1. In children with chronic, non-bloody diarrhea and abdominal pain, a clinical prediction tool using symptoms, C-reactive protein (CRP), hemoglobin, and fecal calprotectin accurately predicted the presence or absence of inflammatory bowel disease (IBD).
2. This strategy may be helpful in reducing the number of unnecessary endoscopies for children with diarrhea and abdominal pain.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Children with chronic abdominal pain and non-bloody diarrhea are frequently referred for endoscopy to rule out IBD. However, these evaluations are often normal and put patients at risk for complications from the procedure and anesthesia, in addition to incurring significant financial costs. In this study, authors sought to develop clinical prediction guidelines to help determine which patients are unlikely to have IBD and can therefore forego endoscopy. Children from the Netherlands and Belgium with persistent or recurrent non-bloody diarrhea and abdominal pain were included in the study. A total of 4 diagnostic strategies were evaluated to predict IBD: (1) symptoms alone, (2) symptoms plus blood markers (CRP and hemoglobin), (3) symptoms plus fecal calprotectin, (4) symptoms plus blood markers plus fecal calprotectin. Sensitivity improved across the diagnostic strategies, with symptoms plus blood markers plus fecal calprotectin being the most sensitive for IBD. The true clinical impact of implementing these strategies is unknown since they were not evaluated using a randomized controlled trial. Furthermore, commonly tested blood markers such as albumin and erythrocyte sedimentation rate (ESR) were not included, which may make it less applicable to clinicians who rely on these markers. Nonetheless, this study’s findings suggest that a combination of history, blood, and stool markers can allow clinicians to accurately exclude IBD, reserving the use of endoscopy only for patients at highest risk for the condition.
In-Depth [prospective cohort]: A total of 193 children (55% male) aged 6 to 18 with persistent or recurrent non-bloody diarrhea were included in the study. Patients with rectal bleeding or perianal disease were excluded, since they would undergo endoscopy regardless of blood or stool study results. Patients with a fecal calprotectin >250 mcg/g underwent endoscopy with biopsies, while patients with values <250 mcg/g were re-evaluated over the next 6 months to further assess for IBD. The primary outcome was IBD confirmed by endoscopy or IBD ruled out by endoscopy or uneventful follow up during a 6-month period. Overall, 22 (11%) patients were diagnosed with IBD. Positive blood markers were defined as CRP >10 mg/L and anemia with a hemoglobin < -2 standard deviations for age and sex. Increased fecal calprotectin was defined as >250 mcg/g. Using strategies 2, 3, or 4, all 22 patients with IBD correctly underwent endoscopy. Using the pretest probability of IBD of 11% in this cohort, strategy 4 resulted in a post-test probability of IBD of 78% (95% CI 60-87%). If blood and stool markers were all negative (strategy 4), the probability of IBD was 0% (95% CI 0-4%). The sensitivity for using symptoms alone was 72.7%, while the sensitivity of strategies 2, 3, and 4 to predict IBD was 100%. The specificity of strategy 4 was superior (96.5%).
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