From the Guidelines
For a patient with elevated fecal calprotectin in the 900's and chronic diarrhea, a comprehensive evaluation for inflammatory bowel disease (IBD) is warranted, with initial steps including colonoscopy with biopsies to assess for mucosal inflammation, particularly focusing on Crohn's disease and ulcerative colitis, as recommended by the AGA clinical practice guidelines 1. The workup should also include:
- Stool studies to rule out infectious causes (C. difficile, parasites, bacterial pathogens)
- Complete blood count
- Comprehensive metabolic panel
- Inflammatory markers like ESR and CRP Upper endoscopy may be warranted if upper GI symptoms are present or to evaluate for Crohn's disease involvement.
Treatment Options
Treatment depends on the specific diagnosis but typically begins with anti-inflammatory medications such as:
- Mesalamine (2-4g daily) for mild to moderate ulcerative colitis
- Budesonide (9mg daily for 8-12 weeks) for ileal Crohn's disease For more severe disease, corticosteroids like prednisone (40-60mg daily with taper) may be used for acute flares. Immunomodulators such as azathioprine (2-3mg/kg/day) or methotrexate (25mg weekly) are options for maintenance therapy. Biologic agents including anti-TNF medications (infliximab, adalimumab), anti-integrins (vedolizumab), or IL-12/23 inhibitors (ustekinumab) are used for moderate to severe disease or when other treatments fail. Supportive care includes hydration, electrolyte replacement, and dietary modifications. Elevated fecal calprotectin reflects intestinal inflammation, and values typically correlate with disease activity, making it useful for both diagnosis and monitoring treatment response, as noted in the guidelines 1 and supported by other studies 1. It is essential to consider the threshold value of 50 mg/g for fecal calprotectin to optimize sensitivity for IBD, as recommended by the AGA clinical practice guidelines 1. In the context of chronic diarrhea and elevated fecal calprotectin, it is crucial to prioritize the evaluation and treatment of IBD, given its potential impact on morbidity, mortality, and quality of life.
From the Research
Workup for Elevated Calprotectin
- The workup for a patient with elevated fecal calprotectin and chronic diarrhea should include a thorough medical history and physical examination to identify potential causes of inflammation in the digestive tract 2, 3.
- Laboratory tests such as complete blood count, electrolyte panel, and liver function tests may be ordered to rule out other conditions that could be contributing to the patient's symptoms 4, 5.
- Endoscopy with histological sampling may be necessary to evaluate the severity of inflammation and rule out other organic pathologies such as inflammatory bowel disease (IBD) 2, 4.
- Imaging studies such as abdominal X-rays or computed tomography (CT) scans may be ordered to evaluate the extent of inflammation and rule out other conditions such as bowel obstruction or abscesses 5, 3.
Treatment for Elevated Calprotectin
- The treatment for elevated calprotectin depends on the underlying cause of the inflammation 2, 4.
- For patients with IBD, treatment may include aminosalicylates, corticosteroids, immunomodulators, or biologic agents to reduce inflammation and induce remission 2, 4.
- For patients with infectious diarrhea, treatment may include antibiotics or antiviral medications to treat the underlying infection 6.
- For patients with other causes of inflammation, treatment may include medications to reduce inflammation, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids, or surgery to remove the source of inflammation 5, 3.
- Lifestyle modifications such as dietary changes, stress management, and bowel habit training may also be recommended to help manage symptoms and reduce inflammation 2, 4.
Monitoring and Follow-up
- Patients with elevated calprotectin should be monitored regularly to assess the effectiveness of treatment and adjust the treatment plan as needed 2, 4.
- Fecal calprotectin levels can be used to monitor disease activity and predict disease relapse in patients with IBD 2, 4.
- Regular follow-up appointments with a healthcare provider are necessary to monitor the patient's condition and adjust the treatment plan as needed 5, 3.