Presenting with IBS symptoms, baseline assessment. IBS pathway 1: Presenting with IBS symptoms, baseline assessment. Bloating in women please consider Ovarian Cancer screening – Nice CG122 Patient AGED <45 YO presenting with lower gastrointestinal symptoms for at least 6 months suggestive of irritable bowel syndrome (IBS) WITHOUT ALARM SYMPTOMS: • Abdominal pain (relieved by defecation, made worse by eating IBS-A) • Bloating (IBS-B) • Constipation (IBS-C) altered bowel frequency or stool form • Diarrhoea (IBS-D) is common; overlap exists (IBS-M– mixed) FBC, U&E, LFT,CRP, Coeliac screen, TFTs, Stool MCS. Constipation, should be refereed directly to the “IBS” treatment options – IBS pathway 2. +Ve Coeliac Screen Diarrheoa Check Faecal Calprotectin (FCALP) RED FLAGS – ANY ONE OF THE FOLLOWING Age >45 Rectal/Abdominal Mass Unintentional weight loss Unexplained IDA Persistent rectal bleeding/bloody diarrhoea that does not resolve. Family history of bowel or ovarian cancer (affected relative <50 years) > 60 years of age, a change in bowel habit lasting more than 6 weeks with looser and/more frequent stools Raised CRP, and/or FCALP >150 Bloods normal and/or FCALP <60 Bloods normal and/or FCALP 60-150 Repeat FCALP in 4 weeks from first test; Stop aspirin/NSAIDs Primary care IBS pathway Referral to GI, Avoid dietary restrictions until endoscopy complete 2WW Referral GI/Colo-rectal Refer for ‘new IBD’ clinic appt Secondary care

IBS pathway 2: Treatment options This only applies to patients that IBD or other significant pathology has been excluded via IBS initial algorithm Treatment for IBS can involve any of the following modalities All treatment options are based on recommendations of NICE CG61 IBS 2015. Medicine Diet Psychological intervention Physical activity High incidence of Anxiety, stress & depression Refer to talking therapies IAPT on 024 7667 1090, or: by email to: cwp-tr.iapt@nhs.net First Line Diet & Lifestyle Advice prior to dietetics referral Key symptom DIARRHOEA CONSTIPATION Second-Line options Primary care: Lubiprostone 24mcg Secondary care Pruculapride 2mg (RICAD) Linaclotide 290mg (RICAD) Trial antispasmodic Eg Colpermin/Buscopan Loperamide 2mg capsules 2-4 caps twice a day max 16 mg daily First Line Ispaghula OR Macrogol for 6/12 Consider any of the following as second line for pain symptoms TCA Eg Amitriptyline 10mg-30mg at night SSRI (if TCA ineffective) Eg Fluoxetine 20mg once daily

Suggested Diet & Lifestyle advice First Line Advice : to be given by primary care on diagnosis prior to pharmacological intervention. - Regular meal pattern of 3 meals a day - 5-a-day recommendation for fruit & vegetables - 1.5-2l fluid per day - Wholegrain starchy carbohydrate choices eg wholemeal bread, wholegrain cereal, brown pasta, brown rice - Reduce caffeine and alcohol intake - Limit high fat foods - Provide literature produced by British Dietetic Association https://www.bda.uk.com/foodfacts/IBSfoodfacts.pdf Summary guidelines www.bda.uk.com/publications/professional/ibs_guidelines_exec