講題二 : 新式糞便標準化裝置於糞便檢查應用之二 : 1. 糞便鈣衛蛋白 (Faecal Calprotectin) 臨床意義及檢查 2. 糞便運鐵蛋白二合一 (FOB+TF 2in1 Rapid Test) 臨床意義及檢查 講員 : 劉呈文醫檢師身分字號 :B120850446 學歷 : 台北醫學大學醫技系經歷 : 台灣羅氏診斷設備股份有限公司業務主任現任 : 西羅亞生技有限公司行銷業務經理
腸道發炎指標糞便鈣衛蛋白檢查 (Faecal Calprotectin Test) 非侵入性腸道發炎檢查 定量數值精準反應腸道發炎 只須採取糞便 講員 : 劉呈文醫檢師學歷 : 台北醫學大學醫技系經歷 : 台灣羅氏診斷設備股份有限公司現任 : 西羅亞生技有限公司行銷業務經理
Calprotectin: Biological Characteristics Background: Abundant: Stable: Complex: Belongs to the S-100 protein family (also known as MRP8/14) Makes up to 60% of total protein concentration in the cytosol fraction in neutrophil granulocytes & macrophages (white blood cells) Resists enzymatic degradation Stable in stools for up to 3~5 days at room temperature. Supports anti-microbial activity (against bacteria & fungi) Hetero-dimeric protein, 2 heavy and 1 light chain
An inflammatory protein Complex from neutrophil With a broad apoptosis- Inducing and Growth- Inhibitory activities. Blood: Rheumatoid arthritis Cystic fiborsis, Abscesses Feces: IBD Ascites : SBP
IBD / IBS differentiation in early disease can be challenging, resulting in delayed treatment for IBD patients No defined biomarker for IBS is available Clinical features of IBD & IBS overlap, esp. early in disease course* 1 3 or more years to diagnose IBD Wait and see approach results in: o Negative impact on patient QoL o Urgent hospital visits o Increased health care costs o Disease progression o Inappropriate treatment regimens Dyspepsia ( 消化不良 ) Irritable bowel syndrome ( 大腸激躁症 ) *Manning IBS criteria are non-specific IBS Rome I & II: 12 wks past yr with abdominal pain and 2/3 of: 1) Relief with defecation 2) Change in frequency of stools 3) Change in appearance of stools IBD (Inflammator y Bowel Disease 腸道發炎疾病 ) Carbohydrate intolerance ( 碳水化合物不耐症 ) Gut 2000;47:506
Irritable bowel syndrome ( 大腸激躁症 ) IBD (Inflammatory Bowel Disease 腸道發炎疾病 ) Dyspepsia ( 消化不良 ) Carbohydrate intolerance ( 碳水化合物不耐症 )
What is the disease association of calprotectin? Calprotectin in stool specifically indicates intestinal inflammation and is elevated in inflammatory bowel diseases (IBD). The most frequent IBD are Crohn s disease and ulcerative colitis. Crohn s disease ( 克隆氏症 ): 主要侵犯大小腸 Ulcerative colitis ( 潰瘍性結腸炎 : 主要侵犯大腸 Fecal calprotectin levels are normal in non-inflammatory intestinal disorders, such as irritable bowel syndrome (IBS) and other functional bowel diseases (e.g. infections, lactose intolerance, food allergy, etc.) 7
IBD 內視鏡檢查 - 小腸鏡 病理組織診斷 影像檢查 : 核磁共振, 電腦斷層, 瘻管攝影 Symptoms and Clinical Findings Invasive Examinations Quantitative Faecal Calprotectin Testing : cut-off 50 ug/g
臨床意義 (Clinical Data Interpretations) Normal values below 50 µg/g: <50 µg/g 表示非腸道發炎, 患者可能不需要侵入性檢查確認發炎的原因 Elevated values between 50 and 200 µg/g: 50-200 µg/g 表示輕度的器官性疾病, 建議可能重覆一次的鈣衛蛋白檢驗或進一步的檢查 Elevated values above 200 µg/g: >200 µg/g 表示活動性狀態的發炎性腸道疾病, 專家建議進一步檢查與治療
姓名 : 病歷號碼 : 寄達日期 : 編號 : 醫師姓名 : 報告日期 : 治療週數 : 送測單位 : 分析項目送檢項目 ( 打 V ) 分析樣本 1. Faecal Calprotectin 定量 ( High Range 高範圍 ) 2. Faecal Calprotectin 定量 ( Low Range 低範圍 ) ( ) ( ) Feces ( 糞便 ) Feces ( 糞便 ) 送檢單位 : 送檢地址 : 送檢電話 : 送檢傳真 : 聯絡人 : 送檢性質 : 備註 : 臨床上建議治療中的檢體選用高範圍 (High Range) 定量, 腸躁症 (IBS) 與腸道發炎疾病 (IBD) 之鑑別則選用低範圍 (Low Range) 定量
BÜ HLMANN fcal ELISA and Quantum Blue Applications for Mucosal Healing in UC Lobaton T. et al. 2012
Calprotectin 1395 ug/g Colonoscopy / SBFT?
