What is the best course of action for a 24-year-old patient with a history of gastrointestinal issues, currently on medication for inflammatory bowel disease (IBD), experiencing ongoing symptoms of hematochezia, abdominal cramps, diarrhea, fatigue, and mucous in stool, who needs a repeated calprotectin test due to a lost pathology report?

Immediate Management for This Patient

This 24-year-old patient with established IBD, ongoing symptoms for 4 months including hematochezia, and a previously elevated calprotectin requires urgent gastroenterology referral and repeat calprotectin testing while awaiting endoscopic evaluation. 1

Repeat Calprotectin Testing

Order a repeat fecal calprotectin test immediately using the first morning stool sample, analyzed within 3 days at room temperature. 1, 2 This patient meets criteria for urgent testing given:

• Rectal bleeding plus abdominal pain, diarrhea, weight loss, and 4-month symptom duration - all red flag features requiring urgent gastroenterology referral per British Society of Gastroenterology guidelines 1
• Known IBD with active symptoms - calprotectin should be measured every 2-4 months in patients being treated for active symptoms 3
• Previous elevated calprotectin - this establishes the patient as a "responder" whose calprotectin reliably correlates with disease activity 1, 3

Concurrent Laboratory Workup

While arranging calprotectin testing and gastroenterology referral, obtain these baseline tests immediately: 1, 2

• Complete blood count - assess for anemia from chronic bleeding and thrombocytosis indicating inflammation 2
• Urea and electrolytes - evaluate for dehydration and electrolyte abnormalities from diarrhea 2
• C-reactive protein - complementary inflammatory marker (though 20% of active Crohn's patients may have normal CRP) 2
• Stool culture - exclude infectious causes that could mimic or complicate IBD flare 1, 2

Urgent Gastroenterology Referral

Refer urgently to gastroenterology for colonoscopy regardless of the repeat calprotectin result. 1 This patient requires endoscopic assessment because:

• Moderate-to-severe symptoms (hematochezia, abdominal cramps, weight loss) persisting 4 months indicate likely active inflammation requiring direct visualization 1, 2
• British Society of Gastroenterology guidelines mandate urgent referral for patients aged 16-40 with rectal bleeding plus any combination of abdominal pain, change in bowel habit, or weight loss 1
• Previous elevated calprotectin with ongoing symptoms suggests treatment failure or inadequate disease control requiring endoscopic reassessment 1, 3

Interpreting the Repeat Calprotectin Result

When the repeat calprotectin result returns, interpret as follows:

If Calprotectin >250 μg/g:

• Active inflammation is highly likely - this threshold has 78.2% specificity for endoscopic disease 2, 4
• Proceed urgently with colonoscopy and consider treatment escalation based on endoscopic findings 1, 4

If Calprotectin 100-250 μg/g:

• Inflammation is possible - this intermediate range requires endoscopic confirmation 1, 2
• Do not delay colonoscopy given the patient's moderate-to-severe symptoms 2

If Calprotectin <100 μg/g:

• Still proceed with colonoscopy given the clinical picture 1, 2
• Consider alternative diagnoses including bile acid malabsorption, microscopic colitis, or medication effects, but do not assume symptoms are non-inflammatory without endoscopic confirmation 1

Critical Pitfalls to Avoid

Do not treat empirically without endoscopy in this patient. 3 The American Gastroenterological Association specifically recommends endoscopic assessment rather than empiric treatment adjustment for patients with mild symptoms and elevated calprotectin >150 μg/g. 3, 2 This patient has moderate-to-severe symptoms making endoscopy even more essential.

Do not delay referral waiting for calprotectin results. 1 The combination of hematochezia, 4-month symptom duration, weight loss, and previous elevated calprotectin mandates urgent gastroenterology evaluation regardless of the repeat test result. 1, 2

Assess for systemic illness requiring hospitalization. 1 If the patient develops fever, severe abdominal pain, distention, or signs of acute severe colitis, admit for urgent inpatient assessment rather than outpatient referral. 1

Monitoring After Initial Assessment

Once endoscopy is completed and treatment adjusted:

• Repeat calprotectin every 2-4 months while treating active symptoms 3
• Once symptomatic remission achieved, monitor every 6-12 months 3
• Target calprotectin <150 μg/g to confirm mucosal healing in established remission 3, 2
• Consider calprotectin <50 μg/g as the target if recently achieved remission (within 1-3 months) to detect endoscopic improvement 3