HNY Policy and Pathway Repository - Humber

This pathway is designed to help identify and triage patients with suspected Irritable Bowel Syndrome (IBS) who may be suitable for first line advice in the community rather than for immediate referral to secondary care services. The pathway uses a screening test (Faecal Calprotectin, FC) to identify patients with high likelihood of IBS from those with a suspected diagnosis of Inflammatory Bowel Disease. As such this relates to patients between the age of 18-60 years, with new onset lower gastrointestinal symptoms, who do not meet criteria for colorectal 2 Week Wait (2WW) referral, and who have had appropriate first line investigations. The FC result will identify patients requiring urgent referral to the Hull University Teaching Hospitals IBD clinics, routine referral to the HUTH General Gastroenterology clinic, or those suitable for community based IBS advice and management.

This pathway is unsuitable for patients with ANY red flag symptoms, including but not limited to:

Patients meeting the criteria for 2WW referral for (see NICE NG12):

1. >40 years with unexplained weight loss/abdominal pain
2. >50 years with unexplained rectal bleeding or associated iron deficiency anaemia
3. >60 years with iron deficiency anaemia or change in bowel habit

These individuals should have a FIT test sent and a referral to the colorectal 2 week wait (2WW) pathway made via the HUTH online system

Patients with acute, severe bloody diarrhoea:

Individuals <50 years with severe, bloody diarrhoea, with a bowel frequency of at least 6 motions in 24 hours with at least one marker of systemic toxicity: pulse rate >90 bpm, temperature >37.8 °C, haemoglobin <105 g/L and/or an CRP >45 and high clinical suspicion of acute severe colitis should be either discussed with the gastroenterology on-call team (0800-1700, Monday-Sunday) or admitted via the Acute Medical Unit at HUTH (1700-0800)

Exclude Red Flag Symptoms

Patients with acute, severe bloody diarrhoea with features of systemic toxicity should be referred as per the details above.

DO NOT REFER

Individuals with baseline FC <100 μg/g:

• These individuals are suitable for first line community based IBS management as detailed above.

Other Exclusion Criteria for this pathway:

• As detailed above, and on the flowchart, individuals meeting criteria for Colorectal 2WW criteria or who have acute, severe bloody diarrhoea with markers of systemic toxicity (consider referral acutely as described above)

Please see supporting information document for further detailed information (Hull University Teaching Hospitals Faecal Calprotectin Pathway, Version 1.1, Date: 19-4-2021, the accompanying Flowchart, Version 1.1, Date: 19-4-2021, and the Community Guide to IBS management, Version 1.1, Date 19-4-2-21)

Individuals not meeting criteria for a FC should be referred via an alternative pathway.

This guideline is intended to help support a diagnosis of IBS in patients with lower gastrointestinal symptoms.

All individuals should undergo basic screening investigations before referral and have negative primary investigations (Full Blood Count (FBC), Urea + Electrolytes (U+E), C - reactive protein (CRP), thyroid function tests (TFT), serum calcium, coeliac screen).

Assuming initial baseline investigations are unremarkable, individuals with a first FC result of <100 μg/g have a high likelihood of IBS and are appropriate for initial community based management. This is summarised in the Community Guide to IBS Management and would include:

• Considering first line dietary advice
• Considering first line medical therapies
• Considering psychological comorbidity

Patients with baseline FC 100-250 μg/g should have a second sample sent after 2 weeks and further management including referral as identified via the Flowchart.

Relevant individuals for referral are those:

• Aged 18-60 years
• New onset lower gastrointestinal symptoms
• Negative baseline investigations

Subsequent referrals are then triaged using the FC result.

Further details are given in the subsequent section.

Any referrals received within these criteria that do not include FC result, will be returned to the referrer

Referrals

Individuals with an initial FC >250 μg/g:

Please send urgent referral to the HUTH IBD clinic using the ERS online referral system AND a copy sent to the IBD administrator on hyp-tr.ibd.bookings@nhs.net

There are 6 dedicated rapid access slots per week in IBD clinics in HUTH per week to allow access to rapid assessment, investigation, and management.

Individuals with an initial FC of 100-250 μg/g:  

Please arrange for repeat FC testing in 2 weeks and then use the following steps:

• If 2nd FC = >250 μg/g – urgent referral to the HUTH IBD clinic (see above).
• If 2nd FC = 100-250 μg/g – please send a routine online referral to the HUTH General Gastroenterology clinic via the ERS online referral system.
• If 2nd FC = <100 μg/g – manage as patient with likely diagnosis of IBS (see above).

Individuals with persistent symptoms after initial FC <100 μg/g:

• If patient >50 years and FC >50 please send routine referral to the HUTH General Gastroenterology clinic via the ERS online referral system. The service is reviewed regularly and referrals will be accepted or occasionally clinical advice given via online message
• For all other individuals with persistent or atypical symptoms, or limited response to first line management strategies please use the HUTH Gastroenterology Advice and Guidance (A+G). This service is reviewed regularly and a reply will be made within 7 days.

Any complete referral should be actioned within 7 days.

Advice and Guidance requests should be answered within 7 days and if further clinical information is then requested as part of A+G then the reviewing physician will keep the discussion open for up to 2 weeks

Information to Include

• Referrals can be made using the ERS system either as an appended clinical letter or with the clinical details including relevant symptoms, relevant negative baseline investigations, and the baseline or subsequent repeat Faecal Calprotectin result to aid triage to the appropriate referral stream.
• FC result must be included with the referral

• Hull University Teaching Hospitals Faecal Calprotectin Pathway
• HUTH Faecal Calprotectin Pathway Flowchart
• Guide to support management of IBS in Primary Care