Practical Guidance on the use of faecal calprotectin
Brookes MJ et al
Frontline Gastroenterology 2018; 9:87-91
Dear Sir
I read this article with interest particularly as I work in a community gastroenterology unit.
Our unit performs straight to test colonoscopy. We are referred a significant number of
patients who present with loose motions but do not have alarm symptoms or worrying family
histories.. Many of them are found to have faecal calprotectin levels which are only slightly
elevated or in the intermediate range.
Many of these patients are also taking proton pump inhibitors on a regular basis. A
colonoscopy is performed and colonic biopsies are taken which are almost always
normal. A paper, albeit with small numbers of patients, showed that proton pump
1
inhibitors may cause a rise in faecal calprotectin levels in normal subjects.
I recommend that, when it is safe and appropriate to do so, the GP considers stopping
proton pump inhibitors in such patients and repeats the faecal calprotectin in four weeks.
The aim here is to avoid unnecessary colonoscopy in a low-risk young patients, most of
whom have functionally related symptoms. I recent...
Practical Guidance on the use of faecal calprotectin
Brookes MJ et al
Frontline Gastroenterology 2018; 9:87-91
Dear Sir
I read this article with interest particularly as I work in a community gastroenterology unit.
Our unit performs straight to test colonoscopy. We are referred a significant number of
patients who present with loose motions but do not have alarm symptoms or worrying family
histories.. Many of them are found to have faecal calprotectin levels which are only slightly
elevated or in the intermediate range.
Many of these patients are also taking proton pump inhibitors on a regular basis. A
colonoscopy is performed and colonic biopsies are taken which are almost always
normal. A paper, albeit with small numbers of patients, showed that proton pump
1
inhibitors may cause a rise in faecal calprotectin levels in normal subjects.
I recommend that, when it is safe and appropriate to do so, the GP considers stopping
proton pump inhibitors in such patients and repeats the faecal calprotectin in four weeks.
The aim here is to avoid unnecessary colonoscopy in a low-risk young patients, most of
whom have functionally related symptoms. I recently communicated this advice to my GP
2
colleagues.
As far as I know there has not been such a larger study looking at the effect of proton
pump inhibitors on faecal calprotectin levels. However I think such a study is urgently
needed as we are all struggling to cope with the increasing demand for
colonoscopy. and some younger patients may avoid unnecessary invasive investigations.
1. Proton pump inhibitors are associated with elevation of faecal calprotectin and may affect specificity
Poullis, Andrewa; Foster, R.a; Mendall, Michael A.b
European Journal of Gastroenterology & Hepatology: May 2003 - Volume 15 - Issue 5 - p 573-574
doi: 10.1097/01.meg.0000059108.41030.23
2.Proton pump inhibitors may cause elevation in faecal calprotectin levels
Cohen M
Br J Gen Pract 2016; 66 (648): 350. DOI: https://doi.org/10.3399/bjgp16X685813
Yours faithfully
Dr Mike Cohen
GP with special interest in Gastroenterology
The authors rightly point out the low yield of gastroscopy in the management of, even complicated, dyspepsia. In fact it looks like gastroscopy is even less useful than the authors claim. There are several important points in the paper that deserve wider discussion. Firstly the authors state that they studied patients over 55 undergoing gastroscopy for dyspepsia, yet the mean age in the cohort was 58 with a standard deviation of 16 years: this implies that actually a substantial proportion of the subjects were in fact well under 55. The data on which the current 2-week wait pathways were based showed that the positive predictive value of all dyspeptic type symptoms, or symptom-combinations, in those under 55 was less than 1%, [1]. Hence by including these patients, the authors have not only confused the reading of their paper but also altered the potential perception of the utility of gastroscopy in relation to the 2-week wait criteria.
Additionally the claimed usefulness of gastroscopy in 16% of cases seems rather high. Of the cancers in the cohort 3 out of 4 would have has a gastroscopy for indications over and above simple dyspepsia, at least 5 of the "positive" cases seemed to have been having the gastroscopy to obtain histology for a previously suspected condition (hence not simple dyspepsia), 12 benign ulcers would have been managed with acid suppression whether or not a gastroscopy was performed, presumably the oesophageal strictures significant enou...
