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The Use of Faecal Calprotectin in Primary Care

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

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

  2. 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

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

  4. 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

  5. Colonoscopy

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

  7. Delay in diagnosis of IBD is important

  8. 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

  9. Faecal calprotectin

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

  11. Organic v IBS

  12. Organic v IBS • Cut off <50µg/g • Sensitivity 99% • Specificity 74% • Cut off <100µg/g • Sensitivity 94% • Specificity 82%

  13. 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

  14. 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

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

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

  17. FC Experience in Lothian Kennedy NA et al, JCC 2014

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

  19. FC together with Alarm Symptoms

  20. Calprotectin: Who to test

  21. FC algorithm

  22. 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 50 - 150 FC<50 FC >150 Repeat calprotectin in 4 – 6 weeks. Functional diagnosis likely Functional diagnosis Referral for investigation

  23. 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! ian.arnott@luht.scot.nhs.uk

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