中國 _ 中山 以鈣衛蛋白做為區別發炎性腸道疾病及 大腸激躁症的新生物指標 Faecal Calprotectin as a Novel Biomarker for Differentiating between Inflammatory Bowel Disease and Irritable Bowel Syndrome 11.22.13 _MMR Accepted CSUH & CMUH, GI Doctors : Dr.Lin & Dr.Chou
The ROC curve for faecal calprotectin in CD(A) and UC(B).The AUC 0.925, 95% CI 0.84 1.00, asymptotic significancep<0. 0001(A), and the AUC 0.939,95% CI 0.869 1.01, asymptotic significancep<0. 0001(B).
The faecal calprotectin levels (log scale) in the examined groups, the cut-off was 50 μg/g. The median value of faecal calprotectin in the CD and UC groups were increased whencompared with the IBS or normal control groups. ***P< 0.0001, ** P< 0.001. 鈣衛蛋白有極佳的 NPV( 陰性預測值 ) 以排出懷疑有臨床症狀的 IBD 患者
林口長庚 糞便鈣衛蛋白應用在兒童感染性腹 瀉的臨床嚴重度評估和區分細菌性 或病毒病原體感染評估的相關標記 Faecal Calprotectin as a Correlative Marker in Clinical Severity of Infectious Diarrhea and Usefulness in Evaluating Bacterial or Viral Pathogens in Children Chen, Chien-Chang*; Huang, Jing-Long ; Chang, Chee-Jen ; Kong, Man-Shan*
FIGURE 1. A, Grouped samples of fecal calprotectin (μg/g feces) in children with gastroenteritis caused by different pathogens, which include the following: rotavirus, norovirus, adenovirus, Salmonella, Campylobacter infection, and healthy control children. The mean fecal calprotectin level was higher in Salmonella- or Campylobacter-infected patients but lower in patients with rotavirus, adenovirus, or norovirus infections. B, Collectively, the same grouped samples of fecal calprotectin (μg/g feces) in children with gastroenteritis caused by viral pathogen or bacterial pathogen, and healthy control children. (Horizontal line: mean; *P < 0.05; #P > 0.05.)
2014_AOCC_POSTER_ 台大 _ 馬偕 _ 中國 _ 中山
IBD Comparsions ITEMS Calprotectin (ug/g) CRP (mg/dl) ESR (mm/hr) α-1-anti- Trypsin Stool Test(A1-AT) Sensitivity (%) Specificity (%) PPV (%) NPV (%) Remark 90 95 94 89 Organic Specific/ Bowel WBC/ Non-Invasive 62 95 92 71 Systemic Inflammtion/ Normalized by Steroid/ Non-Specific/ Invasive 86 75 77 84 Systemic Inflammation/ Non-Specific/ Invasive Protein-losing enteropathy (PLE)/ Mucosal Damage
BOWEL WBC BOWEL SPECIFIC
BÜ HLMANN Calprotectin Tests ( 必爾曼鈣衛蛋白檢測 ) FIRST CHOICE FOR TRUSTED DIAGNOSTIC SOLUTIONS - Gold Standard in Faecal Calprotectin Testing - 23 Siloam Biotech Co.,LTd
1. 2. 3. 4. 反覆滾動 填滿前端插回管體栓緊送檢
THE BÜ HLMANN Quantum Blue Quantitative POINT OF CARE TESTING(QPOCT) 量子藍定量分析儀 -Precise measurement of lateral flow test strips -Documented results -Memory for 100 results -Mobile stand alone device -USB PC-Interface
