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Irritable Bowel Syndrome (IBS) affects 10-20% of the adult population. The condition affects all ages, but typically occurs before the age of 50 and is twice as common in women as in men. The prevalence of Inflammatory Bowel Disease (IBD; including Crohn’s disease and ulcerative colitis) in the Southwest is approaching 1% of the population and can affect patients of all ages.
GP Communication - Implementation of the Devon Faecal Calprotectin Care Pathway - Information for GPs
This guidance refers to:
Please note pre-referral criteria are applicable in this referral and referrals will be returned if this information is not contained within the referral letter.
This guidance does not cover:
Ψ Acute Severe Ulcerative Colitis
Definition: ≥ 6 bloody stools per day AND one or more of following: temp greater than 37.8°C; CRP greater than 30 mg/L; Hb lower than 108 g/L; pulse greater than 90 bpm. If the patient meets these criteria, contact the on-call Consultant Gastroenterologist and/or admit through medical take out of hours. A faecal calprotectin is not needed in this situation and will delay urgent hospital care.
NICE guideline definition of IBS = abdominal pain or discomfort, in association with altered bowel habit, for at least 6 months, in the absence of alarm symptoms or signs
Consider IBS when the patient presents with:
Consider common drug causes of GI upset including:
The classification of IBS patients into sub-groups is useful for clinical practice, but it is common for IBS patients to switch from one subtype to another over time. More than 75% of IBS patients change to either of the other 2 subtypes at least once over a 1-year period.
Based on the history, IBS can be divided into:
IBS-D = diarrhoea predominant
IBS-C = constipation predominant
IBS-mixed = alternating
Differential diagnoses may include:
Diagnostic uncertainty between IBS and IBD
IBS | IBD- ulcerative colitis and Crohns disease |
Abdominal pain | Diarrhoea (especially if nocturnal defaecation) |
Bloating | Blood mixed in stool/bloody diarrhoea |
Change in bowel habit - Typically alternating | Urgency/incontinence Weight loss Abdominal pain |
Other features:
| Family history IBD Erythema nodosum, uveitis, pyoderma gangrenosum, inflammatory arthralgia |
Please see the suspected cancer NICE guidelines NG12 and the latest local DG30 guidelines for faecal immunochemical testing (FIT) in patients 50 years and over.
Patients presenting with these symptoms need to be investigated/ referred to secondary care through the 2 week wait pathway
In adults aged 18-50 years old, with symptoms suggestive of IBS please organise routine blood tests:
If the above bloods tests are normal, but you still suspect IBD, please organise a faecal calprotectin test
CAUTION: In an unwell patient with acute abdominal pain or significant bloody diarrhoea and possible IBD, do not let primary care investigations delay appropriate urgent assessment ΨΨ Acute Severe Ulcerative Colitis
Definition: ≥ 6 bloody stools per day AND one or more of following: temp greater than 37.8°C; CRP greater than 30 mg/L; Hb lower than 108 g/L; pulse greater than 90 bpm. If the patient meets these criteria, contact the on-call Consultant Gastroenterologist and/or admit through medical take out of hours. A faecal calprotectin is not needed in this situation and will delay urgent hospital care.
About the faecal calprotectin stool test
Calprotectin pathway (see flow chart)
a) Faecal calprotectin lower than 100 µg/g:
At 6 weeks: If symptoms remain troublesome AND still no red flags AND faecal calprotectin is lower than 50 µg/g:
At 6 weeks: If symptoms remain troublesome AND still no red flags AND faecal calprotectin is 50-99 µg/g:
b) Faecal calprotectin ≥ 100 µg/g
In an unwell patient with acute abdominal pain or significant bloody diarrhoea and possible IBD, do not let primary care investigations delay appropriate urgent assessment. Look for signs of toxicity: ≥ 6 bloody stools per day and one or more of following: temp greater than 37.8°C; CRP greater than 30 mg/L; Hb lower than108 g/L; pulse greater than 90 bpm. If toxicity present or clinical concern contact the on-call Consultant Gastroenterologist and/or admit through medical take.
If repeat faecal calprotectin lower than 100 µg/g
If repeat faecal calprotectin 100 - 250 µg/g
If repeat faecal calprotectin greater than 250 µg/g
A positive diagnosis of IBS always helps management: patients without 'red flags' and with normal tests should be managed in primary care.
Please see MyHealth Devon website and BSG guidance for strategies to manage IBS symptoms
In general, treatment is targeted at addressing a patient’s most troublesome symptoms, be that abdominal pain, diarrhoea, constipation or bloating.
Explain how gut and mind interact.
Exacerbating factors include post infective, e.g. after gastroenteritis (over half generally settle over time although this may take a few years and is more typically causes IBS-D than IBS-C) and 'Stress', e.g. bereavement, interpersonal relationships.
Common misconceptions and concerns in IBS patients include:
Adjust expectations: 2 in 3 patients experience chronic symptoms with treatment targeted at improving symptoms, rather than complete symptom relief
b. Signpost patients to BDA food fact sheet on IBS and NHS IBS patient webinars
c. Second line dietary interventions
For more information on Diet and Lifestyle: see NICE CG61 and BSG
IBS is a condition to be primarily managed in the community. In patients with symptoms of IBS and that have not responded to simple lifestyle, dietary and pharmacological therapy as recommended by NICE consider referral to the Specialist IBS Dietetic services.
See:
If this is the case refer with:
Note referrals to Gastroenterology with a negative faecal calprotectin ( lower than 50 µg/g) that have not been managed as per this guideline and without the information above will be returned.
2. If faecal calprotectin ≥ 50-99 µg/g:
3. If faecal calprotectin ≥ 100 µg/g: repeat the calprotectin test within 2 weeks (and ensure that stool culture sent already)
Please note that referrals to Gastroenterology with a positive faecal calprotectin will be returned without the following information:
Please note that referrals to Gastroenterology with a faecal calprotectin ≥ 100 µg/g will be returned without the following information:
e-Referrals Service Selection
Specialty: Dietetics
Clinic Type: Gastroenterology
Service: DRSS-Western-Dietetic-Devon CCG -15N
In an unwell patient with acute abdominal pain or significant bloody diarrhoea and possible IBD, do not let primary care investigations delay appropriate urgent assessment, please contact the on-call Consultant Gastroenterologist or use the electronic advice and guidance service.
e-Referral Service Selection
Specialty: GI & Liver
Clinic Type: Lower GI (medical) excl IBD
Service: DRSS-Western-GI & Liver (Medicine & Surgery)-Devon CCG -15N
Please highlight on the referral form that the referral is in relation to refractory IBS
GP Communication - Implementation of the Devon Faecal Calprotectin Care Pathway - Information for GPs
Information on a new workshop for people with a diagnosis of IBS who are living in Devon (not Plymouth)
This is run by Talking Health/Talk Works, and presented by a dietician and psychologist from the gastroenterology team (RDUH/DPT). They envisage these to be ongoing stand-alone workshops.
Please follow the link to more information. The information can be found here under support for managing my IBS TALKWORKS.
Information on a new workshop for people with a diagnosis of IBS who are living in Devon (not Plymouth)
This is run by Talking Health/Talk Works, and presented by a dietician and psychologist from the gastroenterology team (RDUH/DPT). They envisage these to be ongoing stand-alone workshops.
Please follow the link to more information. The information can be found here under support for managing my IBS TALKWORKS.
This pathway was signed off by NEW Devon CCG Clinical Pathway Group.
Publication date: May 2021
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