Symptoms, Biomarkers Help Predict IBD in Children With Nonbloody Diarrhea

By Will Boggs MD

July 22, 2020

NEW YORK (Reuters Health) - Symptom evaluation along with assessment of blood and stool markers is the optimal strategy for predicting inflammatory bowel disease and moving to endoscopy for children at high risk for inflammatory bowel disease (IBD), according to a prospective study.

For children with chronic abdominal pain and nonbloody diarrhea, a triage test can be useful for determining which patients are at a high risk for IBD and therefore need immediate referral to endoscopy.

Dr. Els Van de Vijver from University Hospital Antwerp, Edegem, Belgium and colleagues evaluated 4 diagnostic strategies to predict the presence of IBD in this setting: symptoms alone; symptoms plus blood markers; symptoms plus fecal calprotectin; and symptoms plus blood markers plus fecal calprotectin.

The study included 204 patients, 193 of whom continued along the decision tree until a final diagnosis was made. Ultimately, 22 children (11%) were diagnosed with IBD, including eight with ulcerative colitis and 14 with Crohn's disease.

The basic model, symptoms alone (strategy 1), predicted IBD with an accuracy of 71.8% (by AUROC). All three other strategies performed better, with discrimination accuracies increasing from 93.0% for symptoms plus blood markers (strategy 2) to 96.7% for symptoms plus calprotectin (strategy 3) to 99.7% for symptoms plus blood markers plus calprotectin (strategy 4).

Strategies 2, 3, and 4 all had 100% sensitivity, with specificities of 68.4%, 90.1%, and 96.5%, respectively, according to the online report in Pediatrics.

All IBD-affected patients were correctly exposed to endoscopy, regardless of strategy, and strategies 2, 3, and 4 correctly advised against referring 61%, 80%, and 86% of patients, respectively, for endoscopy.

In decision curve analysis, strategy 4 had the greatest net benefit for predicting IBD across the range of risk thresholds up to 70%. Strategy 1, however, provided hardly any greater net benefit than performing endoscopy in all patients or, alternatively, in no patients.

"Evaluating symptoms plus blood and stool markers in patients with nonbloody diarrhea is the optimal test strategy that allows pediatricians to reserve a diagnostic endoscopy for children at high risk for IBD," the authors conclude.

Dr. Jillian S. Sullivan from University of Vermont Children's Hospital and Larner College of Medicine in Burlington, who coauthored an editorial related to this report, told Reuters Health by email, "Clinicians should consider using this noninvasive testing strategy to predict whether a patient has inflammatory bowel disease or is more likely to have functional gastrointestinal disorders (FGID). If the testing strategy is negative or normal, inflammatory bowel disease is less likely, and it is reasonable to monitor symptoms clinically without pursuing complete endoscopic evaluation."

"However," she said, "when deciding not to pursue complete endoscopic evaluation, patients should be monitored closely for the development of alarm signs or symptoms. Additionally, upper gastrointestinal endoscopy may still be a helpful tool to evaluate for other pathologic (non-IBD) causes of abdominal pain and diarrhea in children."

Dr. Van de Vijver did not respond to a request for comments.

SOURCE: and Pediatrics, online July 21, 2020.