Comparison of the efficacy of granulocyte and monocyte/macrophage adsorptive apheresis and leukocytapheresis in active ulcerative colitis patients: a prospective randomized study

BACKGROUND: Ulcerative colitis (UC) is a chronic inflammatory bowel disease associated with recurring inflammation of the colorectal mucosa. Recently, cytapheresis has emerged as a new treatment for patients with UC. Removal methods are mainly performed with beads [granulocyte and monocyte/macrophage adsorptive apheresis (GMCAP)] or filters [leukocytapheresis (LCAP)]. Both treatments have been reported to be effective for active UC. There have been few trials, however, comparing the efficacy of GMCAP and LCAP. In this study, we prospectively evaluated the efficacy of LCAP and GMCAP for the treatment of active UC. METHODS: Thirty-nine patients [18 male, 21 female; mean age 38.7 years; duration of disease 6 years; clinical activity index (CAI) >6 points] with moderate-to-severe active UC were randomly assigned to the LCAP (n=21) or GMCAP group (n=17). Adacolumn (cellulose acetate beads; Japan Immunoresearch Laboratories, Takasaki, Japan) for GMCAP and Cellsorba EX (polyethylene phthalate fibers; Asahi Medical Co. Ltd, Tokyo, Japan) for LCAP were used for leukocyte removal. Patients received two sessions of cytapheresis in the first week, followed by four weekly administrations. Steroid doses were tapered if patients achieved clinical improvement. When the CAI score had decreased by 5 points or more, the patient was considered to have improved. RESULTS: Thirteen patients in the GMCAP group and 14 in the LCAP group achieved clinical improvement. No significant difference was found in clinical response and clinical course between LCAP and GMCAP. Hemoglobin levels were significantly decreased immediately after one session of cytapheresis in the LCAP group. No severe adverse effects were observed in any of the patients. No significant differences were observed in any clinical parameters predictive of a response to either LCAP or GMCAP. But in all patients receiving cytapheresis, a high CAI score was a significant risk factor for treatment failure. All of the cytapheresis nonresponders had CAI scores >or=16. CONCLUSION: Both GMCAP and LCAP were effective treatments for active UC. Patients with severe UC and a high CAI score were, however, refractory to treatment.     

Relationship Between Fecal Calprotectin, Intestinal Inflammation, and Peripheral Blood Neutrophils in Patients with Active Ulcerative Colitis

Active ulcerative colitis (UC) is associated with elevated granulocytes and monocytes/macrophages (GM) which show activation behavior and increased survival time. Further, fecal calprotectin (a stable neutrophil protein) level parallels intestinal inflammation and can predict UC relapse. Since GM are major sources of inflammatory cytokines and chemokines, they are suspected to have roles in the initiation and perpetuation of UC. Our objective was to investigated relationships between peripheral blood (PB) neutrophils, calprotectin, and UC disease activity. Full PB and calprotectin were determined in 69 healthy controls and 31 patients with UC, then 7 randomly selected patients received GM adsorptive apheresis (GMA) with Adacolumn, 10 sessions of 60-min duration each. Patients with UC had higher neutrophil counts (P < 0.001), but lower lymphocyte counts (P < 0.001) compared with controls. Further, fecal calprotectin levels showed a correlation with UC clinical activity index (CAI; P < 0.001) and mucosal inflammation (P < 0.001). Following GMA, there were falls in neutrophils (P < 0.02), CAI (P < 0.02) and calprotectin (P < 0.02). In conclusion, GM appear to contribute to intestinal inflammation and UC activity and reduction of these cells by GMA should benefit patients with active UC. Further, the correlations among calprotectin, UC activities, and PB neutrophils should serve as the basis for preemptive actions to control this disease.     

Faecal calprotectin and faecal occult blood tests in the diagnosis of colorectal carcinoma and adenoma

