FECAL CALPROTECTIN FOR DETECTING POUCHITIS FOLLOWING ILEAL POUCH ANAL ANASTOMOSIS IN ULCERATIVE COLITIS PATIENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS
Tyler McKechnie*1, Yung Lee1, Colin Kruse1, Karim Ramji2,1, Aristithes Doumouras2,1, Dennis Hong2,1, Cagla Eskicioglu2,1
1McMaster University, Hamilton, ON, Canada; 2St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
Bacground: Total proctocolectomy (TPC) for ulcerative colitis (UC) patients is curative. Ileal pouch anal anastomosis (IPAA) is often performed in addition to TPC in order to restore intestinal continuity. The most common complication following TPC and IPAA for UC is pouchitis, occurring in 20 – 50% of patients. Fecal calprotectin (FC) has high sensitivity for the detection of mild mucosal inflammation and it has been proven to correlate well with the pouchitis disease activity index (PDAI). However, previously established cut-off values for FC levels for the detection of pouchitis have been variable. Therefore, the aim of this systematic review and meta-analysis is to further validate the predictive value of FC for detecting pouchitis following IPAA for UC and to establish clinically relevant cut-off values for FC for detection of pouchitis.
Methods: Search of Medline, EMBASE, CENTRAL and PubMed was performed. Articles were eligible for inclusion if they measured FC levels in the setting of pouchitis in patients who underwent TPC with IPAA for UC and reported associated sensitivity and specificity. The pooled prevalence of sensitivity and specificity was calculated using the Freeman-Tukey double arcsine transformation of proportions. The threshold for statistical significance was set a priori at P < 0.05. Quality assessment for each study was assessed using the quality assessment for studies of diagnostic accuracy studies 2 (QUADAS-2) tool.
Results: From 117 relevant citations, 7 studies (3 prospective cohorts, 2 cross-sectional studies, 2 conference abstracts) with 256 patients (44.8% female, 39.88 years) met inclusion criteria. The pooled prevalence of pouchitis was 42% (95% CI 28-57%). The derived FC cut-off value was 171.89 μg/g (SD 50.6). The pooled sensitivity and specificity for the derived cut-off were 89% (95% CI 74-98%) and 76% (95% CI 61-88%), respectively. According to the QUADAS-2 tool, risk of bias of the included studies was uniformly low throughout 80% of the included studies.
Conclusion: FC is a valid, reliable, and rapid diagnostic tool for pouchitis in patient’s status-post TPC with IPAA for UC. The high sensitivity of FC for detection of pouchitis makes it a valuable test for ruling out a diagnosis of pouchitis and can prevent unnecessary endoscopy in these patients presenting with non-specific abdominal symptoms. However, the moderate specificity means that ruling in a diagnosis of pouchitis with FC alone may be inadequate, as such endoscopy may still be required in some patients. Larger, prospective studies are required to confirm the results of this review and further examine the financial and clinical impacts of the use of FC for detecting pouchitis.
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