen to exclude the diagnosis of IBD with an 87.5% sensitivity and 100% specificity. The CRP levels correlated with those of calprotectin (r꞊0.579, P ꞊ .005). Calprotectin concentrations became abnormally elevated in all UC patients with an Endoscopy Score greater than or equal to 6 (P = .001). Correlation between the endoscopy score for Crohn's disease and calprotectin concentration did not retain significance (ρ꞊0.800; P > .05). Conclusion: Calprotectin dosage is a sensitive test for IBD, excludes unnecessary investigations and accurately predicts disease recurrence and response to treatment.

1214 A Combined Approach to Prioritise Patients for Colonoscopy

Aim Correlating colonoscopy finding with presenting features to assess the diagnostic yield of different symptoms. Method We looked at findings of 100 patients retrospectively who had colonoscopy in Dhaka Medical College Hospital, Bangladesh during first peak of COVID (August 2020 to December 2020). We reviewed NICE guideline for high-risk symptoms and NHS guideline for prioritisation of colonoscopy patients. Results 100 cases were reviewed, 67% were male among the patients, average age was 42.11 (4 – 75 years). 47 were found to have significant pathology. Findings included colorectal malignancy (28%), Polyp (9%), IBD (6%), tuberculosis (2%) etc. PR bleed had highest diagnostic yield (21.27%), followed by abdominal lump (17.02%) and lower abdominal pain (14.89%). Weight loss showed lowest diagnostic yield (4.25%). 28% colonoscopy findings were normal. Patients were chosen based on clinical assessments and imaging results, as stool biochemical marker tests (FIT test, faecal calprotectin) are not available in DMCH. Conclusions Being an aerosol generating procedure which has a considerable amount of risk of transmitting COVID infection from patient to clinician or vice versa, it is important to triage patients with lower GI symptoms for colonoscopy. In a developing country like Bangladesh, it is essential to make the most reasonable use of limited resources. Symptoms-based triaging systems are poor predictors of clinically significant disease on colonoscopy. Therefore, a more holistic and novel approach needs to be studied and formulated using a combination of symptoms, blood, and stool biomarkers in order to reduce the need for a ‘negative’ colonoscopy and avoid unnecessary risks.