2. Introduction
• IBD Inflammatory bowel disease - seem to be increasing in
Asian countries (Rampton and Shanahan, 2008)
• IBD can affect people with all age and sex but the primarily
diagnosis is usually in young adult
• Crohn’s disease and ulcerative colitis are characterized by
periods of symptomatic relapse and remission.
• Diagnosis and assessment of inflammatory bowel disease
has so far been based on clinical evaluation, serum
parameters, radiology and endoscopy.
• Faecal markers such as calprotectin or lactoferrin have
emerged as new diagnostic tools to detect and monitor
intestinal inflammation
3. IBS in India
• Prevalence of IBS is 10–20%.
• The bowel pattern of Indians is different from that of the
Westerners.
• In India, 99% of normal subjects have a stool frequency
of at least 1 or more per day. This is in contrast to a
normal stool frequency of three times per week to three
times per day in the West.
• They define IBS as “a condition characterized by
abdominal pain, bloating or discomfort occurring in
association with disturbed bowel pattern in the absence
of organic causes that can be detected by routine
medical tests”
4. Diagnostic criteria for IBS according to
Rome III
• Recurrent abdominal pain or discomfort for at least 3 days
a month in the last 3 months (with onset at least 6 months
previously) associated with 2 or more of the following:
• 1. Improvement with defecation.
• 2. Onset associated with change in stool frequency.
• 3. Onset associated with change in stool form (appearance
of stool).
5. Multifactorial etiology of IBS
• Genetic Factors
• Visceral Hypersensitivity and Food Intolerance and
Allergy
• Abnormal Gut Motility
• Autonomic Nervous System Dysfunction
• Small Intestine Bacterial Overgrowth (SIBO)
• Postinfectious Irritable Bowel Syndrome
• Psychosocial Factors
6. Investigations in IBS
• CBC
• ESR
• CRP
• Stool routine microscopy
• Colonoscopy is indicated for patients with warning signs
such as bleeding, anemia, chronic diarrhea, older age,
history of colon polyps, cancer in the patient or first-
degree relatives, or constitutional symptoms such as
weight loss or anorexia.
7. D/D for IBS
• Inflammatory bowel disease (IBD)
• Colorectal cancer
• Colonic tuberculosis
• Fructose intolerance
• Gastrinoma
• Infectious colitis
• Medication side effects
• Secretory diarrhea
9. • IBD (Inflammatory
bowel disease)
Crohn'sdisease(CD)
can affect any part
of the tract (skip
lesions)
Ulcerativecolitis(UC)
restricted to the colon
and rectum
10. IBD is considered as an autoimmune disease
The infiltration of leukocytes in the intestinal interstitium would lead to the development
of granulomatous inflammation which will continuously cause tissue damage of
transmural colon where edema, losing goblet cells, reduced mucus, hyperplasia of crypt
cells, developing ulcer occurred. The symptoms are on and off in short period of time
12. Calprotectin
• Calprotectin is present in 60 % of
cytoplasm of neutrophils
• It is marker of inflammation and detected
in faeces
• Cal - it binds to calcium and
• Protectin - has antimicrobial properties
13. • Calprotectin is a 24 kDa dimer of calcium binding proteins S100A8
and S100A9.
• The complex accounts for up to 60% of the soluble protein content
of the neutrophil cytosol.
• Calprotectin has bacteriostatic and fungistatic properties, that arise
from its ability to sequester manganese and zinc
• The complex is resistant to enzymatic degradation, and can be
easily measured in faeces
• It is secreted in good quantity because of cell cytolysis
• National Institute of Health and Care Excellence (NICE) guidelines
recommend using FC testing to differentiate between organic or
functional disease in patients with new lower GI symptoms where
cancer is not suspected
15. Calprotectin versus Colonoscopy
• Though Colonoscopy is gold standard it is invasive, needs
sedation and expensive
• Calprotectin is non invasive screening test, sensitive , specific,
rapid
• In younger people, >60% of colonoscopies showed no
abnormality
• FC has homogeneous distribution in faeces
• The concentration of Calprotectin is directly proportional to the
intensity of the neutrophilic infiltrate in the gut mucosa [Roseth
et al. 1999]
• Endoscopic assessment is especially difficult in paediatric
populations. Children will need hospital or day-care admission,
and experience problems with fasting and bowel preparation
16. Comparison to ESR and CRP
• Compared to CRP, the Mayo score and the CAI, the
faecal concentration of Calprotectin significantly better
reflects the endoscopic and histologic disease activity.
• ESR and CRP lack diagnostic accuracy and can rise in
non intestinal diseases
• ESR + CRP sensitivity is 35 % and specificity is 73 % for
IBD
• The Mayo score is an activity index that consists of four items: stool frequency, rectal
bleeding, endoscopic findings, and a physician global assessment.3 Each item was
scored from 0 to3 and the total score ranges from 0 to 12 points. Active disease was
defined as a Mayo score ≥ 3.
