A recent study (E Van de Vijver et al. Pediatrics 2020; 146: e20192235) shows a logical approach for testing children with diarrhea and abdominal pain.

Abstract and video abstract link: Test Strategies to Predict Inflammatory Bowel Disease Among Children With Nonbloody Diarrhea

Methods:

• Prospective cohort study: n=193, 6 to 18 years who underwent a standardized diagnostic workup.
• Patients with rectal bleeding or perianal disease were excluded because the presence of these findings prompted endoscopy regardless of their biomarkers.
• In addition to symptoms, objective measures included C-reactive protein (>10 mg/L), hemoglobin (<−2 SD for age and sex), and fecal calprotectin (≥250 μg/g).

Key findings:

• Twenty-two of 193 (11%) children had IBD
• “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.“

My take: The approach advocated by the authors of reserving a diagnostic endoscopy for children at high risk for IBD based on stool tests/blood tests in addition to symptoms has merit.  I would add a couple caveats:

1. In this population, I would recommend checking for celiac disease (eg. tissue tranglutaminase IgA antibody, serum IgA level)
2. I think in individuals with ‘borderline’ elevations of calprotectin (50-250 μg/g), followup testing is needed and if remains persistently elevated, then ileocolonoscopy is likely warranted.  (Calprotectin values in younger children tend to be higher -so this approach is best suited in children >5 years of age)

Related blog posts:

• Our Study: Provider Level Variability in Colonoscopy Yield
• Narrowing the Workup for Chronic Abdominal Pain –Carlo DiLorenzo was Right!
• #NASPGHAN19 Postgraduate Course (part 3
• Improving the Value of Pediatric Colonoscopy

• Quality Metrics in Pediatric Colonoscopy
• Colonoscopy and Isolated Abdominal Pain = Low Value Care
• “Sub-10-minute High-quality Diagnostic Colonoscopy”
• Head-to-Head: Capsule Endoscopy versus Colonoscopy
• Why Are So Many “Low Value” Endoscopies Performed?
• Trying to make Cents out of Value Care
• “Show Don’t Tell” –Colonoscopy Prep Instructions
• Adverse Events Following Pediatric Endoscopy –Underestimated Previously
• Does negative testing reassure patients? | gutsandgrowth