Ian Arnott Consultant Gastroenterologist Western General Hospital Edinburgh The Use of Faecal Calprotectin in Primary Care

MH 30 years female 3/12 history of abdominal pain Right sided Constipation – BOx1/week No weight loss, appetite unchanged No past medical history Non-smoker

Investigations Full blood count Hb 127 WCC 7.9 Plt 293 USS normal

Impression “... I think the most likely diagnosis is constipation predominant irritable bowel syndrome. I would suggest a trial of laxatives...” Ian Arnott BUT Faecal calprotectin >2500  g/g

Colonoscopy

Difficult to differentiate organic from functional symptoms IBD more common Up to 2% of population in high areas

Delay in diagnosis of IBD is important

Colonoscopy Key diagnostic tool – Colorectal cancer – Inflammatory bowel disease – Etc etc... BUT patients with IBS do not always need this – Unpleasant – Reinforce doubt about diagnosis – Resource intensive

Faecal calprotectin

Faecal Calprotectin: IBD v IBS Henderson et al. AJG 2014

Organic v IBS

Cut off <50µg/g Sensitivity 99% Specificity 74% Cut off <100µg/g Sensitivity 94% Specificity 82%

Durham Dales Primary Care Pilot 6.3% prevalence of IBD 25% of presenting patients are referred FC testing saved 129 referrals Greater satisfaction for patients Approval from GPs

Gastroenterology in Lothian 1 in 10 consultations in primary care Referrals in Lothian July 13 – June 14 Total 7898 WGH 3379 RIE 3325 St John’s 1126

NICE Guidance Recommended in children and adults IBD v IBS in those with lower GI symptoms, if: Cancer not suspected Appropriate Quality assurance

Cost Effectiveness NICE estimates – most conservative FC assay costs £22 Colonoscopy £741 Compared with current practice FC saves £82 – 240 per patient seen

FC Experience in Lothian Kennedy NA et al, JCC 2014

Faecal calprotectin: Results Functional v other GI conditions Sensitivity 89% Negative predictive value 93% Functional v IBD Sensitivity 99% NPV 100%

FC together with Alarm Symptoms

Calprotectin: Who to test

FC algorithm

Lothian Algorithm - Pilot Age less than 50? Alarm symptoms? Faecal calprotectin, Stool culture, Coeliac screen & FBC FC<50FC >150FC Referral for investigation Functional diagnosisRepeat calprotectin in 4 – 6 weeks. Functional diagnosis likely Consider referral as per current guidance Referral for urgent investigation Referral for D2 bx or other investigation yes no

Conclusions Faecal calprotectin can effectively differentiate between IBS and organic GI conditions Simple to assay Helps select patients for referral or investigation Cost effective Pilot in Lothian planned – please take part!