HNY Policy and Pathway Repository - North Yorkshire

From Monday 2 December 2019, HaRD CCG implemented an Integrated Faecal Immunochemical Test (FIT) and Faecal Calprotectin (FC) Lower GI Pathway for use by GPs as a risk assessment tool.

The pathway embeds an FC care pathway in to the existing FIT Lower GI Pathway at the appropriate point.

The pathway was developed by clinicians for use early in the patient assessment when there is a clinical uncertainty as to the diagnosis of Irritable Bowel Syndrome (IBS) or Inflammatory Bowel Disease (IBD).

See suspected cancer pathways 

Faecal Calprotectin

Calprotectin is a protein released into the gastrointestinal tract when it is inflamed, such as in IBD. It is stable protein, so can be detected in the stool by laboratory assay. Elevated levels of FC are found in IBD. By contrast, in functional disorders of the gastrointestinal tract, such as the IBS, FC levels are normal.

Clinically, it is often very difficult to be able to distinguish IBS from IBD based on symptoms, signs and blood tests (CRP and ESR can be normal). Here, FC can be used as a biomarker to support your assessment. NICE have approved this (http://www.NICE.org.uk/dg11). This FC pathway fits in to an Integrated Lower GI pathway which includes FIT testing and lower GI criteria.

Faecal Calprotectin can be used for monitoring patients with established IBD - see Flare Management within RCGP IBD toolkit for further information: https://www.rcgp.org.uk/ibd 

On whom should I request a faecal calprotectin test?

Faecal calprotectin should be considered in:

• patients aged 18-60 years
• low risk colorectal cancer patients aged <60 years whose FIT results are <10 and remain symptomatic
• low risk colorectal cancer patients aged <50 years when cancer is not suspected and patient has:
• diarrhoea predominant symptoms
• lower gastrointestinal symptoms in whom you suspect IBS or IBD
• where there is diagnostic uncertainty

When do I request a faecal calprotectin test?

Ideally, tests such as those listed below (or any other tests you consider clinically appropriate) should be carried out prior to requesting a Faecal Calprotectin test:

• FBC, urea and electrolytes, C-reactive protein, calcium
• Ferritin
• Coeliac screen
• Thyroid function
• Stool culture and C. difficile request

How do I request a faecal calprotectin test?

Faecal calprotectin tests can be requested from Monday 2 December 2019 via Harrogate and District NHS Foundation Trust ICE (see GP General Pathology / GP Profiles / Integrated FIT & FC Pathway) - use a blue top stool sample pot.

When should I not request a faecal calprotectin test?

• When colorectal cancer is suspected or when there is diagnostic certainty: (https://www.NICE.org.uk/guidance/ng12).
• For young patients with symptoms of diarrhoea with blood and mucus please seek urgent Gastro advice if infective cause has been ruled out

How long will the test take to come back from the laboratory?

The assay is run three times per week. You will receive the result electronically within approximately one week from receipt of stool sample.
 

What should I do with the faecal calprotectin test result?

• Faecal calprotectin <100mcg/g
  • IBS is 98% likely
  • treat as IBS and review in six weeks (http://pathways.nice.org.uk/pathways/irritable-bowel-syndrome-in-adults/managing-irritable-bowel-syndrome)
    • or consider urological and gynaecological diagnoses
  • at review if still symptomatic
  • aged <50 years and the faecal calprotectin is <50mcg/g
    • treat with second line IBS therapy before considering routine gastroenterology referral
  • aged ≥50 years or the faecal calprotectin is ≥50mcg/g
    • refer to gastroenterology routinely
• Faecal calprotectin ≥100mcg/g
  • repeat the test within 2 to 4 weeks
• Repeat faecal calprotectin <100mcg/g
  • IBS is 98% likely, see 1. above
• Repeat faecal calprotectin 100-250mcg/g
  • IBD is 12% likely
  • refer to gastroenterology routinely
• Repeat faecal calprotectin >250mcg/g
  • IBD 50% likelihood
  • refer urgently to gastroenterology

An education video (Faecal Calprotectin testing only) can be viewed at the following link: https://www.youtube.com/watch?v=ah-EH-q0lys&t=5s)

See flowcharts below

If you have any further questions, please feel free to contact

• Dr Bruce Willoughby – Planned Care Lead, HaRD CCG brucewilloughby@nhs.net
• Dr Deven Vani – Consultant Gastroenterologist, HDFT deven.vani@hdft.nhs.uk
• Dr Nuthar Jassam – Consultant Clinical Biochemist, HDFT n.jassam@nhs.net

References

https://www.yhahsn.org.uk/service/population-health-service/faecal-calprotectin/ 

Information sourced from: Faecal Calprotectin Lower GI Pathway Information for GPs

• Harrogate and District