Abdominal Pain
Red Flags — act before continuing if any of these are present
| Red flag | Why dangerous | Action |
|---|---|---|
| Rigid abdomen, rebound tenderness, guarding, or patient lying absolutely still | Signs of peritoneal irritation indicate a surgical emergency: perforated viscus, ruptured ectopic, mesenteric ischaemia. Time-critical — mortality rises sharply with delay to theatre. | 999 now |
| Sudden-onset "worst ever" abdominal pain or pulsatile mid-abdominal mass | Ruptured or leaking AAA — classic triad: tearing/ripping pain, pulsatile mass, haemodynamic instability. Mortality without immediate surgery approaches 90%. Do not delay to investigate. | 999 now |
| Lower abdominal pain + amenorrhoea ± positive pregnancy test in a woman | Ectopic pregnancy until proven otherwise. Rupture causes catastrophic intra-abdominal haemorrhage. Stable with a positive test → early pregnancy assessment unit today (NG126); shock, syncope, severe pain, significant bleeding or shoulder-tip pain → 999. | 999 if unstable · EPU today if stable |
| Unintentional weight loss with new abdominal symptoms, age ≥40 | NICE NG12: FIT at 40+ with abdominal pain; suspected cancer pathway (upper GI) referral at 55+ with weight loss plus upper abdominal pain, reflux or dyspepsia; urgent CT at 60+ for pancreatic cancer. Cancer pick-up rate on investigation is clinically significant at 5–10%. | Suspected cancer pathway referral |
| Rectal bleeding, especially dark blood mixed with stool | NICE NG12: rectal bleeding with abdominal pain or weight loss under 50, or any rectal bleeding at 50+ → FIT; suspected cancer pathway referral if ≥10 µg Hb/g. Dark blood mixed with stool is more sinister than bright blood on paper. Never attribute rectal bleeding to haemorrhoids without examination in patients ≥50. | Suspected cancer pathway referral |
| Change in bowel habit at any age, especially to looser stools (FIT, NG12) | A strong predictor of colorectal cancer, particularly in older adults. Looser stools are more concerning — they suggest left-sided or rectal cancer. Colorectal cancer incidence peaks in the seventh and eighth decade. | Suspected cancer pathway referral |
| Iron-deficiency anaemia (Hb below the laboratory reference range with low ferritin), with or without GI symptoms | Implies occult blood loss — the hallmark of early GI malignancy. Absence of overt rectal bleeding does not exclude colonic cancer. NICE NG12 (updated April 2026): offer FIT at any age and refer on a suspected cancer pathway if ≥10 µg Hb/g. BSG 2021: bidirectional endoscopy for new IDA in men and postmenopausal women. | Suspected cancer pathway referral |
| Dysphagia at any age | NICE NG12 (updated April 2026): dysphagia warrants a suspected cancer pathway referral for oesophageal or stomach cancer regardless of age or other features. Even if abdominal pain seems clearly functional, dysphagia overrides and requires that urgent referral. | Suspected cancer pathway referral |
Safeguarding Considerations — Consider in Every Consultation
🏠 Domestic Abuse / Intimate Partner Violence
- Recurrent unexplained abdominal pain — particularly perineal or lower abdominal — in a woman of any age
- Pain inconsistent with the described mechanism or examination findings
- Partner who accompanies and answers questions on the patient's behalf
- Withdrawal of consent to share records, or reluctance to discuss symptoms in private
- History of multiple attendances with unexplained bruising or injuries
👴 Older Adults / Carer-Related Concern
- Unexplained abdominal pain in a patient dependent on a carer for personal care
- Inconsistent history between patient and carer, or a carer who is unusually controlling
- Evidence of neglect: unintentional weight loss, poor hygiene, dehydration alongside the pain
- Patient appears fearful of the carer or makes eye contact with them before answering questions
🧒 Children in the Household
- A child with recurrent abdominal pain without clear organic cause — consider emotional abuse, bullying, or adverse family environment
- Assess whether children in the household are at risk if the adult is a victim of domestic violence
- Consider fabricated or induced illness if a parent presents repeatedly with a child's unexplained symptoms
- School-aged children with recurrent pain: safeguarding, school non-attendance, and psychosocial causes should always be explored
💊 Self-Harm / Medication Misuse
- Abdominal pain following possible paracetamol or NSAID overdose — even if denied; paracetamol toxicity presents with RUQ pain 24–72 hours after ingestion
- Unexplained abdominal pain in a patient with known mental health disorder or previous self-harm history
- Laxative abuse causing crampy abdominal pain in eating disorder context
- Signs of substance misuse: track marks, small pupils, unexplained episodes of confusion alongside abdominal pain
💼 Occupational Stress & Job Insecurity
Chronic workplace stress activates the HPA axis and suppresses the parasympathetic "rest-and-digest" state. This directly impairs gastric emptying, alters colonic transit, and lowers the visceral pain threshold — producing IBS-like symptoms even without structural disease.
