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The Use of Faecal Calprotectin in Primary Care
Ian Arnott Consultant Gastroenterologist Western General Hospital Edinburgh
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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
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Investigations Full blood count Hb 127 WCC 7.9 Plt 293 USS normal
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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 >2500g/g
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Colonoscopy
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Difficult to differentiate organic from functional symptoms
IBD more common Up to 2% of population in high areas
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Delay in diagnosis of IBD is important
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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
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Faecal calprotectin
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Faecal Calprotectin: IBD v IBS
Henderson et al. AJG 2014
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Organic v IBS
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Organic v IBS Cut off <50µg/g Cut off <100µg/g Sensitivity 99%
Specificity 74% Cut off <100µg/g Sensitivity 94% Specificity 82%
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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
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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
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NICE Guidance Recommended in children and adults
IBD v IBS in those with lower GI symptoms, if: Cancer not suspected Appropriate Quality assurance
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Cost Effectiveness NICE estimates – most conservative
FC assay costs £22 Colonoscopy £741 Compared with current practice FC saves £82 – 240 per patient seen
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FC Experience in Lothian
Kennedy NA et al, JCC 2014
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Faecal calprotectin: Results
Functional v other GI conditions Sensitivity 89% Negative predictive value 93% Functional v IBD Sensitivity 99% NPV 100%
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FC together with Alarm Symptoms
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Calprotectin: Who to test
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FC algorithm
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Lothian Algorithm - Pilot
no Age less than 50? Consider referral as per current guidance yes Alarm symptoms? Referral for urgent investigation Faecal calprotectin, Stool culture, Coeliac screen & FBC Referral for D2 bx or other investigation FC FC<50 FC >150 Repeat calprotectin in 4 – 6 weeks. Functional diagnosis likely Functional diagnosis Referral for investigation
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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!
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