BACKGROUND AND AIMS: Testing for faecal occult blood has become an accepted technique of non-invasive screening for colorectal neoplasia but lack of sensitivity remains a problem. The aim of this study was to compare the sensitivity and specificity of faecal calprotectin and faecal occult blood in patients with colorectal cancer and colonic polyps. METHODS: Faecal calprotectin and occult blood were assessed in 62 patients with colorectal carcinoma and 233 patients referred for colonoscopy. The range of normality for faecal calprotectin (0.5-10.5 mg/l) was determined from 96 healthy subjects. RESULTS: Median faecal calprotectin concentration in the 62 patients with colorectal carcinoma (101 mg/l, 95% confidence interval (CI) 57-133) differed significantly from normal (2.3 mg/l, 95% CI 1.6-5.0) with 90% of patients having elevated levels (normal <10 mg/l) whereas only 36/62 (58%) had positive faecal occult bloods. There was no significant difference in faecal calprotectin levels when considering location or Dukes' staging of tumour. Percentage positivity of faecal occult bloods was significantly higher for Dukes' stage C and D cancers compared with Dukes' A and B. In the colonoscopy group, 29 patients with adenomatous polyps were detected in whom the median faecal calprotectin was 12 mg/l (95% CI 2.9-32). Sensitivity for detection of adenomatous polyps was 55% using the calprotectin method and 10% using faecal occult blood testing. The overall sensitivity and specificity of calprotectin for colorectal cancer and adenomatous polyps as a combined group was 79% and 72%, respectively, compared with a sensitivity and specificity of faecal occult blood of 43% and 92%. CONCLUSIONS: Faecal calprotectin is a simple and sensitive non-invasive marker of colorectal cancer and adenomatous polyps. It is more sensitive than faecal occult blood tests for detection of colorectal neoplasia at the cost of a somewhat lower specificity.     

Faecal calprotectin as reliable non-invasive marker to assess the severity of mucosal inflammation in children with inflammatory bowel disease

BACKGROUND: An accurate monitoring of mucosal inflammation is important for an effective management of patients with inflammatory bowel disease. Intestinal inflammation can be detected by faecal calprotectin level determination. AIM: To comparatively evaluate the accuracy of faecal calprotectin, clinical scores, common serum markers and endoscopy in the assessment of the severity of intestinal mucosa inflammation in children with inflammatory bowel disease. METHODS: Fifty-eight paediatric patients (mean age 13.9 years, 95% CI 2.9-14.8; male 28) with confirmed inflammatory bowel disease (26 Crohn's disease, 32 ulcerative colitis) were enrolled. Before endoscopy, all patients underwent a complete evaluation including: clinical scores, erythrocyte sedimentation rate, C-reactive protein and faecal calprotectin determination. The severity of mucosal inflammation was assessed using specific endoscopic and histologic scores. RESULTS: Faecal calprotectin showed a high correlation (r=0.655) with the histologic grade of mucosal inflammation, similar to that observed for endoscopy (r=0.699), and it resulted the most accurate tool (sensitivity 94%, specificity 64%, positive predictive value 81%, negative predictive value 87%) to detect the presence of active mucosal inflammation when compared to clinical scores and common serum markers. In patients with apparent clinical and laboratory remission the accuracy of faecal calprotectin resulted further improved (sensitivity 100%, specificity 80%, positive predictive value 67%, negative predictive value 100%). CONCLUSIONS: A more accurate assessment of the severity of mucosal inflammation can be achieved by the determination of faecal calprotectin levels compared to other common clinical and laboratory indices. This non-invasive and objective method could be particular useful in patients with apparent clinical and laboratory remission.     

Faecal calprotectin levels in a high risk population for colorectal neoplasia

BACKGROUND: Faecal concentrations of the protein calprotectin have been found to be elevated in patients with colorectal neoplasia, suggesting that it might be used as a screening tool for colorectal cancer as well as adenomas. AIMS: To measure the sensitivity and specificity of faecal calprotectin for the detection of adenomas in high risk individuals undergoing colonoscopy. Also, to investigate between and within stool variability of calprotectin concentrations. SUBJECTS: A total of 814 patients planned for colonoscopy were included for the following indications: positive faecal occult blood test, 25; neoplasia surveillance, 605; newly detected polyp, 130; and family risk, 54. METHODS: Two faecal samples from each of two stools were analysed using the PhiCal ELISA test device (Nycomed Pharma AS). RESULTS: Adenoma patients had significantly higher calprotectin levels than normal subjects (median 9.1 (95% confidence interval 7.5-10.1) v 6.6 (5.6-7.4)mg/l). There was no significant decrease in calprotectin levels after polypectomy. Levels in cancer patients were significantly higher than those in all other subgroups (median 17.6 mg/l (11.5-31.0)). With a cut off limit of 10 mg/l, the sensitivity for cancer was 74% and for adenoma 43%. Corresponding specificity values were 64% for no cancer and 67% for no neoplasia (cancer+adenoma). Specificity varied from 71% for one stool sample to 63% for four samples. Stool variability was small, suggesting that two spots from one stool were as discriminative as two spots from each of two stools. CONCLUSIONS: The sensitivity and specificity of faecal calprotectin levels as a marker for colorectal adenoma and carcinoma justifies its use in high risk groups, but specificity is too low for screening of average risk persons. Lack of a decrease in levels after polypectomy may be due to a more widespread leucocyte migration into the intestinal lumen than that at the polyp site, and needs further investigation.     