"How are things at work at the moment? Have you been under any particular pressure?"If identified: NHS Talking Therapies self-referral, stress management, review of workplace adjustments alongside any pharmacotherapy.
🍽️ Dietary Habits & Eating Patterns
Irregular meal times, rapid eating, high-fat diet, and excessive caffeine are direct mechanical and chemical triggers for abdominal pain. Low dietary fibre is the modifiable cause of constipation-predominant IBS in the majority of cases. The low-FODMAP diet has RCT-level evidence for IBS symptom reduction.
"Can you walk me through a typical day's eating — when you eat, what you eat, and whether meals are regular?"If identified: specific dietary advice before prescribing antispasmodics; dietitian referral is highly cost-effective for IBS.
🧠 Anxiety, Health Anxiety & Somatisation
Generalised anxiety disorder and health anxiety are extremely common drivers of abdominal pain. Anxiety directly increases visceral hypersensitivity by lowering pain perception thresholds. Health anxiety causes chronic symptom monitoring that amplifies normal gut sensations into perceived pain.
"Sometimes when we're feeling anxious or worried, it can affect how our bodies feel — have you noticed any connection between stress and when the pain comes on?"If identified: NHS Talking Therapies referral for CBT-based health anxiety treatment. NICE CG61 lists hypnotherapy, CBT and psychological therapy for refractory IBS (no response to drug treatment after 12 months).
😔 Depression & Chronic Adversity
Depression and abdominal pain have a bidirectional relationship. Serotonin — 95% of which is produced in the gut — regulates both mood and gut motility, explaining why antidepressants improve IBS as well as mood. Patients with depression have lower pain tolerance and are more likely to catastrophise about symptoms.
"Sometimes when we're feeling low or down it can affect how our bodies cope with pain — how have you been feeling in yourself more generally?"If identified: treat depression as part of abdominal pain management, not separately. Low-dose amitriptyline treats both visceral hypersensitivity and low mood in functional bowel disorder.
🤯 Adverse Childhood Experiences (ACEs)
Robust epidemiological evidence links ACEs — physical, sexual, or emotional abuse, neglect, or household dysfunction in childhood — with functional GI disorders in adulthood. Up to 40% of patients with IBS report significant ACEs. Mediated through HPA axis epigenetic changes, altered microbiome, and central pain sensitisation.
"Sometimes difficult experiences earlier in life can affect how our bodies respond to stress. Have you been through anything particularly difficult in your past?"If disclosed: trauma-informed approach; trauma-focused CBT or EMDR may be more effective than any bowel-directed treatment.
💑 Relationship Stress & Social Isolation
Relationship conflict, bereavement, or social isolation are potent activators of the stress-pain axis. Abdominal pain and IBS are significantly more prevalent in patients reporting low social support. Social isolation amplifies symptom awareness and reduces coping resilience.
"How are things at home at the moment — do you feel like you have good support around you?"If identified: social prescribing, community resources, or voluntary sector support may be more beneficial than medication for functional abdominal pain.
- Asking "What brings you in today?" when the case card already states abdominal pain — wastes time, loses Global Skills mark
- Failing to name the cancer fear explicitly — the most common communication failure in this case type
- Moving straight to targeted questions without an open question first
- Not asking about rectal bleeding or weight loss in a patient with new abdominal pain
- Completing data gathering after 8+ minutes — insufficient time for management
- Not screening for urinary or gynaecological symptoms in a woman with lower abdominal pain
999 or Same-Day Hospital
Call 999 / A&E now- Ruptured / leaking AAASudden tearing pain, pulsatile mass, haemodynamic instability, age ≥60 with vascular risk factors — do not examine repeatedly, call 999 immediately
- Ruptured ectopic pregnancyLower abdominal pain + amenorrhoea ± shoulder tip pain ± haemodynamic instability — any woman of reproductive age
- Generalised peritonismRigid abdomen, board-like guarding, rebound tenderness, patient lying absolutely still — perforated viscus until proven otherwise
- Acute mesenteric ischaemiaSevere constant pain out of proportion to examination findings, elderly patient with AF or known atherosclerosis — mortality 60–80% without urgent intervention
- Bowel obstruction with vascular compromiseColicky central pain, absolute constipation, vomiting, distension — strangulation causes constant pain and rapid deterioration
- Acute severe pancreatitisEpigastric pain radiating to back, vomiting, haemodynamic compromise, markedly elevated amylase/lipase
Same-Day GP / Urgent Referral
Hours to 2 weeks- Suspected appendicitisRight iliac fossa pain, anorexia, fever, rebound tenderness in RIF — same-day surgical assessment on clinical findings (Alvarado not validated in primary care); analgesia is fine, but do not discharge
- Acute cholecystitisRUQ pain, fever, positive Murphy's sign, elevated WCC and CRP — same-day hospital/surgical assessment, not a community scan (CG188)
