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How to use faecal calprotectin in management of paediatric inflammatory

bowel disease

Article  in  Archives of Disease in Childhood - Education and Practice · February 2016

DOI: 10.1136/archdischild-2014-307941

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INTERPRETATIONS
1
Paediatric Gastroenterology,
Southampton University Hospital
NHS Trust, Southampton, UK
2
Department of Paediatrics,
Poole Hospital NHS Trust,
Dorset, UK
Correspondence to
Dr Akshay Batra, Paediatric
Gastroenterology, Southampton
University Hospital NHS Trust,
MP 44, G level East Wing,
Tremona Road, Southampton,
SO16 6YD, UK;
Akshay.Batra@uhs.nhs.uk
Accepted 30 December 2015
Published Online First
4 February 2016
To cite: Saha A, Tighe MP,
Batra A. Arch Dis Child Educ
Pract Ed 2016;101:124–128.
124
How to use faecal calprotectin in
management of paediatric
inflammatory bowel disease
Amit Saha,1 Mark P Tighe,2 Akshay Batra1
ABSTRACT
Faecal calprotectin (FC) is a neutrophil-derived
protein released in stool in response to mucosal
inflammation. It is a simple, cheap and non-
invasive test with high sensitivity and moderate
specificity, which can be useful in the diagnosis
and monitoring of inflammatory bowel disease
(IBD). FC levels correlate well with bowel
inflammation (both macroscopic and histological
activity) and are not influenced by disease
location or type of IBD. Despite the shortcoming
with regards to specificity, it is the high sensitivity
of FC that makes it a valuable screening tool in
the diagnosis of IBD. It is especially effective in
identifying children with low probability of IBD
who would not benefit from further
investigations. The cut-off value selected has a
significant impact on the diagnostic accuracy of
the test, influencing its sensitivity and specificity,
and must be interpreted judiciously. Its role in
disease monitoring is as an add-on test to
Paediatric Ulcerative Colitis Activity Index and
Paediatric Crohn’s Disease Activity Index scores
and can be used to differentiate disease relapse
from functional symptoms. High levels of FC are
also seen in a number of other conditions, such
as gastrointestinal infections and coeliac disease.
It is recommended that infective causes affecting
the gut must be excluded first, before FC is
measured.
INTRODUCTION
The incidence of inflammatory bowel
disease (IBD) in children less than
16 years of age in UK has been increasing
and has gone up from 5.2/100 000/year in
2001 to 9.37/100 000/year over a period
of 10 years.1 Crohn’s disease can present
with symptoms of abdominal pain (72%),
weight loss (58%), anorexia (25%) and
lethargy (27%) and children presenting
with ulcerative colitis have a higher preva-
lence of diarrhoea (74%), bleeding (84%)
and abdominal pain (62%),2 although
there may be considerable clinical overlap.
Saha A, et al. Arch Dis Child Educ Pract Ed 2016;101:124–128. doi:10.1136/archdischild-2014-307941
It is noteworthy that a significant propor-
tion of children present with a range of
non-specific symptoms such as lethargy
and mild abdominal discomfort, with
only about 25% presenting with the
‘classic triad’ of diarrhoea, pain, and
weight loss.2 On the other hand, non-
specific abdominal pain remains a
common problem of childhood and repre-
sents a significant burden on primary and
secondary care. It is therefore important
to identify children with functional
abdominal pain without using invasive
investigations especially in the absence of
‘red flag’ symptoms; in whom investiga-
tions identify disease in <5% of chil-
dren.3 In current clinical practice, a large
number of endoscopies performed for
suspected paediatric inflammatory bowel
disease (PIBD) are negative, and there is
an acute need to prioritise children who
need it most.4
Early investigation in suspected cases of
PIBD is imperative, as a delay in diagno-
sis can prolong the period of time
patients suffer from symptoms. One
study of 739 new paediatric IBD cases
reported a median delay of 5 months
(mean 11 months) from the onset of
symptoms to the confirmation of diagno-
sis, with one-fifth of them having symp-
toms for more than a year.2 Sixty per
cent of IBD cases were reported to have
had a delay of less than 6 months, 19% a
delay of 6–12 months, 14% a delay of 1–
3 years, and 7% a delay of more than
3 years. Improved recognition of present-
ing features and judicious use of the
screening, investigative and diagnostic
tests may aid speedy diagnosis, prompt
initiation of treatment and reduce the
impact of disease.
Being a relapsing–remitting illness,
patients with IBD are at risk of relapse
throughout the course of their disease. This
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Interpretations

