This pathway has been developed from published guidance, in collaboration with local gastroenterologists. This guidance is to assist GPs in decision making and is not intended to replace clinical judgment.

IBS Prevalence – 10-20%, affected 2x more than . Symptoms often noticeable 20-30 yrs Make a positive diagnosis based on symptoms rather than exhaustive investigations

Absolute Red Flags - Refer Urgently: Consider in anyone with a history of:  Abdominal, pelvic or rectal masses Abdominal pain/discomfort eased by defecation or associated with  Ascites altered stool form or frequency and at least 2 of:-  Unexplained increased urinary urgency History  >40 jaundice or unexplained weight loss  Bloating, distension, tension or hardness and abdominal pain  Change in stool passage – straining, urgency, incomplete  >50 with unexplained rectal bleeding evacuation Bristol Stool Chart (can be useful)  >60 with deficiency anaemia or  Symptoms worse with eating change in bowel habit or weight loss and one of: change in bowel habit/back pain/  Passage of mucus abdominal pain/nausea/vomiting/new- Other features such as lethargy, nausea, backache and bladder onset diabetes symptoms are common in people with IBS and may be used to Consider Urgent Referral support the diagnosis.  Night symptoms Use Rome Self-fill Questionnaire  Strong FH bowel or ovarian or breast or prostate cancer  Persistent abdominal distension Investigations Examination – Abdo + PR +/- pelvic examination  Pelvic or abdominal pain  Early Satiety/Loss of appetite Investigations as required to support clinical diagnosis-  Raised platelet count FBC, ESR, CRP,  Have a low threshold for thinking about Coeliac screen – Tissue Transglutaminase (TTG) and rarer cancers: pancreatic Immunoglobulins (multidisciplinary diagnostic centre) and (False -ve TTG with IgA deficiency) ovarian (simultaneous CA125 and urgent pelvic USS) (further information) Management If meet IBS Δ criteria no need for scoping, imaging, FOB etc is recommended by NICE as an option to Identify subtype: Constipation predominant = IBS-C support clinicians with the differential Diarrhoea predominant = IBS-D diagnosis of IBD or IBS where there are no Or mixed = IBS-M red flags and in whom specialist assessment is being considered < 60 µg/g normal – likely IBS

Refer to Gastroenterology Pharmacological treatments Dietary advice – give BDA Patient Leaflet  If faecal calprotectin >60 as Pain relief Yoghurt – consider 4 week trial probiotic (not st suggests active bowel prescribable) yoghurt twice a day 1 line antispasmodics  Hyoscine butylbromide - 20mg QDS Trial of a low FODMAP diet (fermentable  If persistent diarrhoea or  Mebeverine hydrochloride - 135mg oligosaccharides, disaccharides, clinical concern monosaccharides and polyols) diet has been tds 20min before meals shown to achieve relief of overall GI symptoms in  Peppermint oil (2nd line) - 1-2 caps  If resistant to treatment 86% of patients particularly where there are tds 20 min before meals symptoms of bloating, flatus and abdo pain 2nd line – Tricyclics(unlicensed) Amitryptyline –5-10mg nocte, max 30mg Psychological therapies – IBS- C add 1 tablespoon linseeds whole or ground consider if relevant to the to food and take with small glass water 3rd line SSRI (unlicensed)if above individual for or if symptoms Fibre – discourage eating insoluble fibre eg bran. If ineffective/not tolerated – Citalopram refractory to treatment need fibre eat soluble fibre eg ispaghula/oats 20mg od, Sertraline 50mg od, Fluoxetine See fibre sheet 20mg od CBT + hypnotherapy endorsed by NICE Fluids >8 cups (2 litres) a day water and non- Constipation – Ispaghula (see BNF for carbonated non-caffeinated drinks dose)+/-Macrogol oral pwdr (presc (Biofeedback/relaxation Lactose intolerance – can cause similar symptoms Laxido) 1-2 sachets/daily therapies and herbal meds – limited evidence currently – not to IBS- D. Consider trial of lactose free diet 2-4 Diarrhoea - Loperamide (see BNF for weeks to see if symptoms improve. sufficient to make dose) recommendations)

References Pathway created 2014 NICE DG11 Oct 13, NICE 2008 CG61, http://www.bda.uk.com/foodfacts/IBSfoodfacts.pdf, BMJ 2012;345:e5836 Approved by: Comments & enquiries relating to medication: Clinical Cabinet 03/2016 CCCG Medicines Management Team [email protected] Medicines Management and Refer to current BNF or SPC for full medicines information Clinical Contact for this pathway for queries: UCLH Dr Anton Emmanuel [email protected] Commissioning committees - 07/16 RFH Prof Owen Epstein [email protected] Review due 07/2019 Faecal Calprotectin

Calprotectin is a stable protein that is released into faeces when gather at the site of any G.I tract inflammation. Calprotectin can provide a non-invasive, inexpensive and objective method for assessing patients who may require referral for additional procedures e.g. Colonoscopy or imaging studies.

The faecal calprotectin test has a relatively high specificity and sensitivity (approximately 90%) for distinguishing between non-inflammatory bowel disorders (e.g. irritable bowel syndrome) and inflammatory bowel disease (e.g. ulcerative and Crohn's disease). Calprotectin will also be elevated in some cases of GI tract malignancy (e.g. colorectal cancer). Calprotectin concentrations relate well to disease activity in the inflammatory bowel diseases and can therefore be used to monitor therapy. The test is non-invasive and can be used on adults and children (not neonates); the same reference range appears to apply to both.

Sample Requirements. Random faecal sample (any time of day, no dietary restrictions required) in a plain universal container and approximately 1 gram in weight. Should not be exposed to temperatures >30°C

NOTE: Samples grossly contaminated with blood are unsuitable for FCALP analysis.