# Fecal Calprotectin a Sign of Inflammatory Bowel Disease



## David in Seattle (Jul 25, 2010)

BMJ. Published online July 16, 2010

A new approach to the diagnosis of inflammatory bowel disease (IBD) — fecal calprotectin testing — is a useful tool for identifying patients who are most likely to need endoscopy for suspected IBD, thereby reducing the number of unnecessary endoscopies, according to a meta-analysis published online July 16 in the British Medical Journal.

"Endoscopic evaluation with histopathological sampling is generally considered indispensable in the investigation of patients with suspected [IBD]," write Patrick F. van Rheine, MD, from Beatrix Children's Hospital, University Medical Center Groningen, the Netherlands, and colleagues. "In a relatively large proportion of people with suspected [IBD,] the results of endoscopy will be negative."

The aim of this meta-analysis was to evaluate whether adding fecal calprotectin testing to the work-up of patients with suspected IBD would reduce the number of unnecessary endoscopies.

Calprotectin is a major protein found in inflammatory cells. It is stable in stool samples for up to 7 days at room temperature, and 1 sample of less than 5 g is sufficient to allow for reliable measurement.

The analysis included 13 prospective studies that compared fecal calprotectin testing with endoscopy as the reference test. Six were done in adults (n = 670), and 7 in children and teenagers (n = 371).

IBD was confirmed in 32% (n = 215) of the adults and in 61% (n = 226) of the children and teenagers. In adults, the pooled sensitivity of fecal calprotectin testing was 0.93 (95% confidence interval [CI], 0.85 - 0.97), and the pooled specificity was 0.96 (95% CI, 0.79 - 0.99). In children and teenagers, the pooled sensitivity was 0.92 (95% CI, 0.84 - 0.96), and the pooled specificity was 0.76 (95% CI, 0.62 - 0.68).

The lower specificity in children and teenagers was significantly different from that in adults (P = .048).

The authors report that screening with fecal calprotectin would reduce the number of adults requiring endoscopy by 67%. They add that 3 of 33 adults who undergo endoscopy will not have IBD but may have a different condition that would still necessitate having an endoscopy.

In children and teenagers, screening with fecal calprotectin would reduce the number of endoscopies by 35%.

However, the downside of such screening would be a delayed diagnosis in 6% (2/32) of affected adults and in 8% (5/61) of affected children because of false-negative test results.

The authors write that the clinical consequences of missing patients with IBD should be balanced against patients without the disease being subjected to endoscopy. A false-negative fecal calprotectin test would lead to delayed treatment and continuation of symptoms, whereas a false-positive test would lead to an unnecessarily invasive endoscopy with possible complications from colonic perforation or tear and anesthesia.

The researchers also point out methodological limitations of their meta-analysis. Two of the included studies in adults did not sample intestinal mucosa, which might have caused some patients to be misclassified as normal. In addition, none of the studies used a well-defined set of clinical findings or flow chart to identify patients with a high probability of IBD. In addition, the number of studies included in the meta analysis was limited, and the studies were restricted to those written in English.

Despite these limitations, the study demonstrates that measuring fecal calprotectin levels is a useful screening tool for identifying patients most likely to need endoscopy, and the test can contribute important information to guide patient management at a tertiary-care level, the authors write.

Finally, they note that the pooled sensitivity and specificity found in their study should be interpreted with caution. "Despite a strict selection of studies based on proper patient recruitment and study design, heterogeneity was considerable."

In an accompanying editorial, Robert Logan, MD, from Kings College Hospital, London, United Kingdom, writes that the sensitivity of 93% and specificity of 96% of the fecal calprotectin test is remarkable, "considering the diverse and complex antigenic environment of faeces."

However, 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. In primary care, patient characteristics and populations are "probably different," which would affect the negative and positive predictive value of fecal calprotectin screening.

"If studies conducted in primary care find a high diagnostic accuracy of the faecal calprotectin test it will be an important step forward in how [IBD] is diagnosed," he concludes.


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## tmgread (Jul 26, 2010)

Do you think this test could be used to diagnose current levels of disease activity?  I would love to avoid my next colonoscopy.
Tina


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## David in Seattle (Jul 27, 2010)

I think at the moment they're using it mostly to avoid unnecessary procedures, but maybe down the road it will be used more diagnostically.  I guess it varies from person to person; I've had 2 colonoscopies & really find them more annoying than something to dread.


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## Entchen (Jul 27, 2010)

Hey, this is great news! The fewer people needing endoscopy, the shorter the wait times.


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## duck68 (Jul 27, 2010)

My Gastro Dr ordered this test for me - and it came back confirming her suspicions - I've also had all the other tests as well - colonoscopy/endoscopy, biopsies, CT scan, blood tests etc etc.  It all pointed to Crohn's...


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## Absentminded (Jul 27, 2010)

I used to have this done regularly with my last Hospital, King's College Hospital in London. 
It's apparently a better indicator than crp as it's specifically for your bowel, whereas CRP is any inflamation in your body. 

I'm not sure what a normal result is, I think it's below 300. When I was admitted to hospital last year my calprotectin was 1379! So just a little bit high....!


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## Mayflower537 (Jul 28, 2010)

Someone on another board posted this.  

http://www.ncbi.nlm.nih.gov/pubmed/15819166

Interesting.


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## Richardv (Jan 21, 2011)

*Calprotectin Use with IBD*

My wife has had UC (not Crohns, still a nasty IBD) since 1988 and has managed the "disease" very well in the last 5-6 years. The first few years were really bad, but they seemed to be made worse by stressful situations, which would bring on a serious relapse. These have been less of a problem to her, but knowing the status quickly has always been an issue unless severe.

I am a scientist by trade and now a marketeer, so this has always kept my attention. My wife has been through an unbelievable number of invasive procedures and I have to respect her ability to continue without complaint. Hence when Calprotectin as a marker of disease activity was brought to my attention it made a great deal of sense and could potentially show flares or simple digestive IBS occurrences.

I have looked into this and commissioned a series of articles on the subject which can be found at: calprotectin.net/faecal-calprotectin.

The issue with all these types of tests (a little like drugs) is that they need to find their way into mainstream pathology testing and then, when accepted and trialled against the gold standards and costed can be adapted to OTC/Pharmacy supply tests. There are OTC tests, but I don't yet think they are CE marked for the high street, just labs! This is the current status, so if you would like a test ask your GP! 

I hope this helps people looking to ease their lives with the medical profession!


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## BlueGlass (Aug 11, 2011)

*FC levels*

I had a FC level of 1550 2 months ago....now it's 960 after 8 weeks on a liquid diet. I think normal is 50 so a long way to go but the trend is looking promising.


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## StarGirrrrl (Aug 12, 2011)

Can you believe in 5 years of GI symptoms (including visible dark blood in stool last 6 months at least) I have never been asked to do this test!


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## BlueGlass (Aug 13, 2011)

I know it's a relatively new test and they will only test once every four weeks but I read that its so accurate in showing up bowel inflammation that often enables patients to avoid endoscopies, which is always a good thing!!


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## Becca1991 (Aug 13, 2011)

My calprotection in 2008* was 82 normal <50 but 2 weeks before i was diagnosed it was on 22 but my CRP was 71 normal <5


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