Stool : Just a stool is required!!!

Stool sample …is that it???

 A young lady with constant abdominal pain and diarehea since past 3 to 4 months , also complaining of severe weakness ,hairfall and lethargy.

This case can present as a chronic gastrointestinal upset,  general physician or even a hematologist.

The biggest worry is to rule out or to diagnose what is our patient suffering from???

Many people are confused when it comes to the differences between inflammatory bowel disease (IBD), Crohn's disease, and ulcerative colitis (UC).

The short explanation is that IBD is the umbrella term for the condition under which both Crohn's disease and ulcerative colitis fall.

 But there is, of course, much more to the story.

Inflammatory Bowel Disease

IBD was seldom seen before the rise of improved hygiene and urbanization at the beginning of the 20th century. Today, it’s still found mainly in developed countries such as the United States. Like other autoimmune and allergic disorders, it’s believed that a lack of germ resistance development has partly contributed to diseases such as IBD.

The word inflammation itself comes from the Greek word for flame. It literally means "to be set on fire."

Crohn’s and UC are the most common forms of IBD. Oftentimes, the terms are interchangeable.

IBD may strike at any age;most people with IBD are diagnosed before the age of 30. It’s more common:

• in urban areas
• among people in higher socioeconomic brackets
• industrialized countries
• northern climates
• in Caucasians as opposed to darker-skinned people and those of Asian descent
• in people who eat high-fat diets

Aside from environmental factors, genetic factors are believed to play a strong role in the development of IBD. Therefore, it’s considered to be a "complex disorder.”

Unfortunately, there’s currently no cure for IBD. This is a lifelong disease, with alternating periods of remission and flare-up. Modern treatments, however, allow people to live relatively normal and productive lives.

IBD should not be confused with irritable bowel syndrome (IBS).IBS is a much less serious affliction than either Crohn’s disease or ulcerative colitis. It doesn’t involve inflammation or appear to have a physiological basis.

Diagnosing IBD

There’s no doubt that IBD can significantly decrease quality of life, between uncomfortable symptoms and frequent bathroom visits.

Calprotectin , found in several body fluids such as serum,saliva,CSF and urine; has a bacteriostatic and mycostatic activity comparable to that of antibiotics even at minimal inhibiting concentrations.

For that reason ,its abundance in neutrophil granulocytes and its antimicrobial activity suggest an important role in the body defense functions.

Its detection in stool offers significant advantages in the evaluation of intestinal inflammation.

Increase in Calprotectin in feces occurs in IBD due to fecal secretion of neutrphils and macrophages migrated from blood stream into intestinal lumen through the inflamed tissues flowing ,in case of bowel , in the feces.

 Faecal calprotectin is a biochemical measurement of the protein calprotectin in the stool.

Elevated faecal calprotectin indicates the migration of neutrophils to the intestinal mucosa, which occurs during intestinal inflammation, including inflammation caused by IBD.

The main diseases that cause an increased excretion of faecal calprotectin are inflammatory bowel diseases, coeliac disease,infectious colitis, necrotizing enterocolitis, intestinal cystic fibrosis and colorectal cancer.

False positive measurements:

Although faecal calprotectin correlates significantly with disease activity in people with confirmed IBD, faecal calprotectin can be false-positive if the laboratory uses low calprotectin cut-off levels. Most importantly, intake of non-steroidal anti-inflammatory drugs (aspirin included) increases calprotectin values, possibly due to the associated induced enteropathy

The key findings :

In adults, FC is a good indicator of inflammation in the bowel and can be used to distinguish between IBS and IBD in cases for which the differential diagnosis is in doubt.

• Calprotectin could be very useful for GPs as a way of confirming a clinical diagnosis of IBS, although it will not be required in all people with IBS, because in some, other features such as a long history, comorbidities, relationship to stress and an absence of weight loss, may tilt the balance of probability to IBS.
• It is not a perfect test because some patients with IBS have raised calprotectin levels but false-negative IBD is unusual if we use the cut-off of 50 µg/g (for ELISA tests) and 15 µg/g (for PreventID POCT) recommended by the manufacturers.
• In children, it is useful for distinguishing between IBD and non-inflammatory conditions.
• From the clinical perspective, the balance of risk between sensitivity (not missing any cases of IBD) and specificity (avoiding false positives – people with IBS thought to have IBD) may best be towards sensitivity because missed IBD can lead to much more serious consequences than an unnecessary colonoscopy, but given the low prevalence of IBD in the primary care population, it is specificity that drives relative costs in this setting.
• There are a few patients who have slightly raised levels (50–150 µg, or perhaps to 200 µg in children) who may only need monitoring. In many cases, calprotectin level will fall and no further investigation will be necessary. In those who have low-grade IBD, calprotectin will usually rise.
• There are few head-to-head comparisons of different tests, but such data as there are do not suggest significant differences in clinical reliability.
• If calprotectin testing is made available in primary care, GPs could be much more selective in whom they refer to specialist care. Referrals will fall considerably.
• In secondary care, both paediatric and adult, the availability of calprotectin testing could lead to a reduction in the number of colonoscopies performed.
• It is likely that delays in diagnosing IBD could be reduced, as a raised calprotectin will alert clinicians. This may be particularly useful in children where the onset can be insidious, as it can also be in some adults.
• Calprotectin testing would lead to cost savings, mainly in secondary care from a reduction in colonoscopies.
• Measurement of ESR and CRP in patients with ?IBS, ?IBD, should cease or may be evaluated???

 Faecal markers can be useful in the following situations:

• Differentiation of IBS and IBD (or other organic GI disorders)

• Assessment of disease activity in IBD
• Monitoring of response to treatment in IBD

To summarize: