What is the diagnosis and management plan for a patient with intermittent loose stools, triggered by spicy food and stress, with mild elevation of fecal calprotectin?

Diagnosis and Management of Intermittent Loose Stools with Fecal Calprotectin 4.5 μg/g

This patient most likely has irritable bowel syndrome (IBS), not inflammatory bowel disease (IBD), and should be managed with dietary modifications, stress management, and symptom-directed therapy rather than endoscopic evaluation or IBD-specific treatment.

Interpretation of Fecal Calprotectin

The fecal calprotectin level of 4.5 μg/g is extremely low and essentially rules out active intestinal inflammation:

• A calprotectin <50 μg/g has a high negative predictive value for IBD, making it excellent for ruling out inflammatory bowel disease in symptomatic patients 1, 2
• The AGA guidelines specify that calprotectin <150 μg/g reliably rules out active inflammation in patients with UC, and this patient's value is far below even the most sensitive threshold 3
• At a cutoff of 50 μg/g, fecal calprotectin has 90.6% sensitivity for detecting endoscopically active disease, meaning this patient's value of 4.5 μg/g makes IBD highly unlikely 1

Clinical Diagnosis

The symptom pattern strongly suggests IBS rather than IBD:

• Intermittent loose stools triggered by specific dietary factors (spicy food) and stress are classic features of IBS, not IBD 3
• The absence of alarm features (no mention of blood, weight loss, or nocturnal symptoms) combined with the normal calprotectin supports a functional diagnosis 3
• Fecal calprotectin consistently differentiates IBD from IBS because of its excellent negative predictive value 4, 5

Management Approach

No endoscopic evaluation is needed at this time given the extremely low calprotectin and functional symptom pattern 3:

Dietary Interventions

• Implement a low FODMAP diet as first-line dietary management for functional GI symptoms, with careful attention to nutritional adequacy 3
• Advise avoidance of known triggers (spicy foods in this case) 3

Stress Management

• Recommend psychological therapies including cognitive behavioral therapy, hypnotherapy, or mindfulness therapy, as these are evidence-based treatments for IBS symptoms triggered by stress 3
• Physical exercise should be encouraged as it benefits functional GI symptoms 3

Pharmacologic Options if Needed

• Hypomotility agents or bile-acid sequestrants may be used for chronic diarrhea if dietary and stress management are insufficient 3
• Antispasmodics can be considered for abdominal pain if present 3
• Avoid opiates for symptom management 3

When to Reconsider IBD

Repeat fecal calprotectin measurement is warranted only if:

• Symptoms worsen significantly or change character (development of nocturnal diarrhea, blood in stool, weight loss) 3
• Symptoms fail to respond to IBS-directed management 3
• New alarm features develop that would require endoscopic assessment regardless of calprotectin 1

Important Caveats

• While this patient's presentation is consistent with IBS, ensure no alarm features are present (rectal bleeding, unintentional weight loss, family history of colorectal cancer or IBD, age >50 with new symptoms) 1
• NSAID use can affect calprotectin levels, though this is more relevant for elevated values 1
• Serial monitoring at 3-6 month intervals is not necessary in this case given the extremely low baseline value and functional symptom pattern 3