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P219 Faecal calprotectin is an accurate predictor of endoscopic and histological disease activity in IBD
Clinical: Diagnosis & outcome evidenced by lower levels of health-related quality of life (HRQOL) especially in children with high levels of abdominal pain. Research examining psychological and social factors related to IBD and associated HRQOL is critical. For children in particular, the family environment might play a crucial role in the their coping with IBD. Dysfunctional levels of overall functioning have been associated with lower HRQOL in chidlren with IBD, yet the impact of specific aspects of family functioning, such as cohesion (i.e., emotional bond or connectiveness), flexibility (i.e., balance between stability and change) and communication patterns (i.e., postive versus negative) is largely unexplored. The purpose of the present study was to investigate the influence of balanced levels of cohesion and flexbility and positive communication on the child’s pain experience and HRQOL. Methods: Thirty children with IBD (14 girls, 16 boys; N = 20 with Crohn’s disease, N = 10 with Ulcerative colitis; Mage = 13.73, SD = 2.30 years) and one parent (25 mothers, 5 fathers Mage = 46.73, SD = 6.47 years) completed questionnaires regarding child’s level of pain and interference, HRQOL (i.e., IMPACT) and family functioning (i.e., Faces IV). Results: Linear regression analyses, controlling for child age, indicated that child report of positive communication and balanced level of cohesion and flexibility were positively associated with their HRQOL. Surprisingly, no significant associations were found between child level of pain and family functioning, while the level of interference in daily functioning due to pain was negatively associated with parent report of balanced cohesion and child report of balanced flexibility and positive communication. Conclusions: The current findings indicate that parent-reported cohesion was only associated with pain-related interference, while child-reported aspects of family functioning were related to HRQOL and pain-related interference. Results also suggest that family functioning is primarily associated with HRQOL and interference in daily functioning rather than the level of pain, adding to our understanding of how family functioning relates to children’s coping with IBD and associated pain. In future research, observational assesment of family functioning (e.g., by means of a conflict-discussion task) and parentchild communication patterns when faced with their child in pain (e.g., observation of parent child interaction during an experimental pain task), will contribute to our understanding of how family functioning influences child functioning and pain experiences. P218 Faecal calprotectin testing reduces need for paediatric colonoscopy T.I. Hassan1 *, C. Hensey1 , M. Hamzawi1 , S. Kiernana1 , A.-M. Broderick1,2 , B. Bourke1,2 , S. Hussey1,2 . 1 Our Lady’s Children’s Hospital Crumlin, Gastroenterology, Dublin, Ireland, 2 University college Dublin, National children reseach centre and school of Medicine and Medical Science, Dublin, Ireland Background: Ireland has a single national centre for paediatric gastroenterology. Up to 70% of children referred to a paediatric gastroenterology centre with suspected inflammatory bowel disease (IBD) do not have the disease. Faecal calprotectin (FC) is a white cell protein and a marker of intestinal inflammation. Faecal calprotectin was recently made available in our institution. Our aim was to assess the clinical performance and cost-benefit of faecal calprotectin (FC) in reducing diagnostic endoscopic procedures in symptomatic children with potential or confirmed inflammatory bowel disease (IBD). Methods: Charts, computerised records and endoscopy results of all patients who had FC testing between Oct 2012 and August 2013 were retrospectively reviewed. New patients with
