REMEDY : BNSSG referral pathways

Inflammatory Bowel Disease

Checked: 20-12-2017 by Rob.Adams Next Review: 20-03-2018

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.

If tests suggest IBD or IBD still needs to be excluded then consider referral for endoscopy.

 

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

If tests suggest IBD or IBD still needs to be excluded then consider referral for endoscopy.

Once diagnosis is confirmed then refer to IBD clinic via e-referral.

Alternatively there is the NBT Urgent Gastroenterology Service via a RAS for both confirmed or suspected IBD where criteria are met.

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 immedicate treatment or admission so please discuss with on call gastroenterology team.

Definition:

More than 6 bloody stools/day AND 1 or more of the following:
  • Pulse > 90
  • Temperature > 37.8
  • CRP > 7.5
  • 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’