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Digestive and Liver Disease 36 (2004) 467–470Alimentary TractDiagnostic value of faecal calprotectin in paediatricgastroenterology clinical practiceR. Berni Canania,∗, L. Rapacciuoloa, M.T. Romanoa, L. Tanturri de Horatioa,G. Terrina, F. Mangusob, P. Cirilloa, F. Paparoa, R. TronconeaaDepartment of Pediatrics, University Federico II of Naples, Via S. Pansini, 5, 80131 Naples, ItalybDepartment of Clinical and Experimental Medicine, University Federico II of Naples, 80131 Naples, ItalyReceived 3 November 2003; accepted 2 February 2004Available online 30 April 2004AbstractBackground.Faecal calprotectin (FC) is a new marker of intestinal inflammation. Data on FC in paediatric gastroenterology clinicalpractice are still scarce.Aims.To assess FC values in different paediatric gastrointestinal diseases comparing them with those obtained in healthy children.Patients.Two hundred and eighty-one children (age range 13–216 months) consecutively referred for gastrointestinal symptoms. Seventy-sixhealthy controls (age range 13–209 months). The exclusion criteria in healthy children were the following: any known underlying chronicdisease or a history of abdominal pain, diarrhoea, acute respiratory tract infection, intake of non-steroidal anti-inflammatory drugs, gastricacidity inhibitors, antibiotics, drugs influencing gut motility, and menstrual or nasal bleeding in the last 3 weeks.Methods.Stool samples stored, prepared and analyzed by an ELISA assay.Results.In healthy children the median FC value was 28.0g/g (15–57 interquartile range) with a 95th percentile value of 95.3g/g. Anincrease in FC concentration was observed in all diseases characterized by gastrointestinal mucosa inflammation, and the active inflammatorybowel disease patients showed the higher FC values. All children affected by functional bowel disorders or by non-inflammatory diseasesshowed normal values. We calculated an optimized FC cut off value of 102.9266g/g (revealed by the receiver operating characteristic curve)to distinguish patients with active organic/inflammatory disorders from healthy subjects and from patients with functional bowel disorders.Conclusions.Calprotectin is a sensitive, but not disease specific, marker to easily detect inflammation throughout the whole gastrointestinaltract. It may help in identifying an organic disease characterized by intestinal mucosa inflammation and in the differential diagnosis of functionalbowel disorders.© 2004 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.Keywords:Functional bowel disorders; Gut inflammation; Inflammatory bowel diseases1. IntroductionTesting children with gastrointestinal symptoms whilelimiting the number of expensive and invasive proceduresis a continuous challenge in paediatric clinical practice,e.g. to distinguish between functional disorders and aprodromal period of inflammatory bowel disease (IBD).A number of leukocyte-derived proteins have been pro-posed as non-invasive inflammation bio-markers, includ-ing eosinophilic cationic protein (ECP), elastase, esterase,∗Corresponding author. Tel.:+39-081-7462680;fax:+39-081-5451278.E-mail address:berni@unina.it (R. Berni Canani).myeloperoxidase, lysozyme, lactoferrin, and calprotectin[1–3]. Compared to these other candidates, calprotectinmay offer performance advantages based on its biologicalcharacteristics. Specifically, this 36.5-kDa non-glycosylatedpolypeptide accounts for up to 60% of the cytosolic proteinsfound in neutrophils and macrophages[4,5]. Additionally,calprotectin is stable in the stools for more than seven dayswhich may be at least in part due to the high Ca2+concen-tration in gut lumen, which makes it resistant to proteolyticdegradation[2,6]. Experiences with IBD children are en-couraging and suggest that faecal calprotectin (FC) providesreliable information in the routine diagnostic work-up[7,8].However, data on FC in other common gastrointestinal pae-diatric diseases are still scarce. The purpose of this study1590-8658/$30 © 2004 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.dld.2004.02.009