Surrogate markers of intestinal inflammation are predictive of relapse in patients with inflammatory bowel disease

BACKGROUND & AIMS: Prediction of relapse of inflammatory bowel disease has important implications for therapeutic strategies. We assessed whether measurement of intestinal permeability and inflammation could predict relapse of inflammatory bowel disease (IBD). METHODS: Forty-three patients with Crohn's disease (CD) and 37 with ulcerative colitis (UC) in clinical remission provided a stool sample to be assayed for calprotectin (a neutrophil-specific marker), and patients with CD additionally underwent a small intestinal permeability test. Relapse was defined using clinical disease activity indices. RESULTS: Twenty-five (58%) patients with CD and 19 (51%) with UC had a relapse over the 12-month period. Median calprotectin levels in the relapse groups (122 mg/L for CD, 123 mg/L for UC; normal <10 mg/L) differed significantly (P<0.0001) from those of the nonrelapse groups (41.5 mg/L for CD, 29.0 mg/L for UC). At 50 mg/L, the sensitivity and specificity of calprotectin for predicting relapse in all patients with IBD were 90% and 83%, respectively. Permeability in the CD patients who relapsed (median, 0.075; normal <0.04) differed significantly (P = 0. 004) from that in the nonrelapse group (median, 0.038). At the level of 0.05, the sensitivity and specificity of permeability in predicting relapse were 84% and 61%, respectively. CONCLUSIONS: Fecal calprotectin predicts clinical relapse of disease activity in patients with CD and UC, whereas small intestinal permeability is a useful predictor of relapse in patients with small intestinal CD.     

Calprotectin is a stronger predictive marker of relapse in ulcerative colitis than in Crohn's disease

BACKGROUND AND AIMS: The clinical course of inflammatory bowel disease is characterised by a succession of relapses and remissions. The aim of our study was to assess whether the predictive value of faecal calprotectin-a non-invasive marker of intestinal inflammation-for clinical relapse is different in ulcerative colitis (UC) and Crohn's disease (CD). METHODS: Seventy nine consecutive patients with a diagnosis of clinically quiescent inflammatory bowel disease (38 CD and 41 UC) were followed for 12 months, undergoing regular clinical evaluations and blood tests. A single stool sample was collected at the beginning of the study from each patient and the calprotectin concentration was assessed by a commercially available enzyme linked immunoassay. RESULTS: In CD, median calprotectin values were 220.1 mug/g (95% confidence interval (CI) 21.7-418.5) in those patients who relapsed during follow up, and 220.5 mug/g (95% CI 53-388) in non-relapsing patients (p=0.395). In UC, median calprotectin values were 220.6 mug/g (95% CI 86-355.2) and 67 microg/g (95% CI 15-119) in relapsing and non-relapsing patients, respectively (p<0.0001). The multivariate Cox (proportional hazard) regression model, after adjustment for possible confounding variables, showed a twofold and 14-fold increase in the relapse risk, respectively, in those patients with CD and UC in clinical remission who had a faecal calprotectin concentration higher than 150 microg/g. CONCLUSIONS: Faecal calprotectin proved to be an even stronger predictor of clinical relapse in UC than in CD, which makes the test a promising non-invasive tool for monitoring and optimising therapy.     

Correlation between faecal excretion of indium-111-labelled granulocytes and calprotectin, a granulocyte marker protein, in patients with inflammatory bowel disease