17.
18. Interpretation of results
• < 50 microgram/gram – Normal - no
inflammation in GIT. No need for
invasive procedure
• 50 to 200 microgram/gram – Mild
inflammation, NSIAD , mild
diverticulitis, IBD in remission phase.
Repeat the measurement and do
further workup
• > 200 microgram/gram – S/O Active
organic disease. Further procedure
suggested to determine cause
19. Limitations of fecal calprotectin
• Causes of false positivity – GI infections, Cancer, Food
intolerance, enteropathy
• Stages of IBD – active or inactive should be considered for
interpretation
• Sample collection method - Patients may be reluctant to
handle faecal material
• Calprotectin concentration depends on different
physiological factors, for example,age, clinical omorbidities,
and may also have considerable day-to-day variation
• No validated cut-off
• Calprotectin does not help to differentiate between CD and
UC.
• Calprotectin cannot be used for localization of IBD
20.
21. Preanalytical
• Variability is seen in the concentrations of Calprotectin in
stool samples collected during a single day
• Since the levels of Calprotectin increases with longer time
between the bowel movements, it seems most appropriate
to analyse stool from the first bowel movement in the
morning.
• Moreover, storage of stool samples at room temperature
for more than 3 days is not advisable
• The median CV was 40.8% for day to day variability
• Furthermore, to be able to compare values over time, the
patients should be recommended to always take their
samples with approximately the same time interval since
the previous bowel movement.
22. Uses of Calprotectin
• Distinguishing organic disease from non-organic
disorders
• IBD - Faecal calprotectin levels are elevated in patients
with active IBD. Calprotectin can be used to differentiate
• between clinically active and inactive IBD [Langhorst et
al. 2008].
• Monitoring disease activity - Faecal calprotectin levels
correlate well with endoscopic and histological disease
activity. In CD, the correlation is better for colonic than
for ileal disease
23. • Monitoring response to treatment- Low faecal calprotectin
levels after treatment indicate response of endoscopic disease
activity better among adult than paediatric patients.
• Establishing mucosal healing - Mucosal healing seems to
indicate controlled IBD activity. It has been associated with
sustained clinical remission as well as reduced rates of
hospitalisation and surgical resection.
• Prediction of IBD relapse - Faecal calprotectin levels <150
μg/g indicate IBD remission with a low risk of relapse.
calprotectin concentration of over 300 μg/g was an
independent risk factor associated with disease relapse [Louis
et al. 2012]
• Calprotectin and lactoferrin may have a role in predicting
recurrence after ileocoecal resection
Uses of Calprotectin
29. • A prior screening for Calprotectin would result
in a 67% reduction in the number of adults
and of 35% in children requiring endoscopy,
• but also lead to delayed diagnosis of IBD in
6% of patients because of a false negative
calprotectin test.
• Thus, the price of delayed diagnosis must be
balanced against the number of unnecessary
colonoscopies
• Thank YOU
Hinweis der Redaktion
Upper abdominal pain is more common in india for IBS and bloating is more common symtom
which a type I T helper cells mediated a chronic inflammatory response (Shi et al.,
2006). The initial stimulating factors and the underlining mechanisms causing
IBD is still uncertain but the inflammation of the intestine is caused by T cell and
macrophage activations to produce inflammatory mediators and cytokines which
act on 1) chemokine gradient to attract neutrophils, 2) enteric tissue damage, 3)
3
disruption of epithelial lining, 4) amplification of inflammatory response, and 5)
local microvasculature e.g. such as the arterioles, capillaries and venules
(Rampton and Shanahan, 2008). Also, T cells present in the affected tissues
release cytokines which further dysregulate the balance of immune response in the
intestine (Tresca, 2010).
Die AAk gegen Becherzellen wurden erstmals 1962 durch Broberger und Perlmann beschrieben.
Sie können nur mittels indirekter IFT nachgewiesen werden. Eine Identifizierung des Antigens erfolgte bisher nicht.
Alle Bereiche des Darmes vom Dünndarm bis zum Rektum sind geeignet.
HSS = high salt stripped
LFS = Laktoferrin spezifisch (alte Bezeichnung, Winfried hat nach der Herausgabe des Produktkataloges eine neue gegeben)
Achtung: ein ANA hom. Reagiert auch auf den HSS Granus und LFS Granus! Intensitätsunterschiede in Zusammenhang zu stellen mit ANA + Anti-LF oder – Anti-LF sind reine Spekulationen!
eindrucksvolle netzig-granuläre Fluoreszenz
häufig zusätzlich tropfige Fluoreszenz vorhanden; kann auch allein auftreten (&gt;10%)
