Can hemorrhoids increase calprotectin levels?

Can Hemorrhoids Increase Calprotectin Levels?

Hemorrhoids can cause false elevations in fecal calprotectin levels due to local bleeding and inflammation, potentially confounding the interpretation of this biomarker when evaluating for inflammatory bowel disease. 1

Understanding Fecal Calprotectin as a Biomarker

Fecal calprotectin is a validated biomarker for intestinal inflammation that:

• Serves as a non-invasive surrogate marker primarily used to detect inflammatory bowel disease (IBD) and differentiate it from irritable bowel syndrome (IBS) 2
• Has high negative predictive value for ruling out IBD in undiagnosed, symptomatic patients 2
• Correlates well with endoscopic and histological disease activity in IBD 2

Factors That Can Elevate Fecal Calprotectin Besides IBD

Fecal calprotectin can be elevated in various conditions other than IBD, including:

• Infectious gastroenteritis 2, 3
• Colorectal neoplasia 4
• NSAID use within the past 6 weeks 2
• Hemorrhoids - as specifically noted in clinical guidelines 1

Hemorrhoids and Calprotectin Elevation

When patients present with rectal bleeding, the National Comprehensive Cancer Network (NCCN) guidelines specifically mention that:

• Hemorrhoids should be considered as a potential cause of gastrointestinal bleeding that can affect calprotectin levels 1
• Patients presenting with blood in the stool should be evaluated for multiple causes, including hemorrhoids, before attributing elevated calprotectin solely to IBD 1

Clinical Approach to Interpreting Calprotectin in Patients with Hemorrhoids

When interpreting calprotectin results in patients with hemorrhoids:

• Consider that acute bleeding from hemorrhoids may cause falsely elevated calprotectin levels 1, 3
• In acute presentations with rectal bleeding, flexible sigmoidoscopy is indicated regardless of calprotectin result to distinguish between hemorrhoids and IBD 3
• For patients with mild symptoms and elevated calprotectin (>150 μg/g), the American Gastroenterological Association suggests endoscopic assessment rather than empiric IBD treatment 1

Practical Recommendations

For accurate interpretation of calprotectin results when hemorrhoids are suspected:

• Document the presence of hemorrhoids during clinical examination 1
• Consider repeat calprotectin testing after hemorrhoidal bleeding has resolved 3
• Use higher thresholds (between 100-250 μg/g stool) to improve positive predictive value for IBD 2
• Remember that in patients with moderate to severe symptoms suggestive of IBD flare, fecal calprotectin >150 μg/g reliably suggests moderate to severe endoscopic inflammation 1

Important Caveats

• Fecal calprotectin has limited specificity for IBD as it can be elevated in multiple conditions including hemorrhoids 4, 2
• In acute diarrhea, calprotectin is likely to be elevated and will not discriminate between IBD and other causes, making endoscopic evaluation necessary 3
• For patients with rectal bleeding, calprotectin is not sensitive enough to exclude colorectal cancer, and cancer pathway referral should be strongly considered rather than relying solely on calprotectin 3