BACKGROUND: Several studies have suggested that clinical indices of disease activity in inflammatory bowel disease (IBD) do not adequately reflect the degree of inflammation in most such patients. Faecal excretion of indium-111-labelled neutrophilic granulocytes has been suggested as the gold standard of disease activity, but its complexity and high cost and the exposure of patients to ionizing irradiation have limited the use of this technique. The aim of this study was to investigate the correlation between the faecal excretion of the granulocyte marker protein calprotectin and that of 111In-labelled granulocytes. METHODS: Calprotectin in stool extracts from 19 patients with Crohn's disease (CD), 10 with ulcerative colitis (UC), and 9 presumably healthy controls was assessed with a simple enzyme-linked immunosorbent assay. Simultaneously, the faecal excretion of autologous 111In-labelled granulocytes was measured. RESULTS: There was a strong correlation between the average daily excretion of calprotectin and that of the total 3-day excretion of 111In-labelled granulocytes (r = 0.87, P < 0.0001). Furthermore, the concentration of calprotectin, assessed in a small stool sample on day 1, also correlated well with the excretion 111In-labelled granulocytes (r = 0.80, P < 0.0001). CONCLUSION: The results suggest that faecal calprotectin reflects the granulocyte migration through the gut wall in patients with IBD and hence might serve as a simple, inexpensive alternative to the indium-111 technique.     

Role of faecal calprotectin as non-invasive marker of intestinal inflammation

BACKGROUND/AIM: Faecal calprotectin, a neutrophil granulocyte cytosol protein, is considered a promising marker of intestinal inflammation. We assessed and compared the faecal calprotectin concentration in patients with organic and functional chronic intestinal disorders. PATIENTS AND METHODS: The study was carried out, using a commercially available ELISA test, measuring calprotectin in stool samples collected from 131 patients with inflammatory bowel diseases, 26 with intestinal neoplasms, 48 with irritable bowel syndrome and 34 healthy subjects. RESULTS: Median faecal calprotectin was significantly increased in Crohn's disease (231 microg/g, 95% confidence interval (CI) 110-353 microg/g), ulcerative colitis (167 microg/g, 95% CI 59-276 microg/g), and neoplasms (105 microg/g, 95% CI 0-272 microg/g), whereas normal values were found in patients with irritable bowel syndrome (22 microg/g, 95% CI 9-35 microg/g) and in healthy subjects (11 microg/g, 95% CI 3-18 microg/g). A positive correlation was observed with clinical activity scores in Crohn's disease and ulcerative colitis. In both groups, patients with clinically active disease showed higher calprotectin levels than those observed in patients with quiescent disease (405 microg/g, 95% CI 200-610 microg/g vs. 213 microg/g, 95% CI 85-341 microg/g in CD patients, p<0.05, and 327 microg/g, 95% CI 104-550 microg/g vs. 123 microg/g, 95% CI 40-206 microg/g in UC patients, p<0.001). CONCLUSIONS: Faecal calprotectin appears to be a promising and non-invasive biomarker of intestinal inflammation. If these findings are confirmed, it may provide a useful test for the diagnosis and follow up of inflammatory bowel diseases.     

Safety and clinical efficacy of granulocyte and monocyte adsorptive apheresis therapy for ulcerative colitis

Active ulcerative colitis(UC)is frequently associated withinfiltration of a large number of leukocytes into the bowelmucosa.Therefore,removal of activated circulatingleukocytes by apheresis has the potential for improvingUC.In Japan,since April 2000,leukocytapheresis usingAdacolumn has been approved as the treatment foractive UC by the Ministry of Health and Welfare.TheAdacolumn is an extracorporeal leukocyte apheresisdevice filled with cellulose acetate beads,and selectivelyadsorbs granulocytes and monocytes/macrophages.Toassess the safety and clinical efficacy of granulocyteand monocyte adsorptive apheresis(GMCAP)for UC,wereviewed 10 open trials of the use of GMCAP to treatUC.One apheresis session(session time,60 min)perweek for five consecutive weeks(a total of five apheresissessions)has been a standard protocol.Several studiesused modified protocols with two sessions per week,with90-min session,or with a total of 10 apheresis sessions.Typical adverse reactions were dizziness,nausea,headache,flushing,and fever.No serious adverse effectswere reported during and after GMCAP therapy,andalmost all the patients could complete the treatmentcourse.GMCAP is safe and well-tolerated.In the majorityof patients,GMCAP therapy achieved clinical remissionor improvement.GMCAP is a useful alternative therapyfor patients with steroid-refractory or-dependent UC.GMCAP should have the potential to allow tapering thedose of steroids,and is useful for shortening the timeto remission and avoiding re-administration of steroidsat the time of relapse.Furthermore,GMCAP may haveefficacy as the first-line therapy for steroid-naive patientsor patients who have the first attack of UC.However,most of the previous studies were uncontrolled trials.Toassess a definite efficacy of GMCAP,randomized,double-blind,sham-controlled trials are necessary.A seriousproblem with GMCAP is cost;a single session costs145 000($1 300).However,if this treatment preventshospital admission,re-administration of steroids and surgery,and improves a quality of life of the patients,GMCAP may prove to be cost-effective.     

