LGI-pathway-test – Diabetes Made Easier

Country

INFLAMMATORY BOWEL DISEASE (IBD)?

COELIAC DISEASE?

IRRITABLE BOWEL SYNDROME (IBS)?

Coeliac screen

FC and/or FIT

IBS

COULD IT BE (IBD)?

IBD often presents with diarrhoea, abdominal pain, rectal bleeding or weight loss but may also present with common symptoms in the box above. Presents at any age but mainly teens/twenties. Family history increases risk especially in Crohn’s.

POTENTIAL DISTINGUISHING SYMPTOMS:

Nocturnal defecation, fevers, night sweats (not to be confused with menopause), enlarged lymph glands, extra intestinal manifestations. Microscopic colitis mainly in women 50+ presents as profuse watery diarrhoea.

The main forms of IBD are and . More rarely, .

COULD IT BE ?

Coeliac Disease is undiagnosed in two thirds of cases. It can present in non-specific ways, e.g. persistent or unexplained nausea and vomiting. It may also present with common symptoms in the box above. More likely if family history (first degree relative 1 in 10 risk), history of autoimmune conditions, Down’s/Turner’s syndromes.

POTENTIAL DISTINGUISHING SYMPTOMS:

Iron deficiency anaemia or B12 or folate deficiency, dermatitis herpetiformis, tooth enamel problems, unexplained subfertility or repeated miscarriages, neurological problems such as ataxia and peripheral neuropathy.

COULD IT BE (IBS)?

IBS is a longstanding illness with frequent abdominal discomfort and bowel symptoms that cannot be explained by any other disease.

PRESENTATION:

Usually presents 20-40 years age
But can be any age
Slightly more women than men
Post gastroenteritis
Can be made worse by emotional stress

Coeliac screen

Coeliac Screen positive🔗. REFER to secondary care for diagnosis. Second serology test required and possible biopsy. If Coeliac diagnosis confirmed🔗, treat in primary care with dietitian support (as per Country🔗 national/local guidance).
Coeliac Screen negative. See green box below and safety netting.

Exact thresholds for Coeliac serology and the requirement for biopsy may vary locally.

Faecal Calprotectin and/or Faecal Immunochemical Test

Faecal Calprotectin for IBD

FC for IBD testing high (>250) with high index of suspicion: REFER to gastroenterology urgently.
FC for IBD testing high (>250) with lower index of suspicion or equivocal (100-250). Repeat FC test within 4 weeks and REFER if result high (>250) or equivocal (100-250).
FC for IBD testing low (<100): See green box below and safety netting

Faecal Immunochemical Test

FIT threshold ≥10µg Hb/g. REFER to Colorectal Cancer pathway.
FIT threshold <10µg Hb/g. See green box below and safety netting.

Exact thresholds for FC and FIT tests may vary and should be based on local assays and audit data

Irrititable Bowel Syndrome (IBS)

Make a positive diagnosis of IBS🔗 if Coeliac and IBD are excluded. TREAT🔗 in primary care and safety net/reassess if symptoms suggest

SAFETY NETTING

No diagnosis of cancer on the cancer pathway – reassess against lower GI pathway
If severe symptoms - urgent GI referral may still be needed
If symptoms persist or symptoms change – reassess
Consider the possibility of:
- upper GI cancer (if not already excluded)
- multiple lower GI conditions at the same time
- false negative FIT tests if ongoing symptoms – could still be IBD
- false negative Coeliac serology – too little gluten in diet, IgA deficiency
- other lower GI conditions (for example, the need to exclude microscopic colitis🔗 by biopsy, bile acid malabsorption🔗, diverticulitis🔗, pancreatic insufficiency🔗, small bowel bacterial overgrowth)

Wales cancer pathway🔗