risk is ill-defined and ill-understood, due to the waxing
and waning nature of the disease, with no treatment
being 100% effective in maintaining remission. The
Paediatric Ulcerative Colitis Activity Index (PUCAI) and
Paediatric Crohn’s Disease Activity Index (PCDAI) scores
are useful at high levels in identifying overt relapse, but
at lower levels, are unable to differentiate between func-
tional symptoms and mild relapse.5 Endoscopy is the
gold standard for assessing recurrence of inflammation
and relapse but its’ use is limited because of the invasive
nature of the test and the common requirement in chil-
dren for a general anaesthetic.
Faecal calprotectin (FC) is a simple, cheap and non-
invasive test with high sensitivity, which can be useful
in identifying such cases. It has been shown to be
diagnostically more accurate than commonly used
blood parameters such as C-reactive protein, erythro-
cyte sedimentation rate, haemoglobin, platelet count,
total white cell count and albumin.6 In its diagnostic
guidance (DG11) published in 2013, the National
Institute for Health and Care Excellence (NICE)
recommends FC testing to support clinicians with the
differential diagnosis of IBD or non-IBD in children.
This review looks at the role of measurement of FC in
diagnosing and monitoring of paediatric IBD.
Physiological background
Calprotectin, a neutrophil-derived protein present in
stool, is a 36 kDa calcium- and zinc-binding protein
found in a number of tissues and released during
inflammation, both acute and chronic.7 Calprotectin
is produced by intestinal neutrophils but is not specific
to gastrointestinal mucosa; it possesses chemotactic
and antimicrobial properties (anticandidal) mediated
by zinc chelation via its histidine-rich regions8 and is
excreted in excess into the intestinal lumen during an
inflammatory process of the gut. It accounts for up to
60% of the total protein content of neutrophil
cytosol, and therefore can be directly proportional to
neutrophil influx into the gut mucosa.9
In the early phase of inflammation, unknown trig-
gers on the gut epithelium lead to the activation of
the intestinal immune system, resulting in the influx
of monocytes, macrophages and granulocytes. These
cells actively secrete inflammatory mediators or
release granule proteins by cell degranulation. The
neutrophil-derived S100 proteins (S100A8/A9 (calpro-
tectin)) are released from the cytosol by activated or
damaged cells under conditions of cell stress.
Cytokines such as IL-1 or TNF-α (secreted by macro-
phages in response to inflammatory trigger) and/or
bacterial products also cause monocytes and intestinal
epithelial cells to synthesise and secrete proteins of
the S100 family. Studies have even implicated high
local concentrations of calprotectin as injurious to
inflamed cells, inducing apoptosis, especially in zinc-
deficient conditions.10 FC then easily passes into the
intestinal lumen due to the inflamed and hyperperme-
able gut mucosa and is deposited onto the faecal
stream (figure 1).

Figure 1 Faecal calprotectin in mucosal inflammation of gastrointestinal tract. (1) Unknown trigger causing activation of gut
immune system generating faecal calprotectin from (A) epithelial cells (B) monocytes and (C) neutrophils. The released faecal
calprotectin passes into the gut lumen and is taken up by the faecal stream.

