Relevance of fecal calprotectin and lactoferrin in the post-operative management of inflammatory bowel diseases

Abstract

The role of fecal lactoferrin and calprotectin has been extensively studied in many areas of inflammatory bowel disease (IBD) patients’ management. The post-operative setting in both Crohn’s disease (CD) and ulcerative colitis (UC) patients has been less investigated although few promising results come from small, cross-sectional studies. Therefore, the current post-operative management still requires endoscopy 6-12 mo after intestinal resection for CD in order to exclude endoscopic recurrence and plan the therapeutic strategy. In patients who underwent restorative proctocolectomy, endoscopy is required whenever symptoms includes the possibility of pouchitis. There is emerging evidence that fecal calprotectin and lactoferrin are useful surrogate markers of inflammation in the post-operative setting, they correlate with the presence and severity of endoscopic recurrence according to Rutgeerts’ score and possibly predict the subsequent clinical recurrence and response to therapy in CD patients. Similarly, fecal markers show a good correlation with the presence of pouchitis, as confirmed by endoscopy in operated UC patients. Fecal calprotectin seems to be able to predict the short-term development of pouchitis in asymptomatic patients and to vary according to response to medical treatment. The possibility of both fecal markers to used in the routine clinical practice for monitoring IBD patients in the post-operative setting should be confirmed in multicentric clinical trial with large sample set. An algorithm that can predict the optimal use and timing of fecal markers testing, the effective need and timing of endoscopy and the cost-effectiveness of these as a strategy of care would be of great interest.

Keywords: Calprotectin; Lactoferrin; Fecal markers; Inflammatory bowel disease; Post-operative; Surgery; Crohn’s disease; Ulcerative colitis

Core tip: Inflammatory bowel diseases (IBDs) are chronic conditions, requiring life-long therapy and monitoring. Surgery is not curative and the disease might recur after operation as post-operative recurrence in Crohn’s disease patients and pouchitis in ulcerative colitis patients. In both cases, endoscopy with histology is the gold standard procedure to assess disease activity. Non-invasive markers of intestinal inflammation, such as fecal calprotectin and lactoferrin, might be useful in the post-operative management of IBD patients, in order to identify individuals requiring endoscopy, so that they can avoid unnecessary invasive investigations. This paper reviews the current knowledge on the use of fecal markers in this specific setting.