Inflammatory Bowel Disease (Suspected) - DRAFT

Overview

Inflammatory bowel disease should be suspected in children or adults with the following symptoms (1) (2):

• Persistent diarrhoea (including nocturnal diarrhoea) with possible blood or mucus in the stool.
• Abdominal pain or discomfort or distension
• Weight loss, faltering growth or delayed puberty (in children).
• Non-specific symptoms such as fatigue, malaise, anorexia, or fever.*

Please see CKS guidelines for :

Crohn's disease (1)

Ulcerative colitis (2)

Please also see the Faecal Calprotectin page for advice on indications and interpretation of this test.

*Local gastroenterologists do not recommend routinely undertaking a faecal calprotectin in patients with non-specific symptoms alone.

Children (aged under 16)

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

Who to Refer

Patients with suspected IBD should be referred urgently for a diagnosis. Please see 'What to do before referral' section below for further advice on investigations that need to be carried out in primary care before referral.

Red Flags

Suspected Malignancy

Patients with suspected lower GI cancer please use the 2WW pathway (Direct to test, if appropriate, or 2WW eReferral) 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:

• Pulse > 90
• Temperature > 37.8
• CRP > 45
• Haemoglobin < 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 team as immediate treatment or admission may be required -  please see red flag section above. 

Investigations in Primary Care

Patients with suspected inflammatory bowel disease where the above red flags have been excluded should initially have investigations in primary care including:

• Bloods : FBC and ferritin, CRP, U and E, TFT, LFT and TTG antibodies to exclude coeliac disease.
• Stool microscopy and culture to exclude infection. Infection can present like IBD and the gastroenterologists request this is done before referral even if the symptoms are chronic (sometimes giardia or campylobacter can cause persistent symptoms). Stool should additionally be sent for C diff if the patient has recently had antibiotics or has recently been a hospital inpatient.  
• Faecal calprotectin (FCP) should be done if symptoms persist for 6 weeks or more (see advice on false positives and interpretation on the Faecal calprotectin page). Please note that certain medications, such as PPIs and NSAIDs can alter the result making it difficult to interpret.

When is in appropriate not to refer

If investigations including faecal calprotectin are normal, then please consider other diagnoses (see Irritable Bowel Syndrome page)

If symptoms have settled at 6 weeks following a previously high FCP , then repeat faecal calprotectin ensuring patient is not on PPI or NSAID.

If faecal calprotectin is falling or less then 250 mcg/g then consider watch and wait in primary care with safety netting and review again if symptoms recur.

If FCP is still raised (>250 mcg/g) then consider requesting gastroenterology advice and guidance. 

If symptoms persist and above investigations still suggest IBD, then refer urgently to gastroenterology via eRS (please specify which hospital is preferred as there are different referral processes for each hospital). Alternatively, a referral for a direct access lower GI endoscopy may be appropriate for some patients with milder symptoms - see Referral Section below.

Normal colonoscopy and persistent symptoms and raised FCP

If patient has had a recent normal colonoscopy (direct access or otherwise)  but faecal calprotectin is persistently raised (>250 mcg/g) and symptoms persist then refer to IBD clinic via eRS (to exclude small bowel disease).

Referral for suspected IBD

Referral or advice options for patients with suspected IBD

If referral in indicated, the most appropriate referral route will depend on the patient's symptoms and outcome of initial investigations in primary care as well as where the patient lives and their preference of provider. Patients who have more severe or acute symptoms or are more likely to have IBD should be referred to secondary care. Other options may be appropriate if the symptoms are mild or less likely to be due to IBD. Patient choice via eRS ais limited due to the different referral criteria and pathways available:

• NBT -The referral route for patients who live closest to NBT hospitals should be via the Urgent Gastroenterology Service . This is a RAS service and referrals may be returned if investigations have not been completed or criteria are not met. Some referrals may also be triaged by a consultant and returned suggesting direct access colonoscopy if considered more suitable. This is often a quicker route to diagnosis for patients with less concerning symptoms. Referrals directed to the routine gastroenterology clinic may also be returned with a request to re-refer to this RAS service.
• UHBW -The referral route for patients who live closest to UHBW hospitals should be via eRS to the IBD clinic. Please mark referral urgent and it will be triaged by the gastroenterology team and patients seen appropriately.
• Direct access colonoscopy - Patients can be referred for direct access colonoscopy for confirmation of diagnosis in patients with milder symptoms. If diagnosis is then confirmed the patient will be discharged back to GP with advice to arrange an onward referral to a IBD clinic. Please remember that a normal colonoscopy does not exclude Crohn's disease so a referral may still be indicated in patients with persistent symptoms and raised faecal calprotectin (>250). Patients with an existing diagnosis of IBD should not be referred via this route.
• Gastroenterology A and G  - Patients who are less likely to have IBD based on symptoms and investigations in primary care can be referred for advice and guidance.
• Primary Care GI Service - Patients who are less likely to have IBD or who have isolated proctitis can be referred to this community service (PRIME) via eRS.

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.