Saha A, et al. Arch Dis Child Educ Pract Ed 2016;101:124–128. doi:10.1136/archdischild-2014-307941 125
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Interpretations
Technological background
FC can be measured in stool by ELISA methods and
requires less than 5 g of stool for reliable assay. FC is
resistant to enzymatic degradation in stool and is
stable for up to 7 days at room temperature.11 This
makes it possible for a sample to be collected and
transported to the laboratory in a plain container.
There are several available technologies to measure
the level of calprotectin in stool sample, including
quantitative laboratory-based tests, fully quantitative
rapid tests and semiquantitative point-of-care tests
(POCTs).12 The fully quantitative laboratory-based
technologies available to the National Health Service
in England mainly use ELISA to detect and quantify
calprotectin in stool. Several manufacturers such as
Bühlmann, Calpro, Eurospital, Immunodiagnostik and
Phadia AB provide an array of quantitative ELISA and
rapid tests with different ranges. Preventis also manu-
factures immunochromatographic rapid tests used as a
POCT, both a semiquantitative one using three set
ranges and a qualitative test using a cut-off value of
50 mg/g of stool.12
Clinical indications in PIBD
In children with abdominal pain and diarrhoea, can a low FC accurately
identify children who do not need further investigations for IBD?
FC can be measured in children presenting with
gastrointestinal symptoms suggestive of PIBD and is
useful in distinguishing IBD from functional gastro-
intestinal disorders. It has been shown to correlate
well with macroscopic and histological activity.13 In
children 4 years and older, FC levels are not influ-
enced by sex or age of the child and are equally reli-
able for Crohn’s disease as well as ulcerative colitis as
they are not affected by disease location.6
Children with new-onset PIBD have a significantly
elevated FC at the time of diagnosis, compared with
controls undergoing endoscopy, as shown by multiple
studies.5 6 13 The cut-off values selected have a signifi-
cant impact on the diagnostic accuracy of the test,
influencing its sensitivity and specificity. A lower
cut-off value increases sensitivity, and as higher cut-off
values are selected sensitivity reduces and specificity
increases (table 1). With a cut-off of 50 mg/g, the test
has a sensitivity of 98%, with negative predictive
value of 96%.
Table 1 Measures of diagnostic accuracy for increasing levels of faecal calprotectin in children with suspected inflammatory bowel disease
Faecal calprotectin cut-off (mg/g) Sens (95% CI)
>50 0.98 (0.92 to 1.00)
>100 0.97 (0.91 to 0.99)
>200 0.93 (0.86 to 0.98)
>300 0.89 (0.81 to 0.95)
>800 0.73 (0.62 to 0.81)
Adapted with permission from Macmillan Publishers Ltd: (Am J Gastroenterol)1. NPV, negative predictive value; PPV, positive predictive value.
126 Saha A, et al. Arch Dis Child Educ Pract Ed 2016;101:124–128. doi:10.1136/archdischild-2014-307941
A recent systematic review by Henderson et al14
included eight studies in the paediatric population
with a total of 715 patients, including 394 PIBD and
321 non-PIBD controls. This showed a pooled sensi-
tivity of 0.978 (95% CI 0.947 to 0.996) and specifi-
city of 0.682 (95% CI 0.502 to 0.863) for the
diagnostic utility of FC in PIBD.14
In a diagnostic meta-analysis published in 2010,
Rheenen et al showed that in children with suspected
PIBD, an elevated FC level would increase the pre-test
probability of having IBD from 61% to 86%; but
more importantly, a normal FC level reduces it from
61% to 15%. The same study demonstrated that FC
screening in children with suspected PIBD would
reduce the number requiring endoscopy by 35%.13
In children with low clinical suspicion of IBD and
normal serological markers, a FC <50 mg/g makes the
diagnosis of IBD unlikely and would not warrant any
further investigations. With judicious interpretation,
there is growing evidence that FC is an asset in sec-
ondary care in determining which children do not
need referral to tertiary care with suspected PIBD;
and in tertiary care in identifying children who do not
require endoscopy for suspected PIBD. The utility of
testing FC must be balanced against patients with
PIBD who have a false negative FC test and adding
FC in the diagnostic pathway would result in up to
8% of children having a delayed diagnosis.13
In children presenting with signs and symptoms consistent with IBD,
does an elevated FC confirm diagnosis?
Raised FC levels are associated with inflammation
of the mucosal lining and are not very specific for
IBD. The specificity increases with increasing value
and levels >800 mg/g are 95% specific for IBD
(table 1). Raised FC is unable to differentiate
between various causes of gut inflammation and its
use is limited to differentiating inflammatory and
functional causes of symptoms. Hence other causes,
such as infections and coeliac disease, must be ruled
out before further investigations are performed. In
children who present with classic symptoms of IBD
with a high index of clinical suspicion, FC does not
add more to the investigations as all these children
need an endoscopy to confirm the diagnosis.15 It
also has limited role in children presenting with
Spec (95% CI) NPV (95% CI) PPV (95% CI)
0.44 (0.34 to 0.55) 0.96 (0.85 to 0.99) 0.62 (0.53 to 0.70)
0.59 (0.48 to 0.68) 0.95 (0.86 to 0.99) 0.68 (0.59 to 0.76)
0.74 (0.64 to 0.82) 0.92 (0.84 to 0.97) 0.77 (0.67 to 0.84)
0.83 (0.74 to 0.90) 0.89 (0.81 to 0.95) 0.83 (0.74 to 0.90)
0.95 (0.89 to 0.98) 0.79 (0.71 to 0.86) 0.93 (0.84 to 0.98)
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Interpretations

