Reflective Practive

Gastrointestinal disease
(IBD, IBS, Coeliac disease)

Differentiating between GI conditions, the symptoms of which are very similar, can be difficult and frustrating for both patients and healthcare professionals; laboratory investigations should be used to help differentiate between GI conditions, potentially reducing the time to diagnosis.1-7

Inflammatory bowel disease

Irritable bowel syndrome (non-inflammatory functional bowel disease)

Coeliac disease

Gastrointestinal disease - example pathway for differentiating between GI symptoms

Patient <45 years with recurring GI symptoms, no red flag symptoms

Bloating

Chronic diarrhoea

Urgent need to visit toilet

Abdominal pain

Blood in stool

Depression

Growth failure

Weight loss

Anaemia

Constipation

Fatigue

Joint problems

Flatulence

Diagnostic tests are an essential tool in differentiating between GI conditions. Explore each of the diagnotic pathways*

Coeliac serology

Faecal calprotectin

Full blood count

Thyroid stimulating hormone

ESR/CRP

Diagnostic tests can be used to help tailor care for patients with GI conditions**

Coeliac disease and patient on gluten-free diet

Crohn's disease

Ulcerative colitis

IBD-unclassified

*Adapted from the National Institute for Health and Care Excellence - Faecal calprotectin guidelines, and the Coventry and Warwickshire NHS Trust Primary Care clinical pathway for patients <45 years with symptoms of IBS for more than one month and no red flag symptoms. The NICE guidelines include coeliac serology, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as tests that should be considered alongside faecal calprotectin but do not include thyroid stimulating hormone (TSH). The Coventry and Warwickshire guidelines do not include ESR and CRP but do include TSH. The tests recommended by the Coventry and Warwickshire guidelines are recommended by Dr Ramesh Arasaradnam and Dr John O'Malley; Professor Colm O'Morain also recommends these tests, however, he also includes ESR and CRP.Their videos are available in the expert opinion section. **Suggested algorithm adapted from evidence presented by Zhang, et al. 2012; Ryan, et al. 2013; Joossens, et al. 2002; and Levine, et al. 2014. †ESR: Erythrocyte sedimentation rate; CRP: C-reactive protein

What are the benefits of early diagnosis?

Coeliac disease is an under-diagnosed, under-managed condition associated with serious long-term complications.6

Testing for coeliac disease can help to:

  • Ensure effective and timely treatment6
  • Prevent other autoimmune processes and reverse intestinal damage16
  • Determine if referral to a specialist is appropriate6
  • Reduce patient symptoms and improve quality of life6
  • Alleviate the symptoms of coeliac disease-associated complications16-21
  • Avoid unnecessary symptoms and costly interventional procedures6
Faecal calprotectin testing may help to reduce delays in diagnosing IBD, ensuring only patients who require an investigative scope for diagnosis are referred, minimising the risk of complications from a non-diagnosis or an avoidable investigative scope and ensuring patients receive the correct treatment sooner. Furthermore, faecal calprotectin testing allows a significant number of patients to leave the diagnostic pathway at an earlier point, providing care closer to home and avoiding hospital attendance.1

How can tests be used to personalise care?

Tissue transglutaminase can help:

  • Monitor adherence in patients on a gluten-free diet6

Faecal calprotectin testing can help:

  • Identify Crohn's disease patients with active disease (higher endoscopic activity, CDAI and CDEI)22,23
  • Identify Crohn's disease patients with increased risk of relapse24,25
  • Identify ulcerative colitis patients with increased risk of relapse24-26
  • Identify which Crohn's disease patients are responding to treatment with biologicals23

ASCA testing can help:

  • Identify patients with Crohn's disease who are at risk of complications such as stricturing or penetrating disease, ileal involvement, perianal disease, or surgery (ASCA IgG)9,10
  • Differentiate Crohn's disease from ulcerative colitis in patients with a diagnosis of IBD-unclassified in combination with pANCA)11,17

How can faecal calprotectin lead to cost savings in your local CCGs?31

Cost benefits of faecal calprotectin testing

What do the experts say?