Questions and answers on the role of faecal calprotectin as a biological marker in inflammatory bowel disease

Faecal calprotectin has been proposed as a non-invasive surrogate marker of intestinal inflammation in inflammatory bowel disease. Close correlation between faecal calprotectin concentration and faecal leukocyte excretion quantified with ¹¹¹indium has been described. This faecal marker can be detected using simple and cheap techniques. Faecal calprotectin has a good diagnostic precision for separating organic and functional intestinal diseases. However, the specificity for the diagnosis of inflammatory bowel disease is lower than desirable, as several diseases other than inflammatory bowel disease – specially colorectal neoplasia and gastrointestinal infection – can also increase faecal calprotectin. High concentration of calprotectin in faeces is a strong argument to carry out a colonoscopy in order to rule out the presence of inflammatory bowel disease or other organic pathologies. Parallelism between faecal calprotectin levels and inflammatory bowel disease activity has been confirmed, although this faecal marker appears to better reflect the disease activity in ulcerative colitis than in Crohn's disease. Faecal calprotectin's capacity to predict inflammatory bowel diseases relapse is promising. It has been suggested that, in inflammatory bowel disease patients receiving treatment, a normalization or decrease in faecal calprotectin concentrations is an accurate indicator of endoscopic healing. Greater faecal calprotectin concentration has been shown in asymptomatic first-degree relatives of patients with inflammatory bowel disease, suggesting that there is a high prevalence of subclinical intestinal inflammation in them.     

Assessment of mucosal inflammation and blood flow in response to four weeks' intervention with probiotics in patients operated with a J-configurated ileal-pouch-anal-anastomosis (IPAA)

BACKGROUND: Pouchitis is a common and troublesome condition in patients operated on with ileal-pouch-anal-anastomosis (IPAA). A disturbed mucosal perfusion in the pouch has been suggested as a possible cause. Laser Doppler flowmetry (LDF) has been used successfully to measure gastric and colonic mucosal perfusion in humans. In a previous study, we demonstrated a reduced mucosal perfusion in the distal part of the pouch, during probiotic intervention, examined by LDF measurement. The aim of the present study was to confirm our previous results in a much larger material, and to compare the results of LDF measurements and inflammatory activity in ulcerative colitis (UC) patients with those in familial adenomatous polyposis (FAP) patients. METHODS: Five hundred millilitres of a fermented milk product (Cultura), containing live lactobacilli (La-5) and bifidobacteria (Bb-12), was given daily for 4 weeks to 41 UC and 10 patients with FAP, operated on with IPAA. Mucosal perfusion was measured with LDF and the degree of inflammation was examined at predefined levels of the distal bowel by histology and faecal calprotectin measurements both before and after intervention. We also evaluated the applicability of a Pouchitis Disease Activity Index (PDAI). RESULTS: The LDF measurements were reproducible in the pelvic pouch at each of the predefined levels, but did not change during intervention. Mucosal perfusion was significantly reduced in the distal compared to the proximal part of the pouch in the UC group (P < 0.05). The perfusion levels were higher in the FAP patients compared to the UC patientsat all predefined levels (P < 0.05). Calprotectin levels and histological score did not change significantlyafter intervention in any of the groups. The calprotectin level was significantly lower in the FAP compared to the UC group both before and after intervention. The PDAI decreased in both groups from alevel considered diagnostic for pouchitis to a level considered as not active pouchitis. The decreasewas significant for the UC patients. CONCLUSIONS: The results did not demonstrate an effect of probiotics on histology, although a significant effect on the PDAI was achieved, which concurs with the previously reported effect on symptoms and endoscopic score. The significantly reduced blood flow in the UC group compared to the FAP group, operated on with the same procedure, and the significantly increased calprotectin levels in the UC group, are original findings. Both findings may be related to an increased risk for pouchitis among UC patients. The lack of effect of intervention on mucosal perfusion does not exclude a role for reduced circulation as a cause of pouchitis based on the reduced LDF measurements in the distal part of the pouch.     

