The Vampire Study: Significant elevation of faecal calprotectin in healthy volunteers after 300 ml blood ingestion mimicking upper gastrointestinal bleeding

The case of a bloody mess - Bictegravir/emtricitabine/tenofovir alafenamide induced colitis

BACKGROUND

Fecal calprotectin is a marker used to differentiate inflammatory bowel disease versus irritable bowel syndrome and is relevant in the diagnosis of ulcerative colitis and Crohn's disease. Markedly elevated calprotectin from stool samples provides evidence of colonic inflammation to support the diagnosis of pancolitis. This report is the first to demonstrate the clinical significance of fecal calprotectin in supporting the diagnosis of pancolitis induced by the anti-viral drug, Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide).

CASE REPORT

A 62-year-old male on Biktarvy for his HIV diagnosis was admitted to internal medicine with abdominal pain, bloody diarrhea and pancolitis. His white blood cell count was 15.8 (4.0-11.0x109/L), neutrophil count was 9.7 (2.0-7.5 × 109/L), monocyte count was 1.2 (0.2-0.8 × 109/L), granulocyte count was 1.5 (≤0.1 × 109/L) and hemoglobin was 163 (140-180 g/L). The patient had a C-reactive protein of 229 (≤11.0 mg/L). Serology and blood culture were negative for microbial testing and abdomino-pelvic computed tomography findings were unremarkable. A bloody stool collected had a fecal calprotectin level of 1,159 (<50 µg/g).

CONCLUSIONS

This case highlights how anti-retroviral therapies such as Biktarvy may elicit medication-induced gastrointestinal symptoms, which may underlie the cause of bloody diarrhea and pancolitis, and consequently a grossly elevated fecal calprotectin.

Fecal Calprotectin in Gastrointestinal Disease

BACKGROUND

Inflammatory bowel disease (IBD) comprises a group of chronic conditions characterized by relapsing and remitting inflammation of the gastrointestinal tract. The incidence is increasing worldwide, and the therapeutic options for management are expanding. Endoscopy is the gold standard investigation for diagnosis of IBD and for assessing mucosal healing, which is increasingly being used as a measure of disease control. However, it is an invasive procedure that is unpleasant for patients and expensive and time-consuming for hospitals. Fecal calprotectin has been shown to be an accurate surrogate marker of gastrointestinal inflammation in IBD.

CONTENT

Fecal calprotectin was initially used for the diagnosis of IBD but is now recognized as having a role in assisting in assessment of disease activity, prediction of relapse, and informing decisions around therapy and may help to minimize requirement for endoscopy. However, there are various preanalytical and analytical factors that can affect interpretation of the results; these need to be understood to optimize clinical care.

SUMMARY

Preanalytical and analytical factors that can potentially influence fecal calprotectin concentrations are examined, and an overview is provided of clinical situations in which fecal calprotectin is commonly measured.

New Faecal Calprotectin Assay by IDS: Validation and Comparison to DiaSorin Method

Background: The faecal calprotectin (FC) measurement is used for inflammatory bowel disease (IBD) diagnosis and follow-up. The aim of this study was to validate for the first time the new IDS FC extraction device and immunoassay kit, and to compare it with the DiaSorin test in patients with and without IBD. Methods: First, the precision of the IDS assay and its stability were assessed. Then, 379 stool extracts were analysed with the IDS kit on iSYS and compared with a DiaSorin Liaison XL assay. Results: The intra- and inter-assay CVs did not exceed 5%. The stool samples were stable up to 4 weeks at −20 °C. Lot-to-lot comparison showed a good correlation (Lot1 = 1.06 × Lot2 + 0.60; p > 0.05). The Passing and Bablok regression showed no significant deviation from linearity between the two methods (IDS = 1.06 × DiaSorin − 0.6; p > 0.05; concordance correlation coefficient = 0.93). According to the recommended cut-offs, the IDS assay identified more IBD and irritable bowel syndrome patients than DiaSorin, which had more borderline results (16 vs. 20%, respectively). Conclusions: The IDS faecal calprotectin had good analytical validation parameters. Compared to the DiaSorin method, it showed comparable results, but slightly outperformed it in the identification of more IBD patients and active disease.

