TI inflammation and fecal calprotectin or lactoferrin tests

We have our first follow-up with Stephen's GI tmrw since starting remicade. I'm going to be asking him how he will be following up how well the remicade is working since almost all blood results were within normal before starting remicade and, in fact, had been steadily improving in the six months prior to starting remi.

As the MRE was the only test (plus scope) that showed inflammation, I am going to ask for another one in June/July (5+ months since starting remi). I'm also going to ask for a fecal calprotectin but, when I asked abt this before, his GI was less than enthusiastic abt it, saying it didn't work for inflammation in the TI.

But, I'm happy to push for it IF there is some info to be gleaned from it. So, my question is how many of your GIs have used FC to determine inflammation when your child's inflammation is limited to the TI? Or, if not FC, how abt Lactoferrin?

Tks

I think we have discussed this before but C's inflammation was located in his TI at dx. About six months in I requested an FC test since he was having symptoms(his usual CD symptoms) and his lab work was normal. The FC level was 1700 at that time.

The second FC test came a couple of months ago when C was in the hospital(non typical flare symptoms) the level at this point was 300. This seemed to fall in line with what the docs were seeing with scope and MRE.

My son had TI disease to start with and normal blood work. The only marker we could use aside from the scope and video capsule was FC. It was 700 when he had his first flare. My GI only uses it as a personal comparison to track over time. So far, it does appear to be a good indicator of what is going on inside for my son. This is something he now plans to continue to use as a tracker for him. It is one of those things that I think is good to track during good times and bad to see if it will be a good marker for each individual. It is easy to do so if it works, it could help dictate changes in treatment before things get bad without invasive testing.

I would ask for it as a starting point. Good luck!

Sarah has had two faecal calprotectin. First one 580 while on pred and the second 620 which occurred with normal inflammatory markers which led to her second MRI which show disease activity only 10cm above where a colonscopy can reach.

Thanks!

I know FC is sometimes not thought to be as reliable at indicating small bowel inflammation so that's why I was wondering how often it was actually used strictly for small bowel/TI inflammation.

I am going to ask that we run this test but wish I'd pushed more for it in the fall as a baseline. GI didn't think it was reliable for small bowel and, not knowing that much about it, I just accepted that but... wish I had that baseline number now! :ymad:

Oh well, live and learn...

Tess, I asked Devynn NP about the fecal calprotectin test last week, and she said they don't do it at HSC. Have you ever had one done there?

No, the first time I asked about it was last Spring at HSC and they told me the same thing. It was right before Stephen transferred to Mt. Sinai, HSC said they were working towards getting approval/authorization for it and maybe Mt. S. was further ahead and already had approval for it??? I never quite understood why one hospital 'might' have approval and not another but we didn't get into more detail.

Most of Johnny's activity is in his stomach and duodenum and his fecal cal was 430 last time. Well above normal. The GI wants to track it over time and never mentioned that it would not be a good indicator for him.

I think it is worth a try. Over time it is a much less expensive and invasive way to measure inflammation. After testing it a few times, especially because you have MRI and scope results to compare, you should know if it is giving you any information.

WE were told by more than one GI that it would be a good indication of disease for DS.
At the time his FC was normal but he felt horrible.
After his latest flare in Jan - two months later FC was 283 (?) so GI is going to watch it trend downward.

Tesscorm said:

Or, if not FC, how abt Lactoferrin?

Tks

Click to expand...

I didn't see it in any of the answers above but what about Lactoferrin?
I know it might not be as accurate as FC but............
is Lactoferrin reliable to tell you about the inflammation in the GI track?


Sorry Tess, I'm not trying to hijack.:yfaint:
:ghug:

Farmwife said:

Sorry Tess, I'm not trying to hijack.:yfaint:
:ghug:

Click to expand...

No hijacking worries! All info shared is great!

I posted re Stephen's apptmt in his thread so won't repeat it all here but re the FC or LF...

Sorry, I didn't end up asking :ack: as the GI suggested another scope in a few months, an MRE and prometheus test... I was embarrassed to ask for MORE tests! :redface:

And, FW, I seem to see FC discussed much more often than LF, not sure why though...