Faecal calprotectin in children with clinically quiescent inflammatory bowel disease

Abstract

Objective. The use of faecal calprotectin as a surrogate marker for intestinal inflammation is emerging. However, the data on faecal calprotectin during maintenance therapy in children with inflammatory bowel disease, IBD, are sparse. Our aim was to study faecal calprotectin levels in paediatric IBD during clinically quiescent disease and to investigate if high levels were associated with a flare-up of the disease. Subjects and methods. Faecal calprotectin level was measured in 72 children with paediatric IBD in clinical remission (median age 13 years). Of these, 37 children had been in clinical remission for more than a year, 20 for 6–12 months and 15 for 3 to <6 months. The clinical outcome of the patients was followed up to the first relapse or up to 12 months. Results. When in clinical remission, 35% (25/72) of the children had normal faecal calprotectin (<100 μg/g) and 13% (9/72) a very high level (>1000 μg/g) while not reporting symptoms. A clinical relapse occurred in 35% (25/72) during the subsequent 12 months. When in clinical remission, the predictive value of faecal calprotectin for an overt relapse was low ranging from 0.396 to 0.429 for faecal calprotectin values >100 μg/g or >1000 μg/g, respectively. The negative predictive value was 0.75 for values <100 μg/g. Conclusions. In paediatric IBD, subjective symptoms and clinical assessment associate poorly with the levels of faecal calprotectin. During maintenance medication in colonic disease, the probability of staying in clinical remission for a subsequent year is high if faecal calprotectin value is low.     

Faecal elastase reflects disease activity in active ulcerative colitis.

Alpha-1-proteinase inhibitor-bound elastase (EPIC) was measured in plasma and fresh stool samples from 20 patients with Crohn's disease (CD), 16 patients with ulcerative colitis (UC), and 10 controls. Median EPIC values were significantly higher than normal in active CD and UC. EPIC was virtually undetectable in the stool samples of control subjects. Median faecal EPIC in 14 patients with active CD (478 ng/ml) or 10 patients with active UC (1159 ng/ml) was significantly higher than in quiescent disease (p less than 0.05) and in control subjects (p less than 0.001 in each case). The difference in the median values between active CD and UC was not significant (p = 0.065). The median faecal EPIC levels were identical in active UC (1159 ng/ml) and patients with large-bowel CD (LBCD) (1015 ng/ml) (p = 0.9), and each was significantly higher than the value of 168 ng/ml in small-bowel CD (SBCD) (p less than 0.01 in each case). In active LBCD but not in SBCD, faecal EPIC correlated significantly with Crohn's disease activity index (R = 0.78, p less than 0.05), plasma C-reactive protein (CRP) (R = 0.9, p less than 0.01), and erythrocyte sedimentation rate (ESR) (R = 0.74, p less than 0.05). In active UC, faecal EPIC correlated significantly with a numerical disease activity index (R = 0.9, p less than 0.01) but not with plasma EPIC and CRP, ESR, and leucocyte counts. Faecal EPIC values may be a better reflection of disease activity in active UC than plasma levels of markers of inflammation.     

Assessment of mucosal inflammation and circulation in response to probiotics in patients operated with ileal pouch anal anastomosis for ulcerative colitis

BACKGROUND: Pouchitis is a common and troublesome condition, and a disturbed microbiological flora and mucosal blood flow in the pouch have been suggested as possible causes. Laser Doppler flowmetry (LDF) has been used successfully to measure gastric and colonic mucosal perfusion in humans. The aim of this study was to evaluate the effect of intervention with probiotics on ileal pouch inflammation and perfusion in the pouch, assessed by endoscopy, histology, fecal calprotectin and LDF. METHODS: A fermented milk product (Cultura; 500 ml) containing live lactobacilli (La-5) and bifidobacteria (Bb-12) was given daily for 4 weeks to 10 patients operated with ileal-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Mucosal perfusion was measured with LDF and the degree of inflammation was examined at predefined levels of the distal bowel by endoscopy and histology. Stool samples were cultured for lactobacilli and bifidobacteria and calprotectin were measured before and after intervention. RESULTS: The LDF measurements were reproducible in the pelvic pouch at each of the predefined levels, but did not change after intervention. The mucosal perfusion was reduced in the distal compared to the proximal part of the pouch. Calprotectin levels did not change significantly after intervention. The median endoscopic score for inflammation was significantly reduced by 50% after intervention, whereas the histological score did not change significantly. CONCLUSION: The results suggest that probiotics primarily act superficially, with change of gross appearance of the mucosa at endoscopy, but without significant effect on histological picture, mucosal perfusion or faecal calprotectin, during a relatively short period of 4 weeks.     