S153 a high clinical likelihood of IBD do not get routine FC testing and were not included in the analysis. FC values <50 mg/g were considered normal; 51 to 200 mg/g indeterminate and >200 mg/g likely to have active GI inflammation. Results: 133 patients had a FC test; of these, 57 (42.8%) had FC >200 (Group A), 76 had FC <200 (Group B). The results are summarised in Table 1. Table 1. The analysis of the FC and the endoscopy results Faecal Total Colonoscopy No colonoscopy Known IBD New IBD calprotectin (n = 133) (n = 35) (n = 98) (n = 33) (n = 11) (mg/g) <50 50 200
48 28
6 4
42 24
1 3
<200 >200
76 57
10 25
66 32
4 29
11
25/57 patients in group A had colonoscopy (43.8%); 11 were newly diagnosed with IBD; 4 of 6 patients with pre-existing IBD had a change in phenotype or treatment regimen following endoscopy findings. Two patients in group A had normal colonoscopy despite high FC. Of the rest in the same group, one patient was diagnosed as proctitis while three had gastritis. 32/57 patients in group A had no colonscopy performed, 24 of these were known to have IBD and five were found to have bacterial or viral GI infection. 10 out of 76 patients in Group B had colonoscopy performed (13.1%), mostly due to persistent symptoms of diarrhoea and/or abdominal pain. None of these had macro- or microscopic abnormalities. Using estimated costs of FC (euro 75 per test) and colonoscopy (euro1000/test), the calculated net cost saving in the year examined was euro 60,300. Conclusions: Faecal calprotectin is a valuable, cost-effective screening test for excluding significant intestinal inflammatory disease and avoiding colonoscopy in children with non-organic gastrointestinal symptoms that mimic IBD. P219 Faecal calprotectin is an accurate predictor of endoscopic and histological disease activity in IBD G. Chung-Faye *, A. Rahman, K. Sandhu, B. Hayee, J. Tumova, R. Sherwood. King’s College Hospital NHS Foundation Trust, Gastroenterology, London, United Kingdom Background: Assessment of disease activity in inflammatory bowel disease (IBD) is challenging as the gold standards of endoscopy and histology are invasive, expensive and impractical for regular use. Faecal calprotectin (FC) is increasingly being used as a marker of intestinal inflammation in IBD. However, evidence of its role in predicting endoscopic and histological changes in IBD is limited. We explore the role of FC to assess histological disease in IBD, in comparison to C-reactive protein (CRP). Methods: Retrospective analyses of 209 IBD cases who had a colonoscopy with FC (mg/g) and CRP (mg/L) measurements. The most severe histological inflammation found was graded according to the simplified histology score (0, normal; 1, mild; 2, moderate; 3, severe). The Kruskal Wallis test (c2 ) was used to look for differences between the groups. Receiver operating characteristic (ROC) curves were used to differentiate patients with normal/mild disease (histology scores 0 1) from patients with moderate/severe disease (histology scores 2 3). Results: In 100 ulcerative colitis (UC) patients, the median FC values for the histology scores; 0, 1, 2, 3 were; 29, 322, 520 and 2497, respectively (graph). The corresponding values for CRP were; 2.5, 5.0, 12.6 and 13.0. Both FC and CRP showed highly significant differences between the different histology groups (FC c2 = 17.2, p = 0.0007; CRP c2 = 16.3, p = 0.001). With
S154 a cut off value of 244, FC had a 74% sensitivity and 52% specificity for predicting moderate/severe histological disease. The corresponding values for CRP >6 were 70% and 67%.
Poster presentations FC, studies where the radiologists reported upper GI or colonic inflammation were excluded (27/119). Results: 150 SBMRI scans were re-evaluated from 123 patients with purely ileal Crohn’s (Montreal L1, n = 109; L3 + previous panproctocolectomy, n = 14; 65% female; median age at MRI 45 years (IQR 32 56); median follow-up 34 months (IQR 25 44). The median (IQR) FC was 80 mg/g (20 142) where SBMRI demonstrated no active ileal disease (simple MRI score = 0, n = 38), 198 mg/g (120 444) for mild to moderate (1 6, n = 30) and 398 m/g (168 771) for severe disease (>6, n = 24) (p < 0.001). ROC analysis showed an AUC of 0.81 (0.72 0.90) for FC which was significantly higher than for CRP (0.65 [0.53 0.77], p = 0.020) (Figure 1).
Graph: Calprotectin vs histology score.
