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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
o Palpable right sided abdominal mass
o Rectal mass
o Unexplained IDA- see IDA guide
o Altered bowel habit
o Rectal bleeding
o Weight loss ( unintentional or unexplained)
 ONSET Sx > 45
 FHx bowel or ovarian cancer
 Nocturnal Sx
 Raised inflammatory markers
y/n
see NICE cancer 2015- reference below
y/n
Consider IBS if a patient presents with >6 month Hx of?:
 Abdominal pain( may be relieved by defaecation)
 Bloating
 Altered Bowel Habit
 Diagnostic criteria:
o Consider diagnosing irritable bowel syndrome only if the
person has abdominal pain or discomfort that is:
o relieved by defaecation, or
o associated with altered bowel frequency or stool form
o and at least 2 of the following:
o altered stool passage (straining, urgency, incomplete
evacuation)
o abdominal bloating (more common in women than men),
distension, tension or hardness
o symptoms made worse by eating
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o passage of mucus.
Lethargy, nausea, backache and bladder symptoms may be
used to support diagnosis.
Does examination reveal any possible cause?
Including Digital rectal examination- if acceptable to patient
y/n
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
If no RED FLAGShas PRIMARY CARE MANAGEMENT been trialled before referral?





y/n
Reassurance and explanation
Dietary advice- see appendix1
Lifestyle advice- encourage exercise and relaxation
Pharmacological management: single or combination treatment
1st line:
o Pain- antispasmodics
 Direct acting e.g. mebeverine MR, alverine, and
peppermint oil – cause less side effects
 Antimuscarinics (anticholinergics) e.g. hyoscine
butylbromide and dicycloverine
o Diarrhoea- antimotility drug loperamide drug of choice in
diarrhoea-predominant irritable bowel syndrome
o Constipation- bulk forming laxatives or macrocols eg laxido
– avoid lactulose- aim for SOFT WELL FORMED STOOL
o Consider use of BRISTOL STOOL CHART
 2nd line
o TCA’s and SSRIs
 Amitryptylline- start 5-10 mgs ON , max 30 mgs
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 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
o Constipation-also available- Linaclotide only if:
 optimal or maximum tolerated doses of previous
laxatives from different classes have not helped and
 they have had constipation for at least 12 months.
 Follow up people taking linaclotide after 3 months.
 BLUE DRUG- specialist initiation
CONSIDER REFERRAL if
 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
http://pathways.nice.org.uk/pathways/irritable-bowel-syndrome-inadults
http://www.nice.org.uk/guidance/cg61
Suspected lower GI cancer
http://www.nice.org.uk/guidance/NG12/chapter/1recommendations#lower-gastrointestinal-tract-cancers
Suspected Upper GI cancer
http://www.nice.org.uk/guidance/NG12/chapter/1recommendations#upper-gastrointestinal-tract-cancers
Thanks to Dr Les Ashton, November 2015
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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 noncaffeinated 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 (of 80 g each) 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, oatbased 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 least 4 weeks while 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
FODMAP diet)
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