Fecal calprotectin

Pick Ordered or Not ordered to see the note.

Indicated when

• —New-onset lower GI symptoms (chronic diarrhea, abdominal pain) where there is diagnostic uncertainty between inflammatory bowel disease and a functional disorder such as IBS, particularly when specialist referral or colonoscopy is being considered and cancer is not suspected [1]
• —Monitoring disease activity in a patient with an established diagnosis of ulcerative colitis or Crohn's disease, to help decide whether to pursue endoscopic assessment or adjust treatment [2]

Not indicated when

• —Routine, repeated testing in a patient already diagnosed with IBS by symptom-based (Rome) criteria who has no alarm features: CAG's IBS guideline recommends against routine fecal calprotectin testing in this setting [3]
• —As a substitute for colonoscopy when cancer or another structural diagnosis is genuinely suspected

Why not

Fecal calprotectin performs well as a screen but is not perfectly specific: a systematic review and meta-analysis found a sensitivity of 88% and specificity of 72% for distinguishing IBD from functional GI disorders, and estimated that at a 1% population prevalence of organic disease, a positive result still only carries a 4.2% positive predictive value, even though a negative result was highly reassuring (100% negative predictive value in that analysis) [1]. This means an isolated positive result in a low-risk patient is much more likely to be a false positive than true IBD, and needs to be interpreted with that in mind rather than triggering immediate invasive investigation.

Better first step

Use fecal calprotectin as a triage step when there is genuine diagnostic uncertainty about IBD versus a functional disorder, not as routine confirmatory testing once IBS is already diagnosed by symptoms with red flags absent [3, 1].

Typical ND rationale

An ND may order fecal calprotectin in a patient with chronic diarrhea, abdominal pain, or other lower GI symptoms, reasoning that it is a useful, noninvasive way to check for bowel inflammation and to decide whether the picture looks more like inflammatory bowel disease or a functional disorder before pursuing further workup.

Ontario coverage & CONO orderability

OHIP status

uninsured

Fecal calprotectin is explicitly noted in docs/research/ontario-coverage.md as absent from the current community Schedule of Benefits, and a full-text search of the 2026 Schedule for 'calprotectin' in this session found no listing, so billing status if a physician ordered it is unverified. Absence from the community Schedule does not rule out hospital-lab or other funding arrangements, which were not identified for this test in this session. ND-ordered testing is privately paid regardless (Reg. 552 s.22(1)). Coverage update (reconciliation pass): LifeLabs' Non-OHIP Billable Test List (2025, republished by an Ontario hospital lab) lists this test as patient-paid in community labs. This is secondary evidence, not a ministry statement. Hospital-lab funding in specialist care (e.g. IGF-1 under endocrinology) was not checked.

CONO orderable

Yes — CONO list #135

CONO 135 'Calprotectin Fecal', stool specimen.

Linked conditions

• ibd ↗
• ibs ↗
• dysbiosis ↗

Counselling script

“When it's unclear whether bowel symptoms come from inflammation or from IBS, fecal calprotectin is a reasonable non-invasive test, and a normal result is quite reassuring. A positive result on its own is often a false alarm when the chance of inflammatory bowel disease is low, so we'd read it together with everything else before deciding on more testing.”

Revisit if

• —Alarm features develop (weight loss, GI bleeding, nocturnal symptoms, iron-deficiency anemia)
• —Symptoms change character or worsen

References

1. [1]Medical Journal of Australia (An et al.) (2019). Faecal calprotectin testing for identifying patients with organic gastrointestinal disease: systematic review and meta-analysis. linkSystematic review/meta-analysis: FC testing sensitivity 88%, specificity 72% for IBD vs functional GI disorders; PPV only 4.2% at 1% prevalence, NPV 100%; clinically useful for distinguishing organic from functional GI disease
2. [2]American Gastroenterological Association (2023). AGA Clinical Practice Guideline on the Role of Biomarkers for the Management of Ulcerative Colitis. linkAGA guideline: noninvasive biomarkers including fecal calprotectin can inform disease monitoring and management in established ulcerative colitis
3. [3]Canadian Association of Gastroenterology (2019). Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Irritable Bowel Syndrome (IBS). linkCAG IBS guideline: routine fecal calprotectin testing is not recommended once IBS is diagnosed
4. [4]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkCommunity lab tests are insured only when ordered under the Schedule by an authorized prescriber
5. [5]Government of Ontario (e-Laws) (2026). Health Insurance Act, R.R.O. 1990, Reg. 552: General, s. 22 (insured laboratory services). linkInsured lab testing requires ordering by an authorized provider who has clinically assessed the patient
6. [6]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkTests ordered by anyone other than an authorized provider, including NDs, are not insured services
7. [7]LifeLabs (republished by Norfolk General Hospital laboratory) (2025). LifeLabs Non-OHIP Billable Test List (republished by Norfolk General Hospital laboratory, effective 2025). linkListed as a non-OHIP (patient-paid) test at LifeLabs Ontario, 2025