Fecal Leukocyte Esterase, an Alternative Biomarker to Fecal Calprotectin in Inflammatory Bowel Disease: A Pilot Series

Background and Aims

Fecal calprotectin (FC) is a noninvasive biomarker used in inflammatory bowel disease (IBD) management and risk stratification of nonspecific gastrointestinal symptoms. Leukocyte esterase is an inexpensive and widely available point-of-care inflammatory marker present on urinalysis test strips. We aim to assess the diagnostic accuracy of fecal leukocyte esterase (FLE) relative to FC and endoscopy and demonstrate its use as an alternative biomarker for IBD.

Methods

In this prospective cohort study, 70 patients who had FC ordered as part of standard clinical care also received FLE testing. FLE levels were compared with various FC cutoff values and endoscopy and pathology findings as the gold standard.

Results

As the FC cutoff increased from 50 to 500 μg/g, FLE sensitivity increased from 67% to 95% while the specificity decreased from 86% to 76%. The area under the receiver operating characteristic (AUROC) curve increased from 0.79 to 0.90. An FLE of ≥1+ had the best test characteristics. Among patients who underwent endoscopic evaluation, FLE demonstrated an identical sensitivity (75%) and specificity (86%) to FC in predicting endoscopic inflammation. AUROC was 0.80 for FLE and 0.85 for FC with an optimal cutoff of ≥2+ and 301 μg/g, respectively. When used to distinguish between patients with active IBD and no/inactive IBD, FLE had a sensitivity of 84% and specificity of 90%, comparable with the 84% and 83%, respectively, of FC. AUROC was 0.88 for FLE and 0.91 for FC with an optimal cutoff of ≥2+ and 145 μg/g, respectively.

Conclusion

FLE demonstrates adequate correlation and comparable accuracy with FC in predicting endoscopic inflammation and distinguishing between patients with active vs inactive IBD.

Can we predict mucosal remission in ulcerative colitis more precisely with a redefined cutoff level of C-reactive protein?

AIM

Most patients with ulcerative colitis (UC) with active mucosal disease have a lower C-reactive protein (CRP) level than the classic accepted cutoff level (≤5 mg/l). We aimed to predict the mucosal remission in UC with an optimal cutoff level of CRP when mucosal activity and extensiveness of UC were both considered.

METHOD

In this retrospective study, we evaluated CRP values and their relation to mucosal extension and UC activity in 331 colonoscopic examinations performed between December 2016 and March 2019. Endoscopic activity and disease extension were assessed using Mayo scores and the Montreal classification.

RESULTS

The Mayo 2 and 3 groups' CRP values were significantly higher when compared with Mayo 0-1 between values of E1 and both E2 and E3 with an increasing trend. The standard CRP cutoff level ≤5 mg/l only yielded 55% specificity in predicting mucosal remission. In the ROC analysis, a CRP cutoff level ≤2.9 mg/l predicted an overall mucosal remission (Mayo 0-1) with 77% sensitivity and 80% specificity, and ≤1.9 mg/l predicted Mayo-0 with 70% sensitivity and specificity. In the clinical remission subgroup, the overall CRP cutoff level was even lower, at ≤1.58 mg/l.

CONCLUSION

An overall CRP cutoff level ≤2.9 mg/l predicts mucosal remission in UC better than the standard cutoff ≤5 mg/l. Mucosal remission in stable clinical remission may present with an even lower CRP level. An increasing trend in the CRP level from E1 through E3 even in mucosal remission suggests that both histological inflammation and extensiveness may have some influence on a CRP-based prediction of endoscopic remission.