Thank you Tess

I don't understand why it wouldn't work for monitoring small bowel disease and have never read a study that suggested otherwise. Calprotectin is a protein in neutrophils which are present in elevated quantities when there is damage to the intestinal mucosa. My understanding is that is the case whether that be in the large or small intestine. But let's make sure...

Aussie -- if you have a minute, what is your opinion on the use of fecal calprotectin for monitoring disease confined to the small bowel? Or should it only be used for disease of the colon?

Farmwife said:

I didn't see it in any of the answers above but what about Lactoferrin?
I know it might not be as accurate as FC but............
is Lactoferrin reliable to tell you about the inflammation in the GI track?

Click to expand...

It is, but for whatever reason, Fecal Calprotectin seems to be the goto test. Here's some data.

Hi David, calprotectin is a great test for inflammation anywhere in the bowel, both large and small. However, inflammation in the large bowel tends to lead to higher calprotectin levels.

Best wishes.

Glad we have some clarification, David. Claire's doc loves the FC and has never commented on disease location making it less valid.

J.

Devynsmom and Tesscorm

I am in BC and my son has had the test done twice but both times it was done at an adult GI's office (at least that is where we took the sample and that is where they processed the sample). I think this was a temporary arrangement and is no longer available.

I recently found out that in the last few months Life Labs is now providing the test but it is not covered by our BC health care so we have to pay for it. I understand that the cost is $100. Can't figure out why our provincial health care won't cover it when it could potentially reduce the number of scopes done which are far more costly to do. In any case I am just happy that my son can get the test done even if I have to pay for it. I googled Life Labs and they are in Ontario and their website indicates that they offer fecal calprotectin there as well.

Twiggy, thank you! I will google them.

Hey Tess dear,
You know The Saint adores lactoferrin and has been doing it WEEKLY for V to assess response to her drug regimen.
FWIW he says it is much more indicative of colon state than small bowel, he uses it to see if her colon is joining the party, not to assess sm bowel so much.

HOWEVER, regarding reliability in individual cases, when she was last scoped (Aug 2011) it was around 4700 but her colon was normal both grossly and histologically.
It was 1800 at diagnosis when she was near death, it has been 5200 when she was asymptomatic.

It was 163 when she had the pillcam in Oct 2012 that showed severe disease in the entire sm bowel.

So for V, it is not a good indicator of sm bowel state.

David
Here is one study which found fecal calprotectin doesn't correlate as well with ileal disease.

Aliment Pharmacol Ther. 2008 Nov 15;28(10):1221-9. doi: 10.1111/j.1365-2036.2008.03835.x. Epub 2008 Aug 26.
Correlation of faecal calprotectin and lactoferrin with an endoscopic score for Crohn's disease and histological findings.
Sipponen T, Kärkkäinen P, Savilahti E, Kolho KL, Nuutinen H, Turunen U, Färkkilä M.
Source
Division of Gastroenterology, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland. taina.sipponen@kolumbus.fi
Abstract
BACKGROUND:
Faecal calprotectin and lactoferrin increasingly serve as surrogate markers of disease activity in IBD. Data on the correlation of these markers with simple endoscopic score for Crohn's disease (SES-CD) and with histological findings are as yet limited. Aim To study the correlation of faecal calprotectin and lactoferrin with SES-CD and histology.
METHODS:
During 87 consecutive ileocolonoscopies, SES-CD was calculated and biopsy specimens were obtained from the ileum, colon and rectum. Faecal calprotectin and lactoferrin were measured.
RESULTS:
In ileocolonic or colonic disease, both faecal calprotectin and lactoferrin correlated significantly with colon SES-CD (P < 0.001) and colon histology (P < 0.001). In patients with normal calprotectin or lactoferrin levels, endoscopic and histology scores were significantly lower than in those with elevated concentrations (P < 0.001). In ileal CD, ileal SES-CD correlated with histology (P < 0.001), but not with faecal calprotectin (P = 0.161) or lactoferrin (P = 0.448).
CONCLUSION:
In ileocolonic and colonic disease, endoscopic score SES-CD and histological findings correlated significantly with faecal calprotectin and lactoferrin. A normal faecal-marker concentration was a reliable surrogate marker for endoscopically and histologically inactive CD. Ileal endoscopic score and histological findings failed, however, to correlate with faecal markers.

