New guidance from the National Institute for Health and Care Excellence (NICE) advises doctors to use simple stool tests as an option to distinguish between potentially serious inflammatory bowel disease (IBD) and less serious irritable bowel syndrome (IBS). The faecal calprotectin test is used in people with recent lower gastrointestinal symptoms that could be due to either type of disorder and in whom assessment by a specialist is being considered.

Patients complaining of lower bowel symptoms such as chronic abdominal pain or discomfort, with diarrhoea or constipation, are common in family doctors' surgeries. Most patients have IBS which is a troublesome and painful condition. It typically causes abdominal pain, discomfort and bloating and although it can reduce quality of life it does not have serious effects in terms of damage to the bowel. However, some patients have IBD, which can lead to serious complications. For example, over half of people with Crohn's disease, a type of IBD, will need surgery within 10 years of diagnosis. People with IBD also have an increased risk of colorectal cancer.

The recommended tests measure the levels of the protein calprotectin which is found in inflammatory cells. The protein is traceable in stool samples for several days. When the bowel is inflamed, higher than normal levels of the protein pass through the walls of the intestine and the quantities present can be used to help distinguish between inflammatory bowel diseases and non-inflammatory bowel diseases.

The Director of the NICE Health Technology Evaluation Centre, Professor Carole Longson, says it is important to distinguish inflammatory bowel diseases from Irritable Bowel Syndrome so that patients can be appropriately managed and monitored: “Bowel disorders can be difficult to diagnose. But the treatments and outcomes can be very different. Faecal calprotectin testing helps doctors to distinguish between non-inflammatory disorders like Irritable Bowel Syndrome where sufferers will not come to serious harm and inflammatory bowel diseases such as Ulcerative Colitis or Crohn's disease - which need to be quickly referred to specialists.

“Currently a number of tests are carried out in both hospitals and GPs' surgeries to rule out conditions rather than to diagnose. This means people often face uncertainty, lots of visits to hospitals and their GP and repeated tests - some of them invasive and uncomfortable. Many people with IBD, particularly children with Crohn's disease, sometimes have to wait for several years for their condition to be diagnosed.

“Looking at the available evidence, we found that faecal calprotectin testing is a good way to distinguish between inflammatory bowel disease and Irritable Bowel Syndrome. As well as being of benefit to patients, the tests will also save the NHS money. They will reduce both the time spent searching for a diagnosis and the numbers of invasive procedures such as colonoscopy. The test is also likely to reduce the demands on colonoscopy departments which will be able to focus on people being investigated for more serious conditions such as bowel cancer.”

Because inflammatory markers are also present in bowel cancer, the draft guidance does not apply to people who are being considered for referral for suspected cancer.

The diagnostics guidance for faecal calprotectin tests for inflammatory diseases of the bowel is available on the NICE website.

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Notes to Editors

About IBS and IBD

1. Irritable Bowel Syndrome is an unexplained disorder, most commonly affecting people aged between 20 and 30 years. It is characterised by frequent bouts of bowel disturbance and abdominal discomfort. There is no clear cause, no distinctive pathology and no definitive treatment. Bouts may be triggered by diet or stress. It is a troublesome condition that interferes with activities of daily life although it does not usually have serious consequences.

2. NICE Clinical Guideline 61 (Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care) suggests the prevalence of the condition in the general population is between 10 and 20%. However the true prevalence of IBS in the whole population may be higher than estimated, because many people with IBS symptoms do not seek medical advice.

3. Inflammatory Bowel Disease is the term normally applied to a group of conditions, comprising mainly Crohn's disease and ulcerative colitis. These are diseases with serious complications, including a high risk of presentations requiring surgery, and an increased risk of colorectal cancer.

• a. Ulcerative colitis: is a relapsing and remitting disease characterised by inflammation of the colon, sometimes intense, with bloody diarrhoea, but is often much milder.
• b. Crohn's disease: can present in different ways, depending on which part of the intestinal tract is affected. Like ulcerative colitis, it is a relapsing and remitting inflammatory disease. However, it is a much more extensive disease and can affect any part of the gastrointestinal tract. Similarly to ulcerative colitis, there is a genetic susceptibility. The cause is unknown, but it appears to be commoner in those with a “westernised” lifestyle. Like ulcerative colitis, it can occur after infectious gastroenteritis and is associated with disturbances in the usual gut flora. The histological features include those similar to tuberculosis but no mycobacteria have been shown to be responsible. There are around 60,000 people with Crohn's disease in the UK, of whom 20-30% are aged under 20.
• c. the outlook in Crohn's disease is worse than in ulcerative colitis. Only 10% of people with this condition have prolonged remission.and approximately 20% require hospital admission each year, and half will require surgery within 10 years of diagnosis. Life expectancy is shown to be slightly decreased in people with Crohn's disease compared with the general population

4. Children: the pattern of symptoms in children is different and children presenting with symptoms of IBD and IBS can have a different range of conditions, making the role of faecal calprotectin testing in this group potentially less clear. The largest prospective survey in the UK and Ireland was carried out by the British Paediatric Surveillance Unit, the British Society of Gastroenterology Research Unit and the Paediatric Register of IBD. The commonest presenting symptoms of Crohn's disease were abdominal pain, weight loss and diarrhoea, but 44% did not report diarrhoea, and only 25% reported the classical triad of abdominal pain, diarrhoea and weight loss. Other symptoms at presentation included lethargy and anorexia. Paediatric IBD is often more extensive at diagnosis than in adults.

About the diagnostics guidance on faecal calprotectin testing

5. In total, 12 tests were included in the assessment conducted by the External Assessment Group.

6. The comparator is standard clinical practice in England. The main tests currently used to measure inflammation are erythrocyte sedimentation rate and C-reactive protein, which can indicate inflammation, but not localise it.

About the NICE Diagnostics Assessment Programme

1. Further information about the NICE diagnostics assessment programme can be found on the NICE website.

2. Topics to be considered by the Programme are routed through the related Medical Technologies Evaluation Programme. Further information about this can be found on the NICE website.

About NICE

The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

Formerly the National Institute for Health and Clinical Excellence, our name changed on 1 April 2013 to reflect our new and additional responsibility to develop guidance and set quality standards for social care, as outlined in the Health and Social Care Act (2012).

Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.

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