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Irritable bowel syndrome (IBS) can be difficult to diagnose, and it is important to reach the correct diagnosis while striking the right balance between too few and too many investigations.
This IBS pathway aims to provide a patient focused and cost effective diagnostic and management pathway for people with irritable bowel syndrome.
The objectives are:
This guidance refers to:
This guidance does not cover:
Consider IBS when the patient presents with:
This is usually accompanied by at least two of the following:
Common additional symptoms include abdominal bloating and distension.
Other features such as lethargy, nausea, depression/anxiety, fibromyalgia, backache & bladder symptoms are common in people with IBS, and may be used to support the diagnosis.
Based on the history, IBS can be divided into:
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.
Differential diagnoses may include:
Please see the suspected cancer NICE guidelines NG12 and the latest local DG30 guidelines for faecal immunochemical testing (FIT)in patients over 50 years. Patients meeting these criteria should be referred via the lower GI 2ww pathway.
In adults 18-49 years old, with symptoms suggestive of IBS please organise:
A positive diagnosis of IBS always helps management: patients without 'red flags' and with normal tests should be managed in primary care. Please see IBS Diagnostic flowchart.
If the above bloods tests are normal but you still suspect IBD please organise:
|IBS Symptoms||IBD-Ulcerative colitis||IBD-Crohns disease|
|Abdominal pain||Blood mixed in stool||Abdominal Pain|
|Bloating||Diarrhoea including nocturnal||Weight loss|
|Change in bowel habit - Typically alternating||Urgency/incontinence||Diarrhoea|
Family history IBD
Erythema nodosum, uveitis
Family history IBD
Erythema nodosum, uveitis
Faecal calprotectin less than 100 µg/g - IBS is 98% likely
If all blood tests and faecal calprotectin are less than 100 µg/g – reassure and manage as IBS – unless there remains a significant clinical doubt as to the diagnosis.
Faecal calprotectin 100-250 µg/g -IBD is 12% likely
This result is equivocal and the Calprotectin should be repeated in 2 weeks. If the repeat result remains greater than 100 µg/g, then refer urgently to gastroenterology highlighting suspected IBD.
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, otherwise:
Before repeating please exclude:
Faecal calprotectin more than 250 µg/g IBD is 46% likely
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, otherwise:
More than 250 µg/g – refer urgently to gastroenterology highlighting suspected IBD. Please ensure a stool sample is sent to rule out infection as a possible cause of the symptoms.
For management guidance please see the 'Symptom management' guidance under the Irritable Bowel Syndrome information in the Formulary section of the website here.
***PLEASE NOTE: The recommendations in the management guidance are currently under review, with possible changes to come***
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.
Referrals should only go on to secondary care gastroenterology with a negative faecal calprotectin (less than 100 µg/g) if there remains a significant doubt of the diagnosis of IBS and in severe refractory cases that have not responded to specialist IBS dietary changes and first- and second-line medical treatment. Note referrals to Gastroenterology that have not been managed as per this guideline will be returned.
e-Referrals Service Selection
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
Please highlight on the referral form that the referral is in relation to refractory IBS
This guideline has been signed off by the Eastern Locality on behalf of NHS Devon CCG.
Publication date: May 2019