Calprotectin: from biomarker to biological function

The incidence of inflammatory bowel diseases (IBD) emerged with Westernisation of dietary habits worldwide. Crohn's disease and ulcerative colitis are chronic debilitating conditions that afflict individuals with substantial morbidity and challenge healthcare systems across the globe. Since identification and characterisation of calprotectin (CP) in the 1980s, faecal CP emerged as significantly validated, non-invasive biomarker that allows evaluation of gut inflammation. Faecal CP discriminates between inflammatory and non-inflammatory diseases of the gut and portraits the disease course of human IBD. Recent studies revealed insights into biological functions of the CP subunits S100A8 and S100A9 during orchestration of an inflammatory response at mucosal surfaces across organ systems. In this review, we summarise longitudinal evidence for the evolution of CP from biomarker to rheostat of mucosal inflammation and suggest an algorithm for the interpretation of faecal CP in daily clinical practice. We propose that mechanistic insights into the biological function of CP in the gut and beyond may facilitate interpretation of current assays and guide patient-tailored medical therapy in IBD, a concept warranting controlled clinical trials.

MicroRNA-320a Monitors Intestinal Disease Activity in Patients With Inflammatory Bowel Disease

In patients with inflammatory bowel disease (IBD), a treat-to-target treatment strategy requires tight monitoring of disease activity. Noninvasive biomarkers may help to monitor the intestinal disease activity. We demonstrated recently that peripheral microRNA (miR)-320a expression in mice follows the course of experimental colitis. The aim of this study was to evaluate the potential of miR-320a to monitor the disease activity in patients with IBD, to predict the course of disease, and to distinguish IBD from infectious colitis.

International consensus on methodological issues in standardization of fecal calprotectin measurement in inflammatory bowel diseases

BACKGROUND

Fecal calprotectin (FC) is a non-invasive marker of gut inflammation which is frequently used to guide therapeutic decisions in patients with inflammatory bowel diseases (IBD). Each step of FC measurement can influence the results, leading to misinterpretations and potentially impacting the management of IBD patients. To date, there is high heterogeneity between FC measurements and no current method is universally accepted as a standard.

AIMS

Our aim was to provide clear position statementsabout the pre-analytical and the analytical phases of FC measurement to homogenize FC levels and to minimize variability and risk of misinterpretation through aninternational consensus.

MATERIALS & METHODS

Fourteen physicians with expertise in the field of IBD and FC from 11 countries attended a virtual international consensus meeting on July 17th, 2020. A systematic literature was conducted and the literature evidence was shared and discussedamong the participants. Statements were formulated, discussed, and voted. Statements were considered approved if all participants agreed.

RESULTS

Nine statements were formulated and approved. Based on the available evidence, quantitative tests should be preferred for measuring FC. Furthermore, FC measurement, if possible, should always be performed with the same method and factors influencing FC levels should be taken into account when interpreting the results.

DISCUSSION

FC has an increasingly important role in the management of patients with IBD. However, large multicenter studies should be conducted to define the reproducibility and to confirm the diagnostic accuracy of the available FC tests.

CONCLUSION

FC concentrations guide clinicians' treatment decisions. Our statements have a relevant impact in daily practice and could be applied in clinical trials to standardize FC measurement.

Cutaneous venous malformations as a clue for possible gastrointestinal tract involvement: Diagnosis and treatment of six cases

Venous malformation (VM) is the most common type among vascular malformations classified by the International Society for the Study of Vascular Anomalies. Most VMs are sporadic (94%), caused in 40% of cases by somatic mutation of TEK gene. VMs can be cutaneous, visceral, or combined. Visceral involvement is rare, and gastrointestinal (GI) tract is the most common localization. Visceral VMs, usually asymptomatic, may manifest with bleeding, anemia, and consumptive coagulopathy, which sometimes require an emergency treatment. Our aim is to study the possible GI involvement in patients with only one cutaneous VM. We analyzed a series of six patients who presented with a single cutaneous VM and have subsequently manifested intestinal involvement at our reference center for vascular anomalies since 2010. In our patients, cutaneous VMs were located on lower or upper limbs, and GI involvement manifested from 3 to 10 years after skin diagnosis. Our experience urges to early diagnose a GI involvement also in patients with only one skin VM and to prevent severe complications. A multidisciplinary approach is mandatory for the diagnosis and treatment of these patients.