fcal ELISA Automation and Packages( 全自動 ) Extraction tools On board first dilutions Competent support Price packages Speedy CE mark protocols Available on most ELISA Automatic Readers
物聯網 IBDoc Calprotectin Home Test ( 愛必達客行動裝置檢測系統 )
鈣衛蛋白轉檢計畫說明書 病人看診 開立委託代檢單 採糞便至定量採便器中 ( 採便說明書 ) 將採便器放入保麗龍盒中 將保麗龍盒及委託代檢單一同放入紙盒中並填寫好宅急便快遞單 ( 益揚提供 ) 放置室溫 電話通知宅急便收取檢體 ( 到付 ) ( 外縣市 ) 或通知益揚收取檢體 ( 台北縣市 ) 或親自送達益揚基因檢測中心 ( 台北市民權東路六段 180 巷 6 號 5 樓 TEL:02-2790-4473) 益揚收到檢體後 3 至 5 個工作天內先以傳真發檢驗報告, 同時寄出檢驗報告 結算檢驗費用
糞便潛血 / 運鐵蛋白 二合一快速檢驗 ifob+itf_2in1 Rapid Test ( 血紅蛋白 + 運鐵蛋白 ) 講員 : 劉呈文醫檢師學歷 : 台北醫學大學醫技系經歷 : 台灣羅氏診斷設備股份有限公司現任 : 西羅亞生技有限公司行銷業務經理
免疫法 ELISA(LFIA)_ 抗原抗體反應原理
應用於免疫法檢測之人體血液中特有蛋白 上消化道出血會出現偽陰性 半套 The false-negative results of immunochemical tests occur because Hb derived from the upper digestive tract is broken down in the intestinal tract. Therefore, the antigenicity of Hb is lost and cannot be detected by the immunochemical occult blood test A COMPARATIVE STUDY OF THREE FECAL OCCULT BLOOD TESTS IN UPPER GASTROINTESTINAL BLEEDING Kaohsiung J Med Sci 2006;22:223 8
抗胃酸, 消化酵素, 腸內細菌之分解 全套 Tf is a glycoprotein that is highly resistant to bacterial degradation as well as to breakdown by digestive enzymes, and Tf was found to be the most stable, suggesting that it could perhaps be used as a marker of GI bleeding. In Miyoshi s studies, suggesting that Tf is stable in feces A COMPARATIVE STUDY OF THREE FECAL OCCULT BLOOD TESTS IN UPPER GASTROINTESTINAL BLEEDING Kaohsiung J Med Sci 2006;22:223 8
糞便潛血方法比較表 方法化學法免疫法 ifob 免疫法 ifob+tf 原理 利用血紅素中之部分結構 Heme 具有過氧化酶的活性, 而使氧化還原反應進行顏色變化 免疫層析法, 只針對人類糞便免疫層析法只針對人類糞便中的中的人類血紅素 (Heomglobin, 人類血紅素 (Heomglobin,Hb) Hb) 進行反應及運鐵蛋白 (Transferrin,TF) 食物影響 藥物影響 受動物血 紅肉 某些水果及蔬菜 受維他命 C 及阿斯匹靈等影響 不受食物影響 不受藥物影響 偽陽性高低低 不受食物影響 不受藥物影響 臨床應用 因不受血紅素抗原性被細菌及胃酸破壞的影响, 適合檢測上 下消化道出血 因人類血紅素易受消化系統中胃酸及糞便中細菌分解而失去其構型, 導致以免疫法檢測時, 較不易被抗體辨識而反應 適用下消化道出血 運鐵蛋白是血液中較安定的蛋白質, 較不會受到胃酸與糞便細菌分解而變形, 且在臨床意義上和 人類血紅素相同 適用上 下消化道, 全腸道出血
68.6%
Positive rate of Tf alone, IFOBT alone, and Tf + IFOBT in fecal samples from colorectal cancer patients(n=40) 90 85 90% 80 75 70 75% 80% 數列 1 65 IFOBT TF TF+IFOBT Transferrin Dipstick as a Potential Novel Test for Colon Cancer Screening: A Comparative Study With Immuno Fecal Occult Blood Test Cancer Epidemiol Biomarkers Prev 2009;18:2182-2185. Published online August 5, 2009. American Association for Cancer Research