rectal bleeding as most cases causing bleeding, such

as infections, rectal polyps and solitary rectal ulcer Test your knowledge
syndrome, would lead to an elevated FC.
1. Faecal calprotectin (FC) level is useful in differentiat-
In children with IBD, is there a role of FC measurements in monitoring
ing inflammatory bowel disease (IBD) from functional
of disease activity?
gastrointestinal disorders if the value is
Children with quiescent disease present with FC con-
A. <50 mg/g
centrations that are higher than the traditionally
B. 50–100 mg/g
accepted normal reference range16 and therefore there
C. 100–200 mg/g
is no defined role of measuring FC levels routinely.
D. >200 mg/g
There is some evidence that FC has some utility as a
2. Faecal calprotectin levels are influenced by
surrogate marker for mucosal healing in IBD and it
A. Age
can be used in assessing the degree of inflammation
B. Gender
and gives an indication of the efficacy of treatment.17
C. Disease location
Studies have shown that measured FC levels correlate
D. All of the above
well with endoscopic severity at colonoscopy15 and
E. None of the above
are useful in identifying disease relapse.18 In one
3. FC levels should be checked routinely for children
study published in 2008, patients with relapse showed
being followed up for IBD
significantly elevated FC levels compared with non-
A. True
relapsed ones, with a FC value of 275 mg/g achieving
B. False
a sensitivity and negative predictive value of 97%, and
4. FC levels are likely to be normal in which of the fol-
specificity and positive predictive value of 85% in pre-
lowing condition
dicting histological relapse.19 The specificity of FC in
A. Coeliac disease
B. Clostridium difficile colitis
C. Small bowel Crohn’s disease
Clinical bottom line D. Ulcerative colitis
E. None of the above
▸ High levels of faecal calprotectin (FC) are also seen 5. The main role of FC measurement is
in a number of other conditions associated with A. To rule out IBD in children with low clinical
mucosal inflammation, such as gastrointestinal infec- suspicion
tions and coeliac disease. Indeed, it is recommended B. To confirm IBD in children with high clinical
that infective causes affecting the gut must be suspicion
excluded first, before FC is measured. Answers to the quiz are at the end of the references.
▸ FC correlates well with bowel inflammation (both
macroscopic and histological activity) and is not influ-
enced by sex, age, irritable bowel disease (IBD) type identifying relapse can be further increased by using it
or disease location. as an add-on test to PUCAI and PCDAI scores (with a
▸ The cut-off values selected has a significant impact cut-off at 500 mg/g).20
on the diagnostic accuracy of the test, influencing its FC, when used in conjunction with clinical and
sensitivity and specificity, and must be interpreted serological markers,5 is useful in differentiating mild
judiciously by an experienced clinician. relapse from functional symptoms and correlates well
▸ The high negative predictive value of a normal FC with mucosal inflammation but there is currently no
can be utilized in risk stratification and screening of robust data to support regular measurement of FC as
children with suspected IBD, that is, children with part of monitoring of PIBD.
low clinical suspicion and levels <50 mg/g do not
need further investigations.
Limitations
▸ FC screening is particularly cost-effective when base-
Although the utility of FC has now been well estab-
line clinical suspicion for IBD is moderate-to-low.
lished in the diagnosis of PIBD, it is, however, not a
Conversely, direct endoscopic evaluation is more cost-
specific test for IBD; especially in children who
effective when the pre-test probability of true IBD in
present with a broad spectrum of symptoms. It also
children is high, and there is little value in measuring
has no role in identifying the site or type if disease.
FC in these patients.
High levels of FC in children are also seen in a
▸ FC is most effective when used as an add-on test to
number of other conditions, notably gastrointestinal
Paediatric Ulcerative Colitis Activity Index and
infections, coeliac disease, immunodeficiency and
Paediatric Crohn’s Disease Activity Index scores in
non-steroidal anti-inflammatory drug induced enter-
differentiating disease relapse from functional
opathy.9 Indeed it is recommended that infective
symptoms.
causes affecting the gut must be excluded first, before

Saha A, et al. Arch Dis Child Educ Pract Ed 2016;101:124–128. doi:10.1136/archdischild-2014-307941 127
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Interpretations
FC is considered, in order to avoid false positive
results that might prompt unnecessary endoscopies.
Future research
Although FC testing has shown promising results for
children with suspected PIBD in secondary care,
further research is needed to establish the place of FC
testing within robust, evidence-based clinical manage-
ment pathways. This includes further research into the
optimal cut-off values, interpretation and guidance on
‘intermediate range’ results and its role in monitoring
disease activity and predicting relapse. Finally, further
prospective studies are needed to fully determine the
effect of FC measurement and its interpretation in the
reduction of endoscopy rates.
Contributors The literature search was done by AS and AB. The
layout of the article was done by AB and was written by AS, AB
and MPT.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer
reviewed.
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Answers to the multiple choice questions
(1) A; (2) E; (3) B; (4) E; (5) A.
 Downloaded from http://ep.bmj.com/ on October 18, 2017 - Published by group.bmj.com

How to use faecal calprotectin in

management of paediatric inflammatory
bowel disease
Amit Saha, Mark P Tighe and Akshay Batra

Arch Dis Child Educ Pract Ed 2016 101: 124-128 originally published
online February 4, 2016
doi: 10.1136/archdischild-2014-307941

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http://ep.bmj.com/content/101/3/124

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Metabolic disorders (70)
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Screening (public health) (43)
Ulcerative colitis (5)

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