In 109 Crohn’s disease (CD) patients, the median FC for the histology scores; 0, 1, 2, 3 were; 85, 175, 644 and 4144, respectively (graph). The corresponding medians for CRP were; 8, 10, 14 and 100. There were highly significant FC differences between the different histology groups (c2 = 62.5, p < 0.0001), while CRP just reached significance (c2 = 9.5, p = 0.02). With a cut-off value of 250, FC had a 90% sensitivity and 82% specificity for predicting moderate/severe disease. The corresponding values for CRP >6 were 72% and 43%. Conclusions: In IBD, FC was strongly predictive of histological disease and with a FC cut off level of ~250 mg/g gave high levels of sensitivity and moderate specificity for predicting moderate to severe disease. FC showed greater accuracy in CD than in UC and also performed better than CRP. This study highlights the importance of FC as a valuable, non-invasive marker for measuring disease activity in IBD, and may be predictive of disease remission and relapse. P220 Faecal calprotectin and ileal Crohn’s disease: correlation with a small bowel MRI score for disease activity F. Fascì-Spurio1,2 *, N.A. Kennedy1,3 *, L. Wong4 , P. MacLean4 , J. Satsangi1,3 , S. Glancy4 , C.W. Lees1,3 . 1 Western General Hospital, Gastrointestinal Unit, Edinburgh, United Kingdom, 2 Sapienza University, Gastroenterology Unit, Rome, Italy, 3 University of Edinburgh, Gastrointestinal Unit, Centre for Genomic and Experimental Medicine, Edinburgh, United Kingdom, 4 Western General Hospital, Department of Radiology, Edinburgh, United Kingdom Background: Small bowel MRI (SBMRI) is the current standard for assessing ileal inflammation in Crohn’s disease. Faecal calprotectin (FC) is closely correlated with colonic inflammation, but is thought to be of less utility in ileal disease. Interpretation of existing data linking FC with SBMRI findings have been confounded by the presence of colonic inflammation. We therefore aimed to ascertain how FC best reflects MRI findings exclusively in the small bowel. Methods: 150 SBMRI studies with matched FC results (±30 days) were identified from the Edinburgh FC Register (2008 12; n = 18,138). Scans were entered into an anonymous ‘teaching’ list on PACS and each re-read independently by 2 expert GI radiologists blind to all clinical and lab data. Technical, quality and disease parameters were recorded onto standard proformas. Scans rated by one or other radiologist as being of poor quality were excluded (n = 31/150). 7/13 disease parameters were excluded due to poor inter-observer variability (Cohen’s kappa <0.5). A 6 item simple MRI score (range 0 10) was derived from assessment of the worst segment (bowel wall thickness, oedema, and relative enhancement, mesenteric oedema and pre-stenotic dilatation) plus total disease extent (overall kappa = 0.85). For comparisons with
Figure 1. ROC curves for abnormal ileum on small bowel MRI scan against various laboratory parameters.
Conclusions: FC correlates closely with SBMRI findings in ileal Crohn’s disease and outperforms other laboratory tests. In future, following validation, we will derive clinical useful MRI and FC cut-offs that predicate on important patient outcomes. P221 Faecal calprotectin concentrations in Crohn’s patients with ileal disease location: correlations with disease activity as seen by MRI enterography F. Fascì-Spurio1 *, A. Chiappini1 , V. Buonocore2 , S. Cannizzaro1 , Z. Maddalena1 , F. Maccioni2 , P. Vernia1 . 1 Sapienza University, Gastroenterology Unit, Policlinico Umberto I, Rome, Italy, 2 Sapienza University, Radiology Department, Policlinico Umberto I, Rome, Italy Background: Faecal Calprotectin (FC) is considered a reliable marker of disease activity in IBD. While its correlation with colonic inflammation has clearly been established, its correlation with ileal inflammation has never been thoroughly investigated and its clinical reliability in patients with ileal CD remains controversial. As MRI enterography is considered of prime importance for assessing disease activity in patients with ileal CD, aim of the present study has been to investigate the correlation between MRI findings and FC. Methods: A series of consecutive patients with known CD referred for MRI enterography at a single institution between December 2010 and June 2013 were prospectively recruited.
