Fecal calprotectin: an innovative relationship between - PowerPoint Presentation

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Fecal calprotectin: an innovative relationship between inflammation and anorexia nervosaDina Moubayed MD, Pierre-Philippe Piché-Renaud MD, Camille Provost, Christophe Faure MD, PhD, Danielle Taddeo MD FRCPC, Olivier Jamoulle MD FRCPC, Jean-Yves Frappier MD FRCPC, Chantal Stheneur MD, PhDDepartment of Adolescent Medicine, CHU Sainte-Justine, Montreal, Canada

IntroductionAnorexia Nervosa (AN) is a serious, potentially lethal mental disorder characterized by a deliberate quest to reduce one’s weight through intake restriction and excessive ways to increase energy loss motivated by a disturbed body image and an intense fear of weight gain1,2. It can have important psychological and physical consequences. AN can be associated with a multitude of gastrointestinal symptoms3, but their origin is not yet fully understood. AN has been associated with changes in the gastrointestinal tract, such as intestinal permeability, microbiome and inflammation4,5.

AimsEvaluate the fecal calprotectin level (fCP), a sensitive marker of inflammation in the gastrointestinal tract, in patients with AN presenting with non-specific gastrointestinal symptoms.

MethodsIn this prospective study turned case series, we reviewed the records of five patients hospitalized at the CHU Sainte-Justine between 2015 and 2019 with no or mild gastrointestinal symptoms. They were tested for fCP to further understand the pathophysiology of AN.

Discussion Case one was the first patient identified with elevated fCP. Her underlying disease and her medication intake could be associated with that finding. Investigation yielded no cause to that elevation. Four other patients with no or mild abdominal symptoms were identified and an fCP was provided for research and academic purposes. None of the patients were diagnosed with a gastrointestinal disease and no underlying cause for the elevated fCP was found. Patients with AN often complain of nonspecific gastrointestinal symptoms, which can overlap with symptoms of other primary gastrointestinal diseases, such as inflammatory bowel disease, and comorbidity is possible6. The difference is often made with evolution of symptoms during the refeeding period. Certain changes in the gastrointestinal tract have been associated with AN, such as changes in the intestinal permeability and modification of the gut barrier and the microbiome4,5. In the presented cases, we hypothesize that an alteration of the patients’ microbiome and gut permeability could have triggered gastrointestinal inflammation and subsequently elevated fCP levels. fCP is highly sensitive for gastrointestinal inflammation, although not very specific7.

Literature Cited 1.Zipfel S, Giel KE, Bulik CM, Hay P, Schmidt U. Anorexia nervosa: aetiology, assessment, and treatment. Lancet Psychiatry. 2015;2(12):1099-111.2.Malczyk Z, Oswiecimska JM. Gastrointestinal complications and refeeding guidelines in patients with anorexia nervosa. Psychiatr Pol. 2017;51(2):219-29.3.Mitchell JE, Crow S. Medical complications of anorexia nervosa and bulimia nervosa. Curr Opin Psychiatry. 2006;19(4):438-43.4.Genton L, Cani PD, Schrenzel J. Alterations of gut barrier and gut microbiota in food restriction, food deprivation and protein-energy wasting. Clin Nutr. 2015;34(3):341-9.5.Monteleone P, Carratu R, Carteni M, Generoso M, Lamberti M, Magistris LD, et al. Intestinal permeability is decreased in anorexia nervosa. Mol Psychiatry. 2004;9(1):76-80.6.Mascolo M, Geer B, Feuerstein J, Mehler PS. Gastrointestinal comorbidities which complicate the treatment of anorexia nervosa. Eat Disord. 2017;25(2):122-33.7.Heida A, Van de Vijver E, Muller Kobold A, van Rheenen P. Selecting children with suspected inflammatory bowel disease for endoscopy with the calgranulin C or calprotectin stool test: protocol of the CACATU study. BMJ open. 2017;7(5):e015636.

Contact information:

dina.moubayed@umontreal.ca

Case 

AgeDiagnosisBMI on admission (kg/m2)Minimal weight (kg)ComorbidityMedicationGastrointestinal symptoms fCP (ug/g of feces) Investigation Weight gain at test day (kg) 113AN13.328.3(-10)Juvenile idiopathic arthritisNaproxen (d/c)MethotrexateFolic acidPrevacid Constipation, abdominal pain423Upper and lower scope, normalAnti-transglutaminase, normalhydrogen breath test, normal+2, 10 days post admission214AN18.151.7(-12)Prerenal insufficiency, resolvedNoneAnal fissure, abdominal pain438Hematest +, from anal fissureAbdominal ultrasound+0,5, 9 days post admission316AN14.939.1(-14)NoneNoneNone243None+2.7, 10 days post admission412AN16.834.4(-5)NoneNoneNone52None+, 7 days post admission517AN17.346(-7)Asthma, anxiety disorder, mild traumatic brain injuryNoneConstipation, abdominal pain124None  +0.7, 8 days post admission

Table 1: Patient characteristics and fCP levels

ConclusionThe elevated fCP in our case series opens possibilities to further explore the pathophysiology of AN and its relationship with inflammation in the gastrointestinal tract, the alteration of microbiome and the modifications in IP. The literature is scarce regarding the relationship between the gastrointestinal tract and AN, although it is a predominant aspect of the symptomatology of the disease. This warrants further research to be conducted to evaluate the effects of restriction, renutrition and weight gain on the gastrointestinal tract in AN with the role of fCP in its pathophysiology.