Fecal excretion of calprotectin in colorectal cancer: relationship to tumor characteristics

BACKGROUND: The aim of this study was to evaluate fecal calprotectin in patients treated for colorectal cancer. Furthermore, the changes in fecal calprotectin concentration from before to after surgery were investigated. METHODS: In 155 patients with newly diagnosed colorectal cancer, two spot samples were taken from the same feces on two consecutive days. RESULTS: Three ways of evaluating calprotectin excretion were compared, (1st spot 1st stool; maximum of 1st spot 1st stool and 2nd spot 1st stool; maximum of 1st spot 1st stool and 1st spot 2nd stool) and gave similar results with median fecal calprotectin values 47 mg/l, 52 mg/l and 54 mg/l, respectively. Median calprotectin concentration did not differ significantly between different tumor stages, although the levels were slightly lower in Dukes stage A tumor than in the rest of the stages. Neither were there any differences in the concentrations related to the localization, size or the histological grading of the carcinoma. As the currently used cut-off level for fecal calprotectin is 10 mg/l, 87% of all patients had elevated fecal calprotectin. Seventy-nine percent of the patients had levels above 15 mg/l and 74% had levels above 20 mg/l (1st spot 1st stool). In patients who delivered fecal samples after the operation the calprotectin value fell significantly from a preoperative median value of 45 mg/l to 14 mg/l after the resection. CONCLUSIONS: The majority of patients with colorectal cancer have increased fecal concentration of calprotectin. One single fecal spot seems to be sufficient for determination of the calprotectin level. Measurement of fecal calprotectin may possibly become of value as a marker for colorectal cancer, although calprotectin, similar to fecal occult blood (FOB) tests, is a non-specific test for colorectal pathology, also being elevated in inflammatory bowel diseases. Further investigation of its specificity is therefore needed.     

Diagnostic value of faecal calprotectin in unselected outpatients referred for colonoscopy: A multicenter prospective study

ObjectivesTo evaluate the role of faecal calprotectin in consecutive outpatients referred for colonoscopy.MethodsOutpatients undergoing colonoscopy at five participating institutions were eligible. Demographic and clinical data were collected. Faecal samples were tested at a single laboratory by means of a commercially available kit.ResultsWe consecutively enrolled 870 patients. Mean levels of calprotectin were significantly higher in patients with neoplastic and inflammatory disorders when compared with subjects with a normal colonoscopy or trivial endoscopic findings. Elevated calprotectin levels (>50 mg/dl) were detected in 85% of patients with colorectal cancer, and 81% of those with inflammatory conditions but also in 37% of patients with normal or trivial endoscopic findings. In patients referred for chronic diarrhoea, sensitivity and negative predictive value were 100% in detecting either any organic colonic disease. In patients referred for symptoms of “suspected functional origin” sensitivity and negative predictive value for colorectal cancer were also 100%.ConclusionsIn unselected outpatients referred for colonoscopy, a single measurement of faecal calprotectin is not sufficiently accurate to identify those with significant colorectal disease. However, a normal result can help rule out organic disease among patients with diarrhoea and those with abdominal pain and/or constipation.     

Laboratory markers in IBD: useful, magic, or unnecessary toys?

Laboratory markers have been investigated in inflammatory bowel disease (IBD) for diagnostic and differential diagnostic purposes, for assessment of disease activity and risk of complications, for prediction of relapse, and for monitoring the effect of therapy. The introduction of biological therapies in IBD has renewed interest in inflammatory markers (especially C reactive protein (CRP)), given their potential to select responders to these treatments. Of all the laboratory markers, CRP is the most studied and has been shown to have the best overall performance. CRP is an objective marker of inflammation and correlates well with disease activity in Crohn's disease (CD). Increased CRP levels are associated with better response rates and normal CRP levels predict high placebo response rates in clinical trials with biologicals. However, despite the advantages of CRP over other markers, it is still far from ideal. Furthermore, CRP correlates less well with disease activity in patients with ulcerative colitis (UC) as compared with CD. Other laboratory markers, including erythrocyte sedimentation rate (ESR), leucocyte and platelet count, albumin, and 1 acid glycoprotein (orosomucoid), have been studied either less extensively in IBD or have proven to be less useful than CRP. Faecal markers seem promising and may be more specific in detecting gut inflammation in patients with established IBD. Promising results have been reported with the use of faecal calprotectin in CD as well as in UC. Recent data however suggest that the performance of the faecal calprotectin test is superior for UC than for CD. Taken together, laboratory markers are useful and should be part of the global management of our IBD patients. They are however not magic and until more data become available, the use of CRP and other laboratory markers should be seen as an additive tool to clinical observation and physical examination rather than a replacement.     