S153 a high clinical likelihood of IBD do not get routine FC testing and were not included in the analysis. FC values <50 mg/g were considered normal; 51 to 200 mg/g indeterminate and >200 mg/g likely to have active GI inflammation. Results: 133 patients had a FC test; of these, 57 (42.8%) had FC >200 (Group A), 76 had FC <200 (Group B). The results are summarised in Table 1. Table 1. The analysis of the FC and the endoscopy results Faecal Total Colonoscopy No colonoscopy Known IBD New IBD calprotectin (n = 133) (n = 35) (n = 98) (n = 33) (n = 11) (mg/g) <50 50 200
48 28
6 4
42 24
1 3
<200 >200
76 57
10 25
66 32
4 29
11
25/57 patients in group A had colonoscopy (43.8%); 11 were newly diagnosed with IBD; 4 of 6 patients with pre-existing IBD had a change in phenotype or treatment regimen following endoscopy findings. Two patients in group A had normal colonoscopy despite high FC. Of the rest in the same group, one patient was diagnosed as proctitis while three had gastritis. 32/57 patients in group A had no colonscopy performed, 24 of these were known to have IBD and five were found to have bacterial or viral GI infection. 10 out of 76 patients in Group B had colonoscopy performed (13.1%), mostly due to persistent symptoms of diarrhoea and/or abdominal pain. None of these had macro- or microscopic abnormalities. Using estimated costs of FC (euro 75 per test) and colonoscopy (euro1000/test), the calculated net cost saving in the year examined was euro 60,300. Conclusions: Faecal calprotectin is a valuable, cost-effective screening test for excluding significant intestinal inflammatory disease and avoiding colonoscopy in children with non-organic gastrointestinal symptoms that mimic IBD. P219 Faecal calprotectin is an accurate predictor of endoscopic and histological disease activity in IBD G. Chung-Faye *, A. Rahman, K. Sandhu, B. Hayee, J. Tumova, R. Sherwood. King’s College Hospital NHS Foundation Trust, Gastroenterology, London, United Kingdom Background: Assessment of disease activity in inflammatory bowel disease (IBD) is challenging as the gold standards of endoscopy and histology are invasive, expensive and impractical for regular use. Faecal calprotectin (FC) is increasingly being used as a marker of intestinal inflammation in IBD. However, evidence of its role in predicting endoscopic and histological changes in IBD is limited. We explore the role of FC to assess histological disease in IBD, in comparison to C-reactive protein (CRP). Methods: Retrospective analyses of 209 IBD cases who had a colonoscopy with FC (mg/g) and CRP (mg/L) measurements. The most severe histological inflammation found was graded according to the simplified histology score (0, normal; 1, mild; 2, moderate; 3, severe). The Kruskal Wallis test (c2 ) was used to look for differences between the groups. Receiver operating characteristic (ROC) curves were used to differentiate patients with normal/mild disease (histology scores 0 1) from patients with moderate/severe disease (histology scores 2 3). Results: In 100 ulcerative colitis (UC) patients, the median FC values for the histology scores; 0, 1, 2, 3 were; 29, 322, 520 and 2497, respectively (graph). The corresponding values for CRP were; 2.5, 5.0, 12.6 and 13.0. Both FC and CRP showed highly significant differences between the different histology groups (FC c2 = 17.2, p = 0.0007; CRP c2 = 16.3, p = 0.001). With
S154 a cut off value of 244, FC had a 74% sensitivity and 52% specificity for predicting moderate/severe histological disease. The corresponding values for CRP >6 were 70% and 67%.
Poster presentations FC, studies where the radiologists reported upper GI or colonic inflammation were excluded (27/119). Results: 150 SBMRI scans were re-evaluated from 123 patients with purely ileal Crohn’s (Montreal L1, n = 109; L3 + previous panproctocolectomy, n = 14; 65% female; median age at MRI 45 years (IQR 32 56); median follow-up 34 months (IQR 25 44). The median (IQR) FC was 80 mg/g (20 142) where SBMRI demonstrated no active ileal disease (simple MRI score = 0, n = 38), 198 mg/g (120 444) for mild to moderate (1 6, n = 30) and 398 m/g (168 771) for severe disease (>6, n = 24) (p < 0.001). ROC analysis showed an AUC of 0.81 (0.72 0.90) for FC which was significantly higher than for CRP (0.65 [0.53 0.77], p = 0.020) (Figure 1).
Graph: Calprotectin vs histology score.