Elevated Intestinal Inflammation in Preterm Infants With Signs and Symptoms of Gastroesophageal Reflux Disease

OBJECTIVES

Reflux is common in infancy; however, persistent signs and symptoms of gastrointestinal distress are often attributed to gastroesophageal reflux disease (GERD). In this pilot study, we aimed to characterize associations between signs and symptoms of suspected GERD and noninvasive markers of intestinal inflammation in preterm infants.

METHODS

We reviewed Electronic Medical Record (EMR) data to identify clinical signs and symptoms among case patients (n = 16). Controls (n = 16) were matched on gestational age. Univariate and multivariate regression analyses were used to compare fecal calprotectin and urinary intestinal fatty acid binding protein (I-FABP) levels between cases and controls.

RESULTS

We found no differences in baseline characteristics between cases and controls. In the multivariate regression analysis controlling for the proportion of mother's milk, cases had higher fecal calprotectin levels than controls, with no differences in I-FABP levels between cases and controls.

CONCLUSION

Our findings suggest that preterm infants with signs and symptoms of GERD have higher levels of intestinal inflammation as indicated by fecal calprotectin compared to their controls. Further studies are needed to evaluate the role of intestinal inflammation in signs and symptoms of gastrointestinal distress and whether fecal calprotectin might have predictive value in diagnosing GERD.

A Practical Guide for Faecal Calprotectin Measurement: Myths and Realities

BACKGROUND AND AIMS

Faecal calprotectin [FC] is a valid and non-invasive marker of mucosal inflammation. It is widely used both in clinical trials and in daily clinical practice for patients with inflammatory bowel diseases, but currently no accepted standardization for FC testing is available. Our primary aim here was to provide a clinician's guide containing all the practical information on FC measurement in order to avoid any confounding factors, to minimize intra- and inter-individual variability in dosage, and to ensure a better and adequate interpretation of the results.

METHODS

We conducted a detailed search of the scientific literature in the PubMed/MEDLINE, EMBASE and Cochrane databases up to January 2020 to find all relevant and available articles on pre-analytical and analytical phases of FC measurement.

RESULTS

FC testing is a multi-step procedure consisting of a pre-analytical phase aimed to collect and process the stool sample and a subsequent analytical phase of FC measurement. Several factors can influence test results determining false positives or false negatives. Importantly, this faecal marker is mostly used for patient follow-up and as a predictor of treatment response. For this reason, any altered data may affect the physicians' decisions, negatively impacting on patient management.

CONCLUSIONS

This review provides for the first time practical advice to minimize dosage variability, although further dedicated studies are needed to compare commercially available tests and identify the best tools for the most precise and accurate FC measurement.

Clinical value of fecal calprotectin

Inflammatory bowel disease (IBD) denotes a group of chronic incurable disorders characterized by relapsing-remitting inflammation of the gastrointestinal tract. IBD represents a growing global burden with a prevalence exceeding 0.3% in the Western world and an accelerating incidence in newly industrialized countries. The target for treating IBD has shifted in recent years from symptom control to mucosal healing (MH), which has been shown to be associated with favorable long-term outcomes. The gold standard for ascertaining MH is endoscopic assessment, but endoscopy is limited by its invasive nature, high cost, and finite availability. Surrogate biomarkers are therefore of great utility. Calprotectin, a cytosolic protein derived predominantly from neutrophils, is now widely used in this capacity. Calprotectin is found in various bodily fluids at concentrations proportional to the degree of inflammation, including in feces at levels roughly six times higher than in the blood. Fecal calprotectin (FCP) therefore reflects intestinal inflammation. Various assays, including point-of-care and home-based tests, are now available for measuring FCP. FCP is used for screening purposes, to aid in distinguishing inflammatory from non-inflammatory gastrointestinal conditions like irritable bowel syndrome (IBS), as well as in the monitoring of known IBD. The aims of this review are to provide an overview of the methods used to measure FCP and to review the evidence supporting the use of FCP in IBD, particularly as it pertains to screening, monitoring and predicting disease relapse.