Background:Distinguishing inflammatory bowel disease (IBD) from functional gastrointestinal (GI) disease remains an important issue for gastroenterologists and primary care physicians, and may be difficult on the basis of symptoms alone. Faecal calprotectin (FC) is a surrogate marker for intestinal inflammation but not cancer.Aim:This large retrospective study aimed to determine the most effective use of FC in patients aged 16–50 presenting with GI symptoms.Methods:FC results were obtained for patients presenting to the GI clinics in Edinburgh between 2005 and 2009 from the Edinburgh Faecal Calprotectin Registry containing FCs from >16,000 patients. Case notes were interrogated to identify demographics, subsequent investigations and diagnoses.Results:895 patients were included in the main analysis, 65% female and with a median age of 33 years. 10.2% were diagnosed with IBD, 7.3% with another GI condition associated with an abnormal GI tract and 63.2% had functional GI disease. Median FC in these three groups were 1251, 50 and 20 μg/g (p < 0.0001). On ROC analysis, the AUC for FC as a predictor of IBD vs. functional disease was 0.97. Using a threshold of ≥ 50 μg/g for IBD vs. functional disease yielded a sensitivity of 0.97, specificity of 0.74, positive predictive value of 0.37 and negative predictive value of 0.99. Combined with alarm symptoms, the sensitivity was 1.00.Conclusions:Implementation of FC in the initial diagnostic workup of young patients with GI symptoms, particularly those without alarm symptoms, is highly accurate in the exclusion of IBD, and can provide reassurance to patients and physicians.

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IntroductionFaecal calprotectin (FC) has been shown to distinguish reliably between functional and inflammatory bowel diseases (IBD) in a number of studies of patients with established gastrointestinal disease. However, it is a poor screening test for colorectal cancer. Presently, diagnostic algorithms incorporating FC at first presentation to the gastroenterology clinic are lacking.MethodsThis study aimed to determine the optimal use of FC, in conjunction with serum markers, in the initial diagnostic workup of patients aged 16–50 years. Patients >50 years were excluded, as they require colonoscopy to exclude malignancy. Detailed clinical, laboratory, endoscopic and radiological parameters were collected. Patients with a prior GI diagnosis were excluded. All stool samples were analysed in the same laboratory using the same FC assay (Calpro ELISA). ROME III and Lennard-Jones criteria were used. Patients were followed up for a minimum of 12 months.ResultsThe Edinburgh FC Register comprises data on 7512 patients (2005–2008) from across Lothian. 1838/7512 were managed at 2 Edinburgh teaching hospitals, and aged 16–50 years at time of FC; 851 were excluded, mostly due to pre-established diagnosis of IBD. 987 (mean±SD age 33.5±9.0 years; 64.8% female) met the strict inclusion criteria. In patients presenting primarily with bloody diarrhoea (n=68), median FC was 690 μg/g (IQR: 72–2323), in contrast to watery diarrhoea (n=325, FC 30 μg/g (20–90), p<0.0001), or abdominal pain (n=271; FC 25 μg/g (20–85), p<0.0001). 193/987 (19.6%) were ultimately diagnosed with organic disease with median FC of 180 μg/g (37–1292), 113/987 (11.4%) with IBD (FC 990.0 (225–2190)) and 605/987 (61.3%) with a functional disorder (FC 20 (20–50)). FC was influenced by NSAID use, but not by age, sex or smoking. ROC analysis of FC in discriminating organic disease and IBD from functional disorders gave an area under the curve of 0.80 (95% CI 0.76 to 0.84) and 0.93 (95% CI 0.90 to 0.96), respectively. Further detailed analysis suggested the following model: FC<70 μg/g with normal blood parameters and no alarm symptoms/signs – no further investigation; FC>50 μg/g with bloody diarrhoea OR raised CRP/low albumin – combined radiological and endoscopic evaluation.ConclusionIn this study, the largest on the clinical utility of FC, we were able to develop clear investigative strategies in adults <50 years, dependent on FC and other clinical/laboratory parameters. This simple algorithm could be rolled out into primary care facilitating timely and appropriate triage of new patients and minimising diagnostic delay in IBD. Abstract OC-013IBD vs functional diseaseCalprotectinSensitivitySpecificityPPVNPV<20 μg/g0.970.4928.099.0<50 μg/g0.930.7043.398.1<70 μg/g0.920.7750.898.1<100 μg/g0.870.8458.497.2