468R. Berni Canani et al. / Digestive and Liver Disease 36 (2004) 467–470Table 1Main demographic characteristics of the study subjectsNo.MaleMedian age,months (range)Controls763578.6 (13–216))Functional disorders441660.3 (13–151)Crohn’s disease6846150.0 (137–209)Ulcerative colitis4533159.0 (101–216)Allergic colitis371243.6 (24–96)Coeliac disease381737.4 (15–81)Polyposis52125.0 (81–168)Acute Gastroenteritis14524.8 (14–38)Gastroesophageal reflux disease17669.5 (13–123)Pouchitis54122.0 (105–210)Hirshsprung’s disease4321.0 (13–32)Congenital chloride diarrhoea2286.0 (70–103)Bile salt malabsorption2214 (13–15)was to assess FC values in common gastrointestinal diseasesin paediatric clinical practice comparing them with thoseobtained in healthy subjects. In addition, reference FC val-ues for healthy children were also presented for convenientuse in clinical practice.2. Patients and methodsChildren (age range 13–216 months) consecutively re-ferred to our department for gastrointestinal symptomswere invited to participate in the study. Two hundred andeighty-one children with gastrointestinal diseases were en-rolled. As controls, a faecal sample was obtained from 76healthy children. These subjects were recruited from chil-dren visiting our department for routine examination andalso from families of our staff. The exclusion criteria werethe following: any known underlying chronic disease ora history of abdominal pain, diarrhoea, acute respiratorytract infection, intake of non-steroidal anti-inflammatorydrugs, gastric acidity inhibitors, antibiotics, drugs influenc-ing gut motility, and menstrual or nasal bleeding in the last3 weeks. The main demographic characteristics of the en-rolled children are reported inTable 1. In children affectedby IBD, coeliac disease or allergic colitis, established clin-ical, laboratory, endoscopic and histological criteria wereused in the initial diagnosis and to assess disease activity[9–11]. In children affected by functional disorders thediagnosis was made using the Rome II criteria[12]. Onestool specimen was collected by each subject using a dis-posable plastic bucket-type device to avoid contact withtoilet water and simplify laboratory sampling. In childrenwith diapers, stools were collected directly from the bottominto a test tube to avoid water absorption by the diaperswhich may increase FC value[2]. Only pre-endoscopy fae-cal samples were analyzed. Samples were stored at−20◦Cand thawed at room temperature before testing. The FCvalues were analyzed by a commercially available ELISAassay (Calprest®, Eurospital Spa, Trieste, Italy), as previ-Table 2Faecal calprotectin values in paediatric gastrointestinal diseasesDiseaseNMedian faecal calprotectinvalues (range)Gastroesophageal reflux disease17138∗(49–300)Acute gastroenteritis14110∗(0.3–244)Polyposis5229∗(157–240)Hirschprung’s disease513.7 (8–36)Pouchites4256.7∗(125–318)Bile salt malabsorption214.5 (3–28)Congenital chloride diarrhoea220.4 (7–41)Controls7628 (1–113)∗P<0.001 vs. controls.ously reported[3,13]. Using this method a coefficient of19.1% of day-to-day variation in FC values was previouslyreported in a paediatric population[4]. Informed consentwas obtained from the parents of all subjects. The protocolwas approved by the Ethics Committee of our Institution.The statistical analysis was performed using the SPSSsoftware package for Windows (release 11.5.2.1, 4 Apr2003; SPSS Inc., Chicago, Ill., USA). Faecal calpro-tectin values in the different groups were compared byMann–WhitneyUtest and by the Kruskal–WallisHtestwith the Dunn test for the post hoc analysis. All tests ofsignificance were two-sided. APvalue of 0.05 or less wasconsidered significant. Simple regression analysis was usedto assess the correlation between FC concentration andage in healthy controls. The ROC curve was obtained withStatsDirect statistical software (release 2.3.3, 15 September2003).3. ResultsThe FC values in healthy children and in patients withvarious gastrointestinal disorders are reported inFig. 1andinTable 2. In healthy children the median FC value was28.0g/g (15–57 interquartile range). There were no dif-ferences in FC values attributable to age or sex. The 5th,50th and 95th percentile FC values in healthy controls were3.0, 28.0 and 95.3g/g, respectively. Children with activeIBD, defined by clinical, endoscopic and histological pa-rameters, showed significantly higher FC values comparedwith those obtained in healthy children(P<0.001)or inIBD subjects in remission(P<0.001). In addition, in fivechildren affected by active pouchitis we observed a sig-nificant increase of FC values, as reported inTable 2.Onthe contrary, IBD children in clinical remission showed FCvalues not statistically different from the controls (Fig. 1).Similarly, children with active allergic colitis or coeliac dis-ease showed significantly higher FC values compared withcontrols(P<0.001)and a reducing pattern toward normalvalues after at least 4 weeks of exclusion diet (P<0.001active versus remission), as shown inFig. 1. Patients withacute gastroenteritis (10Rotavirus,2Salmonella enteritidis,