Inflammatory Bowel Disease (Confirmed)

Overview

For patients with suspected IBD please see the Inflammatory Bowel Disease (suspected) page

Patients with known IBD will normally have been seen initially in secondary care for diagnosis and will be followed up accordingly.

Many patients with stable disease will be discharged back to primary care and should be provided with a treatment plan.

Please see the IBD (suspected) page for patients who do not have an existing diagnosis of IBD.

Please also see CKS guidelines for :

Crohn's disease (1)

Ulcerative colitis (2)

IBD nurses

IBD nurses are available at UHBW and NBT and provide support for patients with IBD who are already under the care of secondary care services. Their contact details will usually be known to their patients or should be available on recent clinic letters and they can be contacted directly by patients or GPs for advice.

Children (aged under 16)

For IBD in children please see the Chronic abdominal pain and IBD (children) page.

Who to Refer

Patients with existing IBD who are not already under follow up with a local gastroenterology team should be referred if they have uncontrolled symptoms. If symptoms are well controlled then referral or advice may be needed to arrange routine colonoscopy surveillance - please see referral section below for further details. 

Patients with well controlled proctitis can be managed in primary care and do not require routine referral to secondary care unless there are additional features or symptoms are difficult to control. Advice on treatment can be found here. These patients can be referred to the Primary Care GI Clinic (PRIME) if needed, for advice on treatment and follow up if required.

Red Flags

Suspected Malignancy

Patients with suspected lower GI cancer please use the urgent suspected cancer pathway (Direct to test, if appropriate, or 2WW e-Referral) or do a FIT test if indicated.

Acute Severe Colitis

Patients with acute severe colitis may need more immediate treatment or admission so please discuss with either the local medical on-call team, IBD specialist nurse/consultant if there’s a known diagnosis, or via A&G if the patient is not known to the unit.

Definition:

• Tachycardia: Pulse > 90
• Pyrexia: Temperature > 37.8
• Raised CRP: Dr Valliani at NBT suggest >20 indicates moderate flare and >45 indicates severe flare.
• Anaemia: Hb < 105 g/l

What to do before referral

Exclude Red Flags

Please ensure patient does not meet criteria for 2WW referral - particularly if there is rectal bleeding. Also consider a FIT test if this is indicated and if positive then refer via 2WW.

If acute severe colitis is suspected then discuss with local gastroentrology -  please see red flag section above. 

Confirmed IBD

Patients who have had a diagnosis of IBD made by one of the direct access endoscopy providers should be referred to their local IBD clinic in secondary care, even if they have been started on treatment.

Patients with pre-existing IBD whose symptoms are not controlled and who are not currently under secondary care follow up or have been lost to follow up should be referred to their local IBD clinic via eRS. Please check bloods and faecal calprotectin and include results with referral.

Patients with pre-existing IBD  whose symptoms are controlled may not be need immediate referral unless CRC screening is due. Please see referral section below for further advice. 

IBD Flares

Local gastroenterologists advise that there is no standard management of patients with flare up of their IBD and the gold standard would be an individualised care pathway, revised at every clinic.

The secondary IBD teams also kindly request that the following tests be arranged in primary care while the patient is waiting to be reviewed as this can speed up treatment decisions:

• Stool tests: Faecal Calprotectin, C. Diff,  MCS.
• Bloods: FBC, CRP, UE, LFT, TFT.

IBD UK has advice which can be helpful:

• Flare pathways | IBD UK

Crohns and Colitis UK also has the following pathways:

• UC_Flare_Pathway_v6
• Crohns_Flare_Pathway_v6 (but depends on disease location and symptoms).

Referral for patients with known IBD

Referral options for patients with confirmed IBD:

For patients already under the care of an IBD service then contact the service directly for advice or follow up (a new eRS referral should not be required).

For patients not under the care of an IBD service or who have moved from out of area or been lost to follow up consider the following options:

• Discuss with on call team or consider admission if there are red flags (see above).
• Refer routinely to your local IBD service via eRS if the patient is not already being followed up in secondary care.
• Refer to Community GI Service (PRIME) via eRS for patients with isolated proctitis or microscopic colitis diagnosed by colonoscopy outside of secondary care. The community service does not otherwise manage patients with IBD.

Referral options for follow up and screening colonoscopy

Patients who have had a previous assessment by an IBD team but are not having regular follow up, do not necessarily need to be referred to secondary care if symptoms are well controlled, simply for the purpose of setting up screening. All patients with colitis should have a screening colonoscopy at 8 years after diagnosis and further intervals will be determined by that colonoscopy. If advice on appropriate screening or follow up is required then consider using gastroenterology A and G.

Resources

The Inflammatory Bowel Disease Toolkit  has been launched by Crohn’s & Colitis UK in partnership between the Royal College of General Practitioners (RCGP). It is designed to be to be a 'one-stop-shop', a user-friendly guide to IBD for GPs and other primary care professionals

The Crohn's and Colitis UK website also has information for patients and professionals.

The British Society of Gastroenterology Clinical Resources page has useful guidelines on management of a range of GI conditions including IBD.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.