Igor posted a good review of biomarkers here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3308116/

Thanks everyone for all the info!

xmdmom said:

David
Here is one study which found fecal calprotectin doesn't correlate as well with ileal disease.

Aliment Pharmacol Ther. 2008 Nov 15;28(10):1221-9. doi: 10.1111/j.1365-2036.2008.03835.x. Epub 2008 Aug 26.
Correlation of faecal calprotectin and lactoferrin with an endoscopic score for Crohn's disease and histological findings.
Sipponen T, Kärkkäinen P, Savilahti E, Kolho KL, Nuutinen H, Turunen U, Färkkilä M.

Click to expand...

Thanks for sharing that xmdmom! I found the full study here and read it about half a dozen times. Good god is it hard to follow. I wish they would have provided patient by patient data instead of only presenting the median and throwing stuff like this at us:

leal disease: In patients with ileal disease and with
normal calprotectin (n= 10), median ileal histology score was 5 (range 0–10) and ileal SES-CD 3 (0–7). Of these, half had no or only architectural changes in the ileal biopsy samples. Compared with those with ileal disease and an elevated calprotectin concentration (n= 11), no significant differences existed in ileal SES-CD or ileal histology score or in any of the scored
histological changes (all P > 0.05).

Click to expand...

They're comparing the SES-CD to fecal calprotectin. SES-CD is the sum of all variables multiplied by the number of affected segments. I believe that the number of affected segments in ileal disease tends to be lower so does that throw anything off?

They conclude with:

and also for histologically inactive CD. In ileal CD, however, normal faecal marker concentration may fail to rule out active inflammation, but this finding should be confirmed in larger studies.

Click to expand...

My guess is this all reinforces the idea of correlating scores on a patient by patient basis. As soon as possible, I believe that a doctor should begin to correlate CRP, ESR, fecal calprotectin, and any other favorite non-invasive tests they have with endoscopic disease activity. Figure out which blood tests and fecal tests are good markers for disease activity in their specific case. Create a baseline for THAT patient to figure out what correlates FOR THEM in an effort to monitor disease activity without endoscopy.

If I'm a parent of a kid with Crohn's I ask that any of these tests that haven't been run when a diagnosis is made be run. Then after some duration of treatment, run them all again and look for changes. Then run some time later to continue to look for correlation. Then when a followup colonoscopy or any imaging studies are performed to gauge disease activity, run them again. Figure out which, if any, are good markers for my child's specific disease.

Aussie -- are you familiar with this study? Any thoughts?

Tess:

http://www.ncbi.nlm.nih.gov/pubmed/21456899

http://www.gesa.org.au/news.asp?id=332

Dusty.

Hi David, I had a quick look at the study - there are a few issues:

1. Quite small numbers.

2. Included upper GI Crohns in the calprotectin scoring, with no way of including it in endoscopic scoring.

3. SES-CD is elevated in stricturing, more common in small bowel disease, which leads to a higher endoscopic score, however, if it is principally fibrostenotic (rather than inflammatory), then you would rightly expect a discrepancy between calprotectin and endoscopic scoring (which you do see in this study).

4. Finally, the small bowel is 3 to 6 meters long, with around half of that the ileum. In colonoscopy, you view the entire colon, giving you a very good idea of the endoscopic burden of inflammation in the colon. You would only be able to view a tiny fraction of the ileal mucosa, which could also lead to discordant results.

At the end of the day, calprotectin isn't perfect, although it's probably the best non-invasive test that we have.

For what it's worth, there was a larger, more recent study published showing no significant difference between calprotectin accuracy in purely ileal disease when compared with colonic and ileocolonic. (Rutgeerts et al. Fecal calprotectin is a surrogate marker for endoscopic lesions in Inflammatory Bowel Disease. Vol 18. 12. Dec 2012).

Best wishes.

Thank you so much Aussie!

Another for you Tess:

http://www.smw.ch/content/smw-2012-13557/

Happy reading.

Dusty.