Introduction Alongside a thorough clinical assessment NICE clinical guideline 61 recommends that patients meeting diagnostic criteria for irritable bowel syndrome (IBS), as defined by the Rome III criteria, should undergo laboratory testing for inflammation (C-reactive peptide (CRP) and plasma viscosity (PV) or erythrocyte sedimentation rate (ESR)), full blood count (FBC) and antibody testing for coeliac disease to exclude non-organic pathology.1 Faecal calprotectin is a reliable and cost effective adjuvant test to help differentiate between functional and inflammatory bowel disease (IBD).2,3 Our aim was to assess local adherence to NICE guidelines on investigating patients who meet diagnostic criteria for IBS.
Methods As part of a wider study into the use of faecal calprotectin as a diagnostic tool within Gloucestershire Hospitals NHS Foundation Trust, we interrogated clinic letters, endoscopy reports and pathology results for patients in whom a negative (<50 mg/g faeces) or intermediate (50–150 mg/g faeces) faecal calprotectin level had been measured between September 2014 and September 2015. In patients diagnosed with IBS, we identified which of CRP, PV/ESR, FBC and antibody testing for coeliac disease had been done prior to or concurrent with faecal calprotectin measurement.
Results Of the 148 patients (age range: 16–81, median age: 35; 72% female) who satisfied inclusion criteria, 63.5% (n = 94) had not undergone at least one of the recommended laboratory tests around the time of faecal calprotectin measurement. PV/ESR had not been checked in a majority (54.1%). Notably, 7.4% of patients had never had coeliac serology checked, 72.7% of whom presented with a change in bowel habit.
Conclusion Although clear guidance exists for the investigation of patients meeting diagnostic criteria for IBS and use of faecal calprotectin as a diagnostic tool, insufficient essential accessory investigations are being completed. This risks conditions such as IBD, gastrointestinal cancer and coeliac disease being misdiagnosed as IBS with significant implications for delays in management and ongoing avoidable morbidity. We are reviewing measures to improve local adherence to NICE guidance, and call on other Trusts nationally to reflect on their own practice.
References 1 Irritable bowel syndrome in adults: diagnosis and management. NICE guidelines [CG61]. Published: February 2008.
2 Konikoff MR, Denson LA. Role of faecal calprotectin as a biomarker of intestinal inflammation in inflammatory bowel disease. Inflammatory Bowel Diseases 2006;12(6):524–34.
3 Faecal calprotectin diagnostic tests for inflammatory diseases of the bowel. NICE diagnostics guidance [DG11]. Published: October 2013.
Disclosure of Interest None Declared