Introduction Faecal calprotectin is recommended by NICE1 for distinguishing between irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) in patients with lower gastrointestinal (GI) symptoms in primary care. If cancer is suspected in these patients and ‘red-flag’ symptoms such as anaemia or bleeding, they should be referred to Gastroenterology in accordance with the NICE suspected cancer guideline.2 We use calprotectin in secondary care and will be extending the service to primary care providers. However, a number of GPs have been requesting faecal calprotectin on an ad-hoc basis for 1 year, giving us valuable insight into how the test performs in primary care.
Methods An audit was carried out of primary care calprotectin data in a 1 year period (Dec 12–Dec 13). This data was compared to an audit of 1 month of secondary care data (Jun 13). Clinical details, such as endoscopy and histology results were extracted from electronic patient records.
Results In total 198 requests for calprotectin came from primary care in 1 year and 40 were unsuitable for analysis (wrong sample type or delayed arrival in lab). Of the remaining 158 calprotectin requests, 76% were considered appropriate, having clinical details including symptoms described by NICE. Worryingly, 17% of requests had inappropriate clinical details such as bleeding; such patients’ referral to Gastroenterology was potentially delayed by requesting calprotectin. In 7% of requests no reason for request was discernable.
Of the primary care requests, 29% results were consistent with intestinal inflammation (>50 µg/g). If GPs use our proposed algorithm which suggests only referring patients with a calprotectin >50 µg/g, and those where strong clinical suspicion remains, there is potential for up to 71% reduction in patients referred to Gastroenterology with ‘IBS/IBD’ symptoms.
Diagnostic performance of calprotectin compared with endoscopy and histology diagnosis in secondary care is excellent with a sensitivity of 100% and a specificity of 91%. In primary care the corresponding data gives a sensitivity of 93% and a specificity of 79%.
Conclusion We received a large number of unsuitable samples. In addition GPs appear to be inappropriately requesting calprotectin in patients with symptoms such as bleeding, therefore it is critical to offer the service in a controlled way as part of a locally agreed care pathway. We are producing a GP information leaflet to advise on appropriate sample collection, result interpretation and the proposed patient pathway. We will re-audit primary care data once this is introduced to investigate whether a targeted approach leads to improved diagnostic performance of calprotectin in primary care.
References 1 Faecal Calprotectin diagnostic tests for inflammatory diseases of the bowel, NICE DG11
2 Referral for suspected cancer, NICE CG27
Disclosure of Interest None Declared.