Lower GI Symptoms (Not acutely unwell)

• For Colorectal Cancer Referrals please see guidance here
• For Ovarian Cancer Referrals please see guidance here
• For Inflammatory Bowel Disease Referrals please see guidance here
• For Coeliac Disease Referrals please see guidance here
• For Irritable Bowel Syndrome Referrals please see guidance here
• For Diverticular Disease Referrals please see guidance here

For any other referrals to Gastroenterology regarding lower GI symptoms that do not fit into one of the referral pathways above then referrals can be sent to:

• RIE >> Gastroenterology – Medical >> GI Lower
• SJH >> Gastroenterology – Medical >> GI Lower
• WGH >> Gastroenterology – Medical >> GI Lower

Please note that the only referral priorities for this referral route are Routine or Urgent. There is no option for USC referral.

PLEASE DO NOT SEND ANY URGENT SUSPICION OF CANCER REFERRALS VIA THE ABOVE ROUTE. ANY REFERRAL FOR LOWER GI SYMPTOMS WHERE THERE IS A QUERY OF CANCER SHOULD BE SENT TO THE COLORECTAL TEAMS AS PER THE GUIDANCE ON THE RefHelp COLORECTAL CANCER PAGE

Basic investigations in Primary Care – Blood tests

• FBC, Ferritin (+/- Iron and transferrin)
• Cr&Es, LFTs, Ca, Alb, TFTs
• CRP
• Coeliac screen: patients must not eliminate or reduce gluten from their diet

​Basic investigations in Primary Care – Stool tests

• Stool sample for C&S including parasitology – in NHS Lothian, all diarrhoeal stools from patients ≥3 years old will automatically be tested for C Diff.
• Faecal calprotectin (FCP) (those under 50 years old)* if appropriate – see guidance on IBD page

* Please remember that FCP is not a test for Colorectal Cancer. If you have any concerns re CRC please refer via the appropriate pathway: Colorectal Cancer. FCP can be a marker for IBD but can also rise in gut infections and with some medications. Please see guidance on the IBD page for how to interpret a raised FCP.

Please note that in National Guidance reference is made to using FIT in Primary Care – in NHS Lothian if this is indicated it will be arranged by secondary care in response to a USC referral via the Colorectal Cancer referral pathway

A 4-week Watch & Wait Policy to see if the condition is self-limiting, is reasonable in those with Low-risk features such as:

• Transient symptoms (less than 4 weeks)
• Patients under 40 years in absence of high-risk features

In these cases consider:

• Assessment and review
• Consider bowel diary
• Appropriate information, counselling and agreed plan for review with GP
• Refer if symptoms persist or recur – see information in Safety netting box above

The What’s up with my Gut website has helpful information for patients. The videos about how to correctly get a stool sample can be useful to share with patients:
Collecting your Faecal Calprotectin sample

Crohn’s and Colitis UK have also produced this video for patients: The What’s Up With My Gut Patient Toolkit – some patients may find it helpful, but they should be advised that how assessment, investigation and referrals work in NHS Lothian are based on local policies and so can differ from national guidance.

Referrers in Primary Care may find this video produced by Crohn’s and Colitis UK helpful, though should remember that there are differences between national pathways and local referral routes / pathways (e.g. FIT testing being different in NHS Lothian).
Primary Care Diagnostic Pathway for Lower Gastrointestinal Symptoms – A Step By Step Guide
(Video endorsed by RCGP and RCN)

Referrers in Primary Care may find this video produced by Crohn’s and Colitis UK (with RCGP and RCN) helpful, though it should remember that there are differences between national pathways and local referral routes / pathways. This video gives a summary of how the pathway was created.
Primary Care Diagnostic Pathway for Lower Gastrointestinal Symptoms: Creation of the pathway
(Video endorsed by RCGP and RCN)

Information on the national pathways (UK) can be found here: What’s Up With My Gut – resources for Healthcare Professionals

Information on the national pathways (Scotland) can be found here: Lower gastrointestinal symptoms (not for acutely unwell symptoms) | Right Decisions

The following Educational Resources may also be helpful:

Assessing lower-GI symptoms in primary care: Educational resource introducing the national Primary Care Diagnostic Pathway for Lower Gastrointestinal symptoms. Local GP and Clinical Lead Dr Jane Marshall contributed to its development via her role as Clinical Champion for the Pathway

Hot Topics Lower GI Disease Clinic | NB Medical: A free interactive webinar on Lower GI Disease.

https://apps.nhslothian.scot/refhelp/education/reftalks/: Scroll down the page to find a link to the 2024 RefTalk on Inflammatory Bowel Disease from WGH Consultant Dr Blackwell