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Test Strategies to Predict Inflammatory Bowel Disease Among Children With Nonbloody Diarrhea
Els Van de Vijver1, Anke Heida2, Solomon Ioannou3
1Department of Paediatric Gastroenterology, Hepatology, and Nutrition, University Hospital Antwerp, Edegem, Belgium; els.vandevijver@uza.be.
Insights
A new diagnostic strategy combining symptoms with blood and stool markers accurately predicts inflammatory bowel disease (IBD) in children. This approach helps reserve endoscopy for high-risk pediatric patients, improving diagnostic efficiency.
Area of Science:
- Pediatric Gastroenterology
- Diagnostic Accuracy
- Inflammatory Bowel Disease Research
Background:
- Chronic nonbloody diarrhea and abdominal pain are common symptoms in children, often necessitating differentiation between various gastrointestinal conditions.
- Inflammatory Bowel Disease (IBD) requires timely diagnosis and management, but diagnostic uncertainty can lead to invasive procedures.
- Current diagnostic pathways may benefit from refined strategies to improve accuracy and resource allocation.
Purpose of the Study:
- To evaluate four distinct diagnostic strategies for predicting IBD in pediatric patients presenting with chronic nonbloody diarrhea and abdominal pain.
- To determine the optimal combination of clinical symptoms, blood markers, and fecal markers for IBD diagnosis in children.
- To assess the potential of a refined diagnostic approach to reduce unnecessary endoscopic procedures.
Main Methods:
- A prospective cohort study involving 193 children (aged 6-18 years) with chronic nonbloody diarrhea and abdominal pain.
- Assessment included patient symptoms, C-reactive protein, hemoglobin levels, and fecal calprotectin.
- Exclusion criteria were rectal bleeding or perianal disease, which mandated immediate endoscopy.
Main Results:
- The study found that combining symptoms with blood (hemoglobin) and stool (fecal calprotectin) markers significantly improved the diagnostic accuracy (AUC 0.997) for IBD compared to symptoms alone (AUC 0.718).
- A triaging strategy incorporating symptoms, blood, and stool markers would expose 14% of patients to endoscopy, with a minimal false negative rate for IBD.
- This integrated approach demonstrated superior performance in identifying children with IBD.
Conclusions:
- The optimal diagnostic strategy for pediatric IBD suspicion involves evaluating clinical symptoms alongside blood and stool markers.
- This approach enables pediatricians to judiciously reserve diagnostic endoscopy for children identified as high-risk for IBD.
- Implementing this strategy enhances diagnostic precision and potentially reduces the burden of invasive procedures on children without IBD.
Objectives:
We evaluated 4 diagnostic strategies to predict the presence of inflammatory bowel disease (IBD) in children who present with chronic nonbloody diarrhea and abdominal pain.
Methods:
We conducted a prospective cohort study including 193 patients aged 6 to 18 years who underwent a standardized diagnostic workup in secondary or tertiary care hospitals. Each patient was assessed for symptoms, C-reactive protein (>10 mg/L), hemoglobin (<-2 SD for age and sex), and fecal calprotectin (≥250 μg/g). Patients with rectal bleeding or perianal disease were excluded because the presence of these findings prompted endoscopy regardless of their biomarkers. Primary outcome was IBD confirmed by endoscopy or IBD ruled out by endoscopy or uneventful clinical follow-up for 6 months.
Results:
Twenty-two of 193 (11%) children had IBD. The basic prediction model was based on symptoms only. Adding blood or stool markers increased the AUC from 0.718 (95% confidence interval [CI]: 0.604-0.832) to 0.930 (95% CI: 0.884-0.977) and 0.967 (95% CI: 0.945-0.990). Combining symptoms with blood and stool markers outperformed all other strategies (AUC 0.997 [95% CI: 0.993-1.000]). Triaging with a strategy that involves symptoms, blood markers, and calprotectin will result in 14 of 100 patients being exposed to endoscopy. Three of them will not have IBD, and no IBD-affected child will be missed.
Conclusions:
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.
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