ABSTRACT
Background: Elevated Faecal Calprotectin (FCP) is established as a valuable tool in differentiating Inflammatory Bowel Disease (IBD) from Irritable bowel syndrome (IBS) and monitoring IBD activity. Initial implementation studies in the UK demonstrated benefit from repeat testing to exclude false positives. This is not currently mandated by IBD consensus guidelines. Growing waiting times are increasing pressure to include a single result in straight to test pathways. No one level for significant elevation is defined with levels between 100-250ug/g used We present our experience of the real-world utility of FCP used in a primary care referral pathway Methods: From Jan 2021-Nov 2022, new referrals were streamed into a rapid access 'Inception IBD' clinic on the basis of symptoms and raised FCP. A repeat FCP (kit sent in advance) was brought to the first appointment, with same day processing using the Buhlmann fCAL Turbo Test. Results and accompanying diagnosis and outcome data was collected prospectively. There was no standardised testing interval but median time from referral to review was 34 days Results: A single FCP was available for 425 patients with a final diagnosis Two pre-treatment FCPs were available in 185. Median initial FCP was 949ug/g in those subsequently diagnosed with IBD (Ulcerative colitis 1162ug/g, Crohn's 893ug/g) vs 353ug/g in those without IBD This difference heightened on retesting, with median FCP in IBD 749ug/g vs 34ug/g in non-IBD (Fig 1). FCP fell between 1st and 2nd measurement in 88.6% of patients who had IBD excluded In IBD, baseline FCP showed strong correlation with established disease activity markers (Fig 2) Baseline FCP levels were significantly higher in IBD patients who went on to require biologic treatment (Mann-Whitney U 2763, p<0.001) A variety of FCP cut-off values were assessed (Fig 4). A two sample >200ug/g cut off performed best as assessed by Area Under the Curve (AUC). However, sensitivity fell to 81.5% at this level Of 15 IBD patients who didn't have two FCPs >200ug/g, 7 had an increase between the 1st and 2nd FCP (median 147 vs 487ug/g). The remaining 8 comprised 4 ileal Crohn's, 3 mild proctitis and 1 stricturing colonic Crohn's in whom FCP failed to correlate with disease activity Overall, 83% (48/58) of patients with increasing 1st to 2nd FCP were diagnosed with IBD Conclusion(s): Our data supports repeat testing of FCP to avoid unnecessary investigations adding to post COVID endoscopy backlogs. A cut off of two values >200ug/g had the best overall performance but can miss a small number of IBD cases, particularly those with isolated ileal disease or a more indolent disease course. This cut off should not be used in those with a marked increase between 1st and 2nd result, where IBD is likely.
ABSTRACT
Introduction Iron deficiency anaemia (IDA) can be a sign of serious underlying disease but often overlooked. Recently updated guidelines of the British Society of Gastroenterology (BSG) recommend male and postmenopausal female patients with IDA should be screened for coeliac disease and undergo dual endoscopy (or CT). Aims This project looked to assess current adherence to these guidelines at the Queen Elizabeth Hospital in Birmingham. Methods A retrospective audit was performed using health informatics for patients who attended AMU/CDU from April 2018 to March 2021. The number of patients with IDA in this time frame was identified. A further analysis of this group was made to determine the proportion of patients with IDA who had IgA TTG measured as well as those who had OGD and colonoscopy/CT colonoscopy requested. Results There were 67797 patients in this study period. 32422 (47.8%) were anaemic (Hb < 120g/dl for women, <130g/dl for men as per WHO guidelines) of which 6357 (19.6%;9.38% of total) had a microcytic anaemia (MCV <83 as per University Hospitals Birmingham laboratory reference range). Ferritin was tested in 3337 (52.5%) of this group, and of those, 1041 (31.2%) were found to have overt IDA (ferritin <30 mg/mL). Rate of investigation The patient cohort with confirmed IDA comprised 334 males (32.0%), 556 post-menopausal females (53.4%, defined as age ≥45) and 151 pre-menopausal females (14.5%). A further analysis was made to explore how male and postmenopausal female cases were investigated, and if the rate of investigation was affected by the COVID-19 pandemic from 1st March 2020 onwards in this subgroup. Results are shown in the table below. In general, only a minority of patients underwent further investigation with males more likely to undergo OGD than females. Surprisingly, apart from increased TTG check latterly, little difference was seen after onset of the COVID-19 pandemic. Conclusions This large-scale study found that only a small minority of patients with IDA underwent further investigation. Whilst the study period includes the pandemic era, our results don't suggest this made a significant impact on practice. Nevertheless, these findings indicate a strong need for increased awareness and quality improvement about optimising IDA investigation according to BSG guidelines.
ABSTRACT
Background: Vitamin D, a key regulator of immune response, is known to be lower in Inflammatory Bowel Disease (IBD) patients than the general population. Disparity in the incidence of deficiency between ethnic groups has previously been demonstrated. We measured vitamin D in a unique multi-ethnic inception cohort to correlate this with traditional IBD scores and patient reported outcome measures including the 'IBD Disk'. Methods: Data regarding demographics, ethnicity, faecal calprotectin (FCAL) and baseline blood results including Vitamin D was collected prospectively from January-October 2021, from adults presenting with suspected IBD. Montreal classification, Harvey-Bradshaw Index or Partial Mayo score, endoscopic disease severity indices and IBD Disk score were documented in those with confirmed diagnosis at endoscopy. Vitamin D deficiency was defined as <50nmol/l. Results: 179 patients had a Vitamin D level recorded;58 Ulcerative colitis (UC), 58 Crohn's disease (CD), 53 non-IBD controls and 10 still awaiting diagnosis. 44(76%) CD, 32(55%) UC and 28(53%) non-IBD control patients were Vitamin D deficient at first presentation. Median levels were lowest in CD, with a significant difference between CD and non-IBD (median 35nmol/l;IQR 24.05 vs. median 48.9nmol/l;IQR 49.1;p=0.004). Regression analysis demonstrated patients with Crohn's disease were four times more likely to have Vitamin D deficiency compared to UC (OR 4.08;95% CI 1.35-12.36) at diagnosis. No correlation was seen between absolute vitamin D levels or vitamin deficiency state and faecal calprotectin when controlled for various factors regardless of the IBD subtype. The cohort distributions are demonstrated in Figure 1. Within the IBD cohort, Vitamin D levels were significantly lower in Black or Asian patients vs White patients (median 28.5;IQR 20.85 vs median 43.3;IQR 33.95;p=0.004). Figure 2 provides an overview of the cohort distributions. Vitamin D levels at presentation, as demonstrated in Table 1, did not correlate with Disease activity markers (DAMS) whereas baseline haemoglobin did, albeit weakly. Interestingly, Vitamin D and Haemoglobin correlated without reaching statistical significance (Spearman's rho 0.149;p=0.08). Conclusion: Our inception dataset demonstrates high rates of Vitamin D deficiency comparable to prior studies in IBD patients. Both CD and Black or Asian ethnicity were strongly associated with Vitamin D deficiency. Baseline Vitamin D did not correlate with disease activity markers whereas anaemia showed consistent weak association. Our study demonstrates the problem of hypovitaminosis D and the importance of measurement and supplementation, particularly in Black and Asian CD patients, from diagnosis.