References
  1. Waugh N, et al. Health Technology Assessment 2013; 17.
  2. Green PHR, et al. Am J Gastroenterol 2001; 96(1): 126-131.
  3. Jatla M, et al. Pract Gastroenterol 2008; 32(4): 18-34.
  4. Van Assche G, et al. J Crohns Colitis 2010; 4: 7-27.
  5. National Health Service: Irritable bowel syndrome (IBS) - Symptoms. 2013. Available from: http://www.nhs.uk/Conditions/Irritable-bowel-syndrome/Pages/Symptoms.aspx; last accessed May 2014.
  6. National Institute for Health and Care Excellence. Coeliac Disease: recognition, assessment and management (NG20). 2015. London: National Institute for Health and Care Excellence.
  7. National Institute for Health and Care Excellence. NICE pathways - Irritable bowel syndrome in adults. Available from http://pathways.nice.org.uk/pathways/irritable-bowel-syndrome-in-adults; last accessed May 2014.
  8. Burri E and Beglinger C. Swis Med Wkly 2012; 142: w13557.
  9. IBD standards - standards for the healthcare of people who have inflammatory bowel disease (IBD). Available from http://www.ibdstandards.org.uk/uploaded_files/IBDstandards.pdf; last accessed July 2015.
  10. Crohn's and colitis UK. Final report of a study entitled 'An examination of aspects of the occurrence natural history and consequences of inflammatory bowel diseases utilising available electronic records'. 2010-2012. Available from http://www.crohnsandcolitis.org.uk/Resources/CrohnsAndColitisUK/Research%20Awards%20-%20Medical%20Awards/dr-timothy-card-final-report.pdf; last accessed July 2015.
  11. National Institute for Health and Care Excellence. Irritable bowel syndrome in adults - Diagnosis and management of irritable bowel syndrome in primary care (CG61). 2008. London: National Institute for Health and Care Excellence.
  12. National Institute for Health and Care Excellence. Faecal calprotectin diagnostic tests for inflammatory disease of the bowel (DG11). 2013. London: National Institute for Health and Care Excellence.
  13. Harkness EF, et al. BMC Fam Pract 2013; 14: 92.
  14. Gujral N, et al. World J Gastroenterol 2012; 18(42): 6036-6059.
  15. Coeliac UK. Available from https://www.coeliac.org.uk/coeliac-disease/myths-about-coeliac-disease/; last accessed July 2015.
  16. AGA Institute. Gastroenterology 2006; 131: 1977-1980.
  17. Holmes GKT. Arch Dis Child 2002; 87: 495-499.
  18. Mohseninejad L, et al. Eur J Health Econ 2012; November.
  19. Rastogi A, et al. Indian J Endocrinol Metab 2012; 16(5): 780-785.
  20. Shah S and Leffler D. Womens Health (Lond Engl) 2010; 6(5): 753 -766.
  21. Szodoray P, et al. Rheumatol Int 2004; 24(5): 278-282.
  22. Schoepfer AM, et al. Am J Gastroenterology 2013; 108: 1744-1753.
  23. Sipponen T, et al. Inflamm Bowel Dis 2008; 14: 40-6.
  24. Tibble JA, et al. Gastroenterology 2000; 119: 15-22.
  25. Gisbert JP, et al. Inflamm Bowel Dis 2009; 15: 1190-8.
  26. De Vos M, et al. Inflamm Bowel Dis 2013; 19: 2111-7.
  27. Ryan JD, et al. Ailment Pharmacol Ther 2013; 38: 274-83.
  28. Zhang Z, et al. Dig Dis Sci 2012; 57(11): 2944-2954.
  29. Levine A, et al. J Pediatr Gastroenterol Nutr 2014; 58: 795-806.
  30. Joossens S, et al. Gastroenterology 2002; 122: 1242-7.
  31. Harvey Walsh. NHS HES data 2013/2014.
  32. Hunt R, et al. World Gastroenterology Organisation Global Guidelines: coping with common GI symptoms in the community. Available from http://www.worldgastroenterology.org/assets/export/userfiles/2013_FINAL_Common%20GI%20Symptoms%20_long.pdf; last accessed June 2015.
  33. Turner D, et al. J Pediatr Gastroenterol Nutr 2014; 55: 340-361.
  34. Ruemmele FM, et al. J Crohns Colitis 2014; doi: 10.1016/j.crohns.2014.04.005.
  35. Kovács M, et al. World J Gastroenterol 2014; 20(17): 4873-4882.
  36. Zhou N,et al. J Zhejiang Univ Sci B 2011; 12: 280-286.
  37. Burakoff R. J Clin Gastroenterol 2004; 38: S41YS43.
  38. Bousvaros A, et al. J Pediatr Gastroenterol Nutr 2007; 44(5): 653-74.

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