SUSPECTED IRRITABLE BOWEL SYNDROME
Onset of Symptoms < age 40 and lasting more than 6 months
GSTT
Contact details:
KCH
Other
Address
Phone
Email
Referral Date
Referring Clinician
Practice Details
~[Today...]
~[Free Text:Referring
Clinician?]
~[Surgery Address Line 1]
~[Surgery Address Line 2]
~[Surgery Address Line 3]
~[Surgery Address Line 4]
~[Surgery Tel No.]
Patient Name
DOB
~[Forename] ~[Surname]
~[Date Of Birth]
Patient Address
~[Patient Address Block]
Patient Tel
Mobile
NHS Number
Hospital Number
~[Telephone Number]
~[Mobile]~[Mobile Number]
~[NHS Number]
~[Hospital Number]
Referral Checklist
Prior to referral please review this chart below and offer a trial of dietary changes +/- medication
according to the dominant symptoms
Symptoms
Diet
Medication
Constipation no Bloating/Gas
-
High-fibre
□
Laxative
□
Constipation + Bloating/Gas
-
Low-fibre +
Ispaghula Husk
□
Mebeverine
□
Peppermint oil
□
Loperamide
□
Diarrhoea (irrespective Gas)
Mixed no Bloating/Gas
Mixed + Bloating/Gas
-
Low-fibre
□
-
Low-FODMAP
□
-
High-fibre or
Ispaghula Husk
□
-
Low-FODMAP
-
- Low-fibre +
Ispaghula Husk
-
□
Treatment guided by
predominant
symptom
□
Mebeverine
□
□
Peppermint oil
□
- Low-FODMAP
Please circle the dominant symptoms and tick treatment given.
Final Version – February 2013
□
Have you considered the 2 week wait criteria
e.g. weight loss, anaemia
□
Straining/Rectal Symptoms
(If yes, please refer to Pelvic Floor Unit)
Lifestyle advice offered
□
Dietary advice offered
□
Physical exam. (incl PR) done
□
Findings:
Investigations
All cases: Please perform the following diagnostic tests prior to referral
FBC, U/Es, eGFr, LFTs, Coeliac Screen, F. Calprotectin* Normal
□
+ Diarrhoea ± Bloating-Flatus: Stool c/s
Normal
□
+ Constipation: TSH, Calcium
Normal
□
+ Lower Abdo Pain (female): U/S Pelvis
Normal
□
Normal
□
Ca125
Psychological Assessment done*
□
CBT
□
Information

Faecal Calprotectin: Normal upper limit is 100. If result is in between 100-150, please repeat and if
normal, then refer along this pathway.

History: An exact description of symptoms and associated symptoms with start date, circumstances
(travel, BBQ, change life-style/diet), aggravating/relieving factors, systemic symptoms, past
medical/family histories.

Psychological Assessment: eating habits, symptom timing to life-events, stress/anxiety, and impact
of symptoms /remedial actions on lifestyle/psych. Consider GAD7/PHQ9.

FODMAP diet information please see: http://www.bda.uk.com/publications/IBSdietary_resource.pdf
Final Version – February 2013