In 109 Crohn’s disease (CD) patients, the median FC for the histology scores; 0, 1, 2, 3 were; 85, 175, 644 and 4144, respectively (graph). The corresponding medians for CRP were; 8, 10, 14 and 100. There were highly significant FC differences between the different histology groups (c2 = 62.5, p < 0.0001), while CRP just reached significance (c2 = 9.5, p = 0.02). With a cut-off value of 250, FC had a 90% sensitivity and 82% specificity for predicting moderate/severe disease. The corresponding values for CRP >6 were 72% and 43%. Conclusions: In IBD, FC was strongly predictive of histological disease and with a FC cut off level of ~250 mg/g gave high levels of sensitivity and moderate specificity for predicting moderate to severe disease. FC showed greater accuracy in CD than in UC and also performed better than CRP. This study highlights the importance of FC as a valuable, non-invasive marker for measuring disease activity in IBD, and may be predictive of disease remission and relapse. P220 Faecal calprotectin and ileal Crohn’s disease: correlation with a small bowel MRI score for disease activity F. Fascì-Spurio1,2 *, N.A. Kennedy1,3 *, L. Wong4 , P. MacLean4 , J. Satsangi1,3 , S. Glancy4 , C.W. Lees1,3 . 1 Western General Hospital, Gastrointestinal Unit, Edinburgh, United Kingdom, 2 Sapienza University, Gastroenterology Unit, Rome, Italy, 3 University of Edinburgh, Gastrointestinal Unit, Centre for Genomic and Experimental Medicine, Edinburgh, United Kingdom, 4 Western General Hospital, Department of Radiology, Edinburgh, United Kingdom Background: Small bowel MRI (SBMRI) is the current standard for assessing ileal inflammation in Crohn’s disease. Faecal calprotectin (FC) is closely correlated with colonic inflammation, but is thought to be of less utility in ileal disease. Interpretation of existing data linking FC with SBMRI findings have been confounded by the presence of colonic inflammation. We therefore aimed to ascertain how FC best reflects MRI findings exclusively in the small bowel. Methods: 150 SBMRI studies with matched FC results (±30 days) were identified from the Edinburgh FC Register (2008 12; n = 18,138). Scans were entered into an anonymous ‘teaching’ list on PACS and each re-read independently by 2 expert GI radiologists blind to all clinical and lab data. Technical, quality and disease parameters were recorded onto standard proformas. Scans rated by one or other radiologist as being of poor quality were excluded (n = 31/150). 7/13 disease parameters were excluded due to poor inter-observer variability (Cohen’s kappa <0.5). A 6 item simple MRI score (range 0 10) was derived from assessment of the worst segment (bowel wall thickness, oedema, and relative enhancement, mesenteric oedema and pre-stenotic dilatation) plus total disease extent (overall kappa = 0.85). For comparisons with
Figure 1. ROC curves for abnormal ileum on small bowel MRI scan against various laboratory parameters.
Conclusions: FC correlates closely with SBMRI findings in ileal Crohn’s disease and outperforms other laboratory tests. In future, following validation, we will derive clinical useful MRI and FC cut-offs that predicate on important patient outcomes. P221 Faecal calprotectin concentrations in Crohn’s patients with ileal disease location: correlations with disease activity as seen by MRI enterography F. Fascì-Spurio1 *, A. Chiappini1 , V. Buonocore2 , S. Cannizzaro1 , Z. Maddalena1 , F. Maccioni2 , P. Vernia1 . 1 Sapienza University, Gastroenterology Unit, Policlinico Umberto I, Rome, Italy, 2 Sapienza University, Radiology Department, Policlinico Umberto I, Rome, Italy Background: Faecal Calprotectin (FC) is considered a reliable marker of disease activity in IBD. While its correlation with colonic inflammation has clearly been established, its correlation with ileal inflammation has never been thoroughly investigated and its clinical reliability in patients with ileal CD remains controversial. As MRI enterography is considered of prime importance for assessing disease activity in patients with ileal CD, aim of the present study has been to investigate the correlation between MRI findings and FC. Methods: A series of consecutive patients with known CD referred for MRI enterography at a single institution between December 2010 and June 2013 were prospectively recruited.