Concurdance of ifob and Tf tests in fecal samples from colorectal cancer patients, Premalignant subjects, and low-risk subjects ( n=110 ) A. Colorectal Cancer ( n=40 ) with histologic confirmation Tf(+) Tf(-) Total ifob ( + ) 26(65.0%) 4(10.0%) 30 ifob ( - ) 6(15.0%) 4(10.0%) 10 Total 32 8 40
Concurdance of ifob and Tf tests in fecal samples from colorectal cancer patients, Premalignant subjects, and low-risk subjects ( n=110 ) B. Premalignant lesions ( n=36 ) 1cm Tf(+) Tf(-) Total ifob ( + ) 14(38.9%) 2(5.6%) 16 ifob ( - ) 12(33.3%) 8(22.2%) 20 Total 26 10 36
Concurdance of ifob and Tf tests in fecal samples from colorectal cancer patients, Premalignant subjects, and low-risk subjects ( n=110 ) C. Low risk ( n=34 ) < 0.5 cm or no abnormalities Tf(+) Tf(-) Total ifob ( + ) 2(5.0%) 2(5.0%) 4 ifob ( - ) 6(15.0%) 24(60.0%) 30 Total 8 26 34
itf/ifob 2 in 1 臨床應用 同時偵測人類血紅素及運鐵蛋白之免疫法糞便潛血對上消化道出血 下消化道出血 大腸直腸癌之檢測性能均優於傳統化學法及偵測單一血紅素之免疫法 全腸道出血篩檢 ( 全套 )
IFOB/ITF 2 IN 1 RAPID TEST 使用限制 二合一糞便潛血快速檢驗 偽陽性 (False positive): 生理及藥物引起 _ 病人的檢體可能會干擾實驗結果, 如月經出血 痔瘡出血 便秘出血 血尿, 建議排除上述干擾後再行檢測 _ 酒精及一些藥物如 aspirin, indomethacin, resepine,phenylbutazone, corticosteroids 及抗過敏非類固醇的藥物, 可能在有些病人身上造成腸胃刺激不間斷出血, 有可能會引起糞便潛血檢測的偽陽性 建議在受測前 48 小時起停用, 以減少干擾 偽陰性 (False negative): 採檢步驟及過程引起 _ 偽陰性可能發生在潛血 / 運鐵蛋白不是非常均勻分佈在糞便情況或未依標準步驟採檢 若在臨床症狀有所懷疑時, 請重做測試 _ 檢體中若含有明礬或漂白劑類的物質亦可能造成錯誤的結果, 如果懷疑檢體內含有上述成份, 請再準被另一新鮮無異常檢體做檢測
大腸直腸癌發生的部位 32% 68%
腸道糞便成型的過程 多點針刺法? 表面擦過法?
1. 2. 3. 4. 刮除孔 反覆滾動 填滿前端插回管體栓緊送檢..\2in1_PPT\MSGH\SAMPLING_NORMAL.mp4
測試步驟 加 2.5ml 檢體混合 取下 ( 手或小工具 ) 栓蓋換上過濾裝置 進行快篩滴定 (3 滴 ) 判讀色卡 判讀結果 (5~10 分 )
2in1 定量採便 + 糞便採集盒 有效預防虎克效應 (Preventing Hook Effect) 定量採便 0.1 公克 (Quantitative 0.1 gm) 12 個視窗及骨架結構容易檢視及檢體運送 (Windows for Inspection and transfer by skeletal structure) 定量標準滴定 (35ul/drop) 材質柔軟易於按壓滴定精準 創新的糞渣 - FluA/B 過濾裝置 - Others (Innovated Filter) 適用各種糞便快速檢驗 (Device for Rapid Test) - ifob - itf+ifob - Adeno/Rotavirus - HpSA 2015/5/7 49
IFOB/ITF 2 IN 1 RAPID TEST 二合一糞便潛血快速檢驗 依據蛋白質特性之判讀結果 ( 僅供臨床參考 ) 測試項目 運鐵蛋白 (itf) + - 血紅蛋白 (ifob) + 確定消化道存在出血下消化道出血 * - 上消化道出血 ** 陰性反應 * 檢體中運鐵蛋白含量過少, 低於其檢測閾值或受檢者體內缺乏運鐵蛋白或出血濃度未達檢測閾值 ( 血紅蛋白血中濃度值是運鐵蛋白的 40~70 倍 ) ** 當下消化道大量出血, 血紅蛋白超出其檢測閾值,FOB 結果會顯示假陰性
腸道健診 - 小腸疾病出血篩檢 項目胃鏡大腸鏡 ifob/itf 出血位置 上消化道 + - +/+ -/+ 下消化道 - + +/+ +/- 上 下消化道 - - +/+ +/- -/+ 食道, 胃, 十二指腸 大腸直腸 小腸疾病出血 消化道 - - -/- 陰性 註 1: 小腸鏡健診執行困難, 目前以膠囊內視鏡為主, 缺點是價格昂貴而且不易看到出血點註 2: 此表僅以目前健診方法學比對, 目前國內尚無臨床研究報告文獻發表.
1.FOB(+)/TF(+): 確定存在消化道出血, 需進一步檢查出血原因 實驗室 解釋 2.FOB(-)/TF(+) : 消化道存在出血, 但上消化道出血的可能性較高, 需進一步檢查出血原因 3.FOB(+)/TF(-) : 消化道存在出血, 但下消化道出血的可能性較高, 需進一步檢查出血原因 4.FOB(-)/TF(-) : 陰性反應
Thank you. ( Q & A )