Patients with recurrent gastrointestinal symptoms: overview of changing practice

Gastrointestinal disease, including conditions such as inflammatory bowel disease (IBD; most commonly Crohn's disease and ulcerative colitis), irritable bowel syndrome (IBS), coeliac disease and food allergy, is a significant healthcare burden on the NHS.1,2 Gastrointestinal symptoms are one of the most common complaints patients present with and frequently these symptoms are representative of several gastrointestinal diseases, making it difficult to diagnose on a clinical history alone.3–8

Guidelines on faecal calprotectin testing changed practice
Prior to publication of the National Institute for Health and Care Excellence (NICE) guidelines on faecal calprotectin testing, before endoscopy, diagnostic tests to exclude IBD consisted of non-specific inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). In 2013, the NICE guidelines changed this practice, recommending faecal calprotectin testing, a specific marker of gastrointestinal (GI) inflammation, as a clinical option for the differential diagnosis of IBS or IBD. Owing to the potential cost savings through reducing the number of avoidable endoscopies and other patient benefits, this change in practice led to a significant increase in test requests, an increased burden on laboratory resources.8

Recommended panel of tests may change practice again
Although faecal calprotectin testing can help to differentiate between IBD and IBS,8 it does not cover the spectrum of disorders that present with recurrent GI symptoms. As such, since 2011, primary care practices in the Coventry and Warwickshire area have been using a clinical pathway devised by Dr Ramesh Arasaradnam and colleagues to determine the need for referral in patients aged less than 45 years with symptoms of IBS for more than one month with no red flag symptoms. The clinical pathway recommends testing for:
* full blood count to identify patients with anaemia
* thyroid stimulating hormone to identify patients with hypothyroidism
* tissue transglutaminase to identify patients with coeliac disease
* faecal calprotectin to identify patients who may have an inflammatory disease of the bowel.
Dr Arasaradnam reports that the clinical pathway has been a huge success,9 has helped to reduce the burden on secondary care gastroenterology, and has provided primary care with a tool to inform clinical decisions. This in turn has helped to improve the patient experience.