Clinical value of fecal calprotectin in determining disease activity of ulcerative colitis

AIM： To investigate possibility and clinical application of fecal calprotectin in determining disease activity of ulcerative colitis （UC）. METHODS： The enzyme-linked immunosorbent assay （ELISA） was used to measure the concentrations of calprotectin in feces obtained from 66 patients with UC and 20 controls. C-reactive protein （CRP）, erythrocyte sedimentation rate （ESR）, acid glycoprotein （AGP） were also measured and were compared with calprotectin in determining disease activity of UC. The disease activity of UC was also determined by the Sutherland criteria. RESULTS： The fecal calprotectin concentration in the patients with active UC was significantly higher than that in the inactive UC and in the controls （402.16 ± 48.0 μg/g vs 35.93 ± 3.39 μg/g, 11.5 ± 3.42 μg/g, P 〈 0.01）. The fecal calprotectin concentration in the inactive UC group was significantly higher than that in the control group （P 〈 0.05）. A significant difference was also found in the patients with active UC of mild, moderate and severe degrees. The area under the curve of the receiver operating characteristics （AUCR~c） was 0.975, 0.740, 0.692 and 0.737 for fecal calprotectin, CRP, ESR and AGP, respectively. There was a strong correlation between the fecal calprotectin concentration and the endoscopic gradings for UC （r = 0.866, P 〈 0.001）. CONCLUSION： Calprotectin in the patient＇s feces can reflect the disease activity of UC and can be used as a rational fecal marker for intestinal inflammation in clinical practice. This kind of marker is relatively precise, simple and noninvasive when compared with other commonlyused markers such as CRP, ESR and AGP.     

Fecal M2-pyruvate kinase (M2-PK): a novel marker of intestinal inflammation

BACKGROUND: Surrogate markers of bowel inflammation are increasingly being recognized as important, not only as markers of disease activity in inflammatory bowel disease (IBD) but also to differentiate irritable bowel syndrome (IBS) from IBD. The dimeric M2-isoform of pyruvate kinase (M2-PK) has been reported to be elevated in fecal specimens from colorectal cancer (CA) patients, but its role in IBD is unknown. This study investigated the usefulness of fecal M2-PK in cohorts of patients with IBD, IBS, and CA. METHODS: Stool samples were obtained for calprotectin and M2-PK measurements in patients with previously diagnosed IBD or new patients being investigated for lower gastrointestinal (GI) symptoms in a UK university hospital. Other investigations were performed as directed by the investigating physician and patients with known IBD were assessed for disease activity by a physician global assessment, Harvey-Bradshaw index (HBI), or endoscopic grading. RESULTS: Fecal M2-PK and calprotectin measurements were obtained for 148 patients: 50 with ulcerative colitis (UC); 31 with Crohn's disease (CD), 43 with irritable bowel syndrome/functional bowel disorders (IBS); 7 with colorectal CA, and 17 with miscellaneous conditions (excluded from the analysis). Median M2-PK values (U/mL) were significantly elevated in UC: 20.0 (95% confidence interval [CI] 5.4-69.0, P < 0.0001), CD: 24.3 (95% CI 6.4-44.0, P < 0.0001), and CA: 7.0 (95% CI 4.3-88.0, P < 0.0006) compared to IBS: 0.1 (95% CI 0.0-3.2). There was a strong linear correlation of M2-PK with calprotectin levels. A predetermined cutoff level of 3.7 U/mL for a normal M2-PK test produced a sensitivity, specificity, and positive predictive value (PPV) of 73%, 74%, and 89%, respectively, for organic disease. Furthermore, M2-PK levels were significantly elevated in active, compared to inactive, disease for CD (30 versus 0.55 U/mL, P < 0.005) and UC (40 versus 1.2 U/mL, P = 0.006), respectively. CONCLUSIONS: Fecal M2-PK is elevated in IBD as well as in CA patients and is a sensitive and relatively specific marker for organic GI pathology, with a PPV of 89%. Furthermore, it appears to be a potentially valuable, noninvasive marker of disease activity in IBD.