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WORLD GASTROENTEROLOGY NEWS APRIL 2018
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tive FC revealed abnormal findings in
80%.8 This included Crohn’s disease,
angioectasia, nonsteroidal anti-inflammatory
drug enteropathy, tuberculosis
and polyps. The sensitivity of FC in
this cohort was 88%. However, video
capsule endoscopy is an expensive test
and may not be easily accessible in
resource-limited settings. Clinicians
should thus take into account / address
the following reasons apart from
IBD for an elevated FC:7
a. Infections (Giardia lamblia, bacterial
dysentery, viral gastroenteritis,
H. pylori gastritis)
b. Malignancy (colorectal cancer, gastric
cancer, intestinal lymphoma)
c. Drugs (nonsteroidal anti-inflammatory
drugs, proton pump
inhibitors)
d. Untreated food allergy
e. Age < 5yrs
f. Other: reflux disease, cystic
fibrosis, untreated celiac disease,
diverticular disease, microscopic
colitis, cirrhosis
False negative FC results in patients
with chronic diarrhea have been associated
with celiac disease and giardiasis.9
Cost-effectiveness of FC testing
Savings in the “cost of colonoscopy”
is the main selling point for the widespread
use of FC testing. Although
there is evidence that suggests FC
testing may lead to a reduction in
colonoscopy requests, this needs confirmation
across different settings.10, 11
Furthermore, the cost of colonoscopy
and FC may vary across different
health care systems even within the
same country (“private vs. public”).
The development of cheaper point of
care FC testing may improve the costeffectiveness
and accessibility.
Disease monitoring in
Inflammatory Bowel Disease (IBD)
In patients with an established diagnosis
of IBD, FC is a useful indicator
of persistent bowel inflammation,
even in the absence of clinical symptoms.
12 A low FC predicts sustained
clinical remission in IBD patients.13
It may also be useful in IBD patients
to distinguish between active inflammation
and a possible overlap with
IBS symptoms. Fecal calprotectin
can serve to guide therapy and avoid
unnecessary endoscopic examinations
to assess for disease activity.14 In
patients with Crohn’s disease, FC can
be reliably used to assess for disease
recurrence and monitoring following
intestinal resection.15 A low fecal
calprotectin provides reassurance
that current maintenance therapy
is satisfactory. Fecal calprotectin is
probably unnecessary in patients who
had a recent endoscopic examination,
patients with obvious clinical features
of a relapse and those requiring hospitalization
for acute severe ulcerative
colitis. It is not clear how often to
check the fecal calprotectin in stable
IBD patients. Should it replace the
CRP and /or ESR or performed as an
additional test of disease activity? To
contain costs while ensuring satisfactory
disease monitoring, clinicians
will need to make prudent decisions
about the frequency and type of tests
ordered with an appreciation of the
local healthcare resources.
Conclusion
FC is a valuable test to screen patients
for intestinal inflammation and for
monitoring IBD patients. It is imperative
that gastroenterologists play a key
role in educating clinicians and develop
locally applicable guidelines to
ensure appropriate and cost-effective
use. Testing for FC should not serve
as a substitute for a thorough clinical
assessment and judgement.
References
1. Menees SB, Powell C, Kurlander
J, Goel A, Chey WD. A metaanalysis
of the utility of C-reactive
protein, erythrocyte sedimentation
rate, fecal calprotectin, and fecal
lactoferrin to exclude inflammatory
bowel disease in adults with
IBS. The American journal of gastroenterology.
2015;110(3):444-
54.
2. Waugh N, Cummins E, Royle
P, Kandala N-B, Shyangdan D,
Arasaradnam R, et al. Faecal
calprotectin testing for differentiating
amongst inflammatory and
non-inflammatory bowel diseases:
systematic review and economic
evaluation. 2013.
3. Pavlidis P, Chedgy FJ, Tibble JA.
Diagnostic accuracy and clinical
application of faecal calprotectin
in adult patients presenting with
gastrointestinal symptoms in primary
care. Scand J Gastroenterol.
2013;48(9):1048-54.
4. Hestvik E, Tumwine JK, Tylleskar
T, Grahnquist L, Ndeezi G,
Kaddu-Mulindwa DH, et al.
Faecal calprotectin concentrations
in apparently healthy children
aged 0-12 years in urban Kampala,
Uganda: a community-based survey.
BMC Pediatr. 2011;11(1):9.
5. Jeevagan A, Clayton L, Soni S,
Austin M. PTU-065 Is There
A Role For Faecal Calprotectin
In The Investigation Of Diarrhoea
In Patients With Hiv? Gut.
2014;63(Suppl 1):A67-A.
6. Larsson G, Shenoy KT, Ramasubramanian
R, Thayumanavan
L, Balakumaran LK, Bjune GA,
et al. High faecal calprotectin
levels in intestinal tuberculosis
are associated with granulomas
in intestinal biopsies. Infect Dis.
2015;47(3):137-43.
There is a need for further
research in developing
countries where there is a
higher burden of infectious
diseases such as HIV,
tuberculosis and parasites
to help define the role of FC
use in these contexts.