Shaping better health
REMEDY : BNSSG referral pathways

Inflammatory Bowel Disease

Checked: 04-02-2019 by Rob.Adams Next Review: 04-02-2020

Introduction

Please see CKS guidelines for :

Crohns disease

Ulcerative colitis

Patients with suspected inflammatory bowel disease should initially have investigations in primary care including:

  • Bloods : FBC and ferritin, CRP, U and E, LFT and TTG antibodies to exclude coeliac disease.
  • Stool microscopy and culture to exclude infection.
  • Faecal calprotectin (see advice on interpretation under the Faecal calprotectin heading below).

If tests suggest IBD or IBD still needs to be excluded then consider referral for direct access colonoscopy or sigmoidoscopy or refer to gastroenterology via eRS if there are contraindications to a direct access investigation.

If acute severe colitis is suspected then direct access colonoscopy is not appropriate and urgent referral to gastroenterology would be indicated -  please see red flag section below.

 

Additional 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

Referral

Endoscopy - If endoscopy is indicated and considered appropriate then please see the Remedy guide on endoscopy for details on how to refer. 

Gastroenterology Referral via eRS - Once diagnosis is confirmed or if direct access endoscopy is contra-indicated or not appropriate then refer to Gastroenterology/IBD clinic via eRS (patients will be offered a choice of provider).

Further care - For patients already known to the IBD clinic with a flare of symptoms then please contact the appropriate IBD nurse (patients will usually have their contact details anyway). These patients do not need a new eReferral.

Urgent Referrals - If a patient has more severe symptoms or signs then please mark your referral Urgent and local trusts will endeavour to see patients more quickly.

NBT have a separate  Urgent Gastroenterology Service on eRS via a RAS for both confirmed or suspected IBD where criteria are met (click on link for details).

Red Flags

Suspected Malignancy

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

Acute Severe Colitis

Patients with acute severe colitis may need more immediate treatment or admission so please discuss with local on call gastroenterology team (IBD nurse or on call registrar/consultant).

Definition:

More than 6 bloody stools/day
AND
One or more of the following:
  • Pulse > 90
  • Temperature > 37.8
  • CRP > 45
  • Haemoglobin < 105 g/l

Faecal Calprotectin

Faecal calprotectin test (FC)– This stool test is now widely available and can be requested on ICE across Bristol. It can help to rule out inflammatory bowel disease. Caution should be used in interpreting this test however as many other conditions can cause a raised or equivocal level. Local clinicians advise that it should only be done if a referral is being considered (see below).  If FC is only marginally raised and no other alarm symptoms or concerns then it may be better to repeat rather than immediately refer for colonoscopy.

Mike Cohen from PRIME comments:

‘We are gaining more experience with FC. GP’s need to know it detects any sort of inflammation in the gut and slight or moderate rises in FC levels may not mean too much. Infections and drugs can push up FC as well. If it is only slightly raised then my suggestion would be to repeat it- off NSAIDs and if possible PPI for 4 weeks. My mantra would be to use FC only if referring patient and NOT to use it routinely.’

Tom Creed advises:

‘if the first test result is elevated but less than 200, repeat the test after 4 to 6 weeks and ensure the patient is not on NSAIDs at the time of testing’