Pre referral Checklists GASTROENTEROLOGY

IRRITABLE BOWEL SYNDROME

  • Most cases or IBS can be diagnosed and treated in primary care
  • 5-20% patients may develop post infectious IBS after gastroenteritis

Are there any RED FLAGS?
  • Possible 2ww Sx or signs
  • Palpable right sided abdominal mass
  • Rectal mass
  • Unexplained IDA- see IDA guide
  • Altered bowel habit
  • Rectal bleeding
  • Weight loss ( unintentional or unexplained)
  • ONSET Sx > 45
  • FHx bowel or ovarian cancer
  • Nocturnal Sx
  • Raised inflammatory markers
see NICE cancer 2015- reference below / y/n
Consider IBS if a patient presents with6 month Hx of?:
  • Abdominal pain( may be relieved by defaecation)
  • Bloating
  • Altered Bowel Habit
  • Diagnostic criteria:
  • Consider diagnosing irritable bowel syndrome only if the person has abdominal pain or discomfort that is:
  • relieved by defaecation,or
  • associated with altered bowel frequency or stool form
  • andat least 2 of the following:
  • altered stool passage (straining, urgency, incomplete evacuation)
  • abdominal bloating (more common in women than men), distension, tension or hardness
  • symptoms made worse by eating
  • passage of mucus.
Lethargy, nausea, backache and bladder symptoms may be used to support diagnosis. / y/n
Does examination reveal any possible cause?
Including Digital rectal examination- if acceptable to patient / y/n
Have investigations been performed?
  • FBC
  • CRP/ ESR
  • Coeliac screen
  • Ca125 ( women especially > 50)
  • Consider faecal calprotectin if persistent loose stools to exclude IBD (off nsaids 4w to avoid false +ve)
  • Consider imaging to exclude differential diagnoses if required eg USS
/ y/n
If no RED FLAGS-
has PRIMARY CARE MANAGEMENTbeen trialled before referral?
  • Reassurance and explanation
  • Dietary advice- see appendix1
  • Lifestyle advice- encourage exercise and relaxation
  • Pharmacological management: single or combination treatment
  • 1st line:
  • Pain- antispasmodics
  • Direct acting e.g. mebeverine MR, alverine, and peppermint oil – cause less side effects
  • Antimuscarinics (anticholinergics) e.g. hyoscine butylbromide and dicycloverine
  • Diarrhoea- antimotility drug loperamide drug of choice in diarrhoea-predominant irritable bowel syndrome
  • Constipation- bulk forming laxatives or macrocols eg laxido – avoid lactulose- aim for SOFT WELL FORMED STOOL
  • Consider use of BRISTOL STOOL CHART
  • 2nd line
  • TCA’s and SSRIs
  • Amitryptylline- start 5-10 mgs ON , max 30 mgs
  • Consider SSRIs if TCAs ineffective, are contraindicated, or are not tolerated eg
  • Citalopram: 10 mg to 20 mg daily,
  • Fluoxetine: 20 mg daily.
  • Follow up at 4weeks then 6-12 mths
  • Constipation-also available- Linaclotide only if:
  • optimal or maximum tolerated doses of previous laxatives from different classes have not helpedand
  • they have had constipation for at least12 months.
  • Follow up people taking linaclotide after 3 months.
  • BLUE DRUG- specialist initiation
/ y/n
CONSIDER REFERRALif
  • 2WW criteria
  • Diagnostic uncertainty
  • Symptoms not controlled despite treatment / lifestyle factors as above
  • Consideration for linaclotide
  • Ix suggest IBD/ coeliac
  • Please stipulate reason if referring IBS
/ y/n
References
NICE IBS


Suspected lower GI cancer

Suspected Upper GI cancer

Thanks to Dr Les Ashton, November 2015
Appendix1
Diet
Assess diet and nutrition and give the following general advice:
  • Have regular meals and take time to eat.
  • Avoid missing meals or leaving long gaps between eating.
  • Drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas.
  • Restrict tea and coffee to 3 cups per day.
  • Reduce intake of alcohol and fizzy drinks.
  • Consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice).
  • Reduce intake of 'resistant starch' (starch that resists digestion in the small intestine and reaches the colon intact), often found in processed or re-cooked foods.
  • Limit fresh fruit to 3 portions (of80 geach) per day.
  • For diarrhoea, avoid sorbitol, an artificial sweetener found in sugar-free sweets (including chewing gum) and drinks, and in some diabetic and slimming products.
  • For wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to 1 tablespoon per day).
Review the person's fibre intake and adjust (usually reduce) according to symptoms.
  • Discourage intake of insoluble fibre (for example, bran).
  • If more fibre is needed, recommend soluble fibre such as ispaghula powder, or foods high in soluble fibre (for example, oats).
If the person wants to try probiotics, advise them to take the dose recommended by the manufacturer for at least4 weekswhile monitoring the effect.
Discourage use of aloe vera for irritable bowel syndrome.
If a person's IBS symptoms persist while following general lifestyle and dietary advice, offer advice on further dietary management. Such advice should:
  • include single food avoidance and exclusion diets (for example, a low FODMAPdiet)

1