The authors rightly point out the low yield of gastroscopy in the management of, even complicated, dyspepsia. In fact it looks like gastroscopy is even less useful than the authors claim. There are several important points in the paper that deserve wider discussion. Firstly the authors state that they studied patients over 55 undergoing gastroscopy for dyspepsia, yet the mean age in the cohort was 58 with a standard deviation of 16 years: this implies that actually a substantial proportion of the subjects were in fact well under 55. The data on which the current 2-week wait pathways were based showed that the positive predictive value of all dyspeptic type symptoms, or symptom-combinations, in those under 55 was less than 1%, [1]. Hence by including these patients, the authors have not only confused the reading of their paper but also altered the potential perception of the utility of gastroscopy in relation to the 2-week wait criteria.
Additionally the claimed usefulness of gastroscopy in 16% of cases seems rather high. Of the cancers in the cohort 3 out of 4 would have has a gastroscopy for indications over and above simple dyspepsia, at least 5 of the "positive" cases seemed to have been having the gastroscopy to obtain histology for a previously suspected condition (hence not simple dyspepsia), 12 benign ulcers would have been managed with acid suppression whether or not a gastroscopy was performed, presumably the oesophageal strictures significant enough to cause dysphagia and were not purely incidental findings? These exclusions drop the yield in those with dyspepsia significantly. The inclusion of oesophageal candidiasis is also controversial, if this was significant candida in a predisposed patient causing dysphagia or odynophagia, or minor candida unrelated to dyspepsia symptoms, these also should probably be removed from the "positives." This leaves yield of only 9.7%. Whilst these issues may not alter the message from the authors, it is important that these important debates over the use of expensive and relatively limited resources are fully and accurately informed.
1. Stapley S, Peters TJ, Neal RD, Rose PW, Walter FM, Hamilton W. The risk of oesophago-gastric cancer in symptomatic patients in primary care: a large case-control study using electronic records. Br J Cancer. 2013 Jan 15;108(1):25-31. doi: 10.1038/bjc.2012.551.
Practical Guidance on the use of faecal calprotectin
Brookes MJ et al
Frontline Gastroenterology 2018; 9:87-91
Dear Sir
I read this article with interest particularly as I work in a community gastroenterology unit.
Our unit performs straight to test colonoscopy. We are referred a significant number of
patients who present with loose motions but do not have alarm symptoms or worrying family
histories.. Many of them are found to have faecal calprotectin levels which are only slightly
elevated or in the intermediate range.
Many of these patients are also taking proton pump inhibitors on a regular basis. A
colonoscopy is performed and colonic biopsies are taken which are almost always
normal. A paper, albeit with small numbers of patients, showed that proton pump
1
inhibitors may cause a rise in faecal calprotectin levels in normal subjects.
I recommend that, when it is safe and appropriate to do so, the GP considers stopping
proton pump inhibitors in such patients and repeats the faecal calprotectin in four weeks.
The aim here is to avoid unnecessary colonoscopy in a low-risk young patients, most of
whom have functionally related symptoms. I recent...
Show MoreThe authors rightly point out the low yield of gastroscopy in the management of, even complicated, dyspepsia. In fact it looks like gastroscopy is even less useful than the authors claim. There are several important points in the paper that deserve wider discussion. Firstly the authors state that they studied patients over 55 undergoing gastroscopy for dyspepsia, yet the mean age in the cohort was 58 with a standard deviation of 16 years: this implies that actually a substantial proportion of the subjects were in fact well under 55. The data on which the current 2-week wait pathways were based showed that the positive predictive value of all dyspeptic type symptoms, or symptom-combinations, in those under 55 was less than 1%, [1]. Hence by including these patients, the authors have not only confused the reading of their paper but also altered the potential perception of the utility of gastroscopy in relation to the 2-week wait criteria.
Show MoreAdditionally the claimed usefulness of gastroscopy in 16% of cases seems rather high. Of the cancers in the cohort 3 out of 4 would have has a gastroscopy for indications over and above simple dyspepsia, at least 5 of the "positive" cases seemed to have been having the gastroscopy to obtain histology for a previously suspected condition (hence not simple dyspepsia), 12 benign ulcers would have been managed with acid suppression whether or not a gastroscopy was performed, presumably the oesophageal strictures significant enou...