- Acute diverticulitisLeft iliac fossa pain, fever, change in bowel habit, elevated CRP — well and uncomplicated: consider no antibiotic with review at 48 h; co-amoxiclav if systemically unwell or comorbid; same-day hospital if complicated (NG147)
- Severe IBD flareBloody diarrhoea ≥6/day, fever, tachycardia — Truelove and Witts criteria; hospital admission if severe; IV corticosteroids
- NICE NG12: suspected cancer pathway referral criteria metFIT for change in bowel habit or IDA (any age), rectal bleeding with pain or weight loss (under 50), rectal bleeding, abdominal pain or weight loss (50+) → suspected cancer pathway referral if ≥10 µg Hb/g; rectal mass → suspected cancer pathway referral
- Suspected ectopic (stable)Lower abdominal pain + positive pregnancy test without ultrasound evidence of intrauterine pregnancy — same-day EPU assessment
Manage in Primary Care
GP practice- IBS / functional abdominal painRome IV criteria met, no red flags, normal examination — lifestyle modification, dietary advice, antispasmodics, psychology if needed
- Constipation-related painInfrequent hard stools, straining, lower abdominal discomfort — dietary fibre, macrogol, review medications
- GORD / peptic ulcer pain (no red flags)Epigastric burning, post-prandial, age <55, no dysphagia, no weight loss — H. pylori test; PPI trial 4–8 weeks
- Suspected biliary colic (stable)Episodic RUQ pain, no fever, no jaundice, normal examination — USS abdomen; elective surgical referral if gallstones confirmed
- Stable IBD review (shared care)Known IBD, no flare features — gastroenterology shared-care review, FBC/CRP/albumin/vitamin D, colonoscopic surveillance schedule
- Unexplained symptoms without red flags (age <40)Investigations first (FBC, CRP, coeliac, faecal calprotectin) — review in 4–6 weeks with results; consider gastroenterology if persistent
- Missing a suspected cancer pathway referral criterion and failing to refer (age, bleeding, weight loss, bowel habit change ≥6 weeks)
- Sending home a patient with peritonism or suspected ruptured ectopic without calling 999
- Prescribing analgesia only for suspected appendicitis and booking routine follow-up
- Failing to state the triage decision and rationale clearly to the patient
- Saying "I'm going to do a suspected cancer referral" without explaining what this means to the patient
- Not offering abdominal examination at all in a new presentation of abdominal pain
- Failing to mention vital signs (particularly temperature in an acute presentation)
- Not mentioning a chaperone when offering intimate examinations (PR, pelvic)
- Missing the hernial orifice check in a patient with groin pain and abdominal distension
- Failing to record weight as a baseline when weight loss is part of the complaint
- Pressing deeply without warning the patient first and asking permission
- Ordering investigations without explaining to the patient what each one is looking for
- Not checking pregnancy test in any reproductive-age woman with lower abdominal pain
- Prescribing PPI for dyspepsia without testing for H. pylori first
- Failing to order faecal calprotectin before diagnosing IBS or referring for colonoscopy
- Starting the patient on a gluten-free diet before checking anti-TTG
- Listing investigations without stating the clinical question they will answer
"What I think is going on is something called irritable bowel syndrome, or IBS. Think of it like this: your bowel is a muscle, and like any muscle, it can go into spasm or cramp when it's irritated or under stress. In IBS, the bowel is working normally — nothing is damaged or diseased — but it's behaving as though it's oversensitive. Stress, certain foods, and sometimes hormonal changes can all set it off. The good news is that IBS, although it can be really uncomfortable, doesn't damage the bowel and doesn't turn into anything more serious. But I also want to make sure we do some tests first to confirm this and to rule out anything else, especially given your mum's history."
"I think I'm just stressed — it'll sort itself out."
"Stress really can contribute significantly to bowel symptoms — you're right about that connection. But because these symptoms have been going on for several months, and because of your family history, I think it's worth checking a few things properly first. That way we can reassure you with much more confidence."
"It's probably just something I'm eating."
"Diet is definitely one of the most important factors in IBS and can make a big difference. Once we have the test results, I'd like to talk through some specific dietary changes that have really good evidence behind them — and I can also refer you to a dietitian who specialises in bowel problems. But let's do the tests first so we know exactly what we're dealing with."
IBS (Irritable Bowel Syndrome)
Rome IV: recurrent abdominal pain ≥1 day/week in last 3 months associated with ≥2 of: related to defaecation; change in stool frequency; change in stool form. Requires normal FBC, CRP/ESR and coeliac serology, with faecal calprotectin where IBD is possible and FIT for a change in bowel habit (NG12); in women ≥40 with persistent or frequent bloating, check CA-125 (NG12, updated April 2026). Diagnosis of confidence, not purely of exclusion.
Functional Constipation
Rome IV: ≥2 of straining, hard stools, incomplete evacuation, anorectal obstruction, manual manoeuvres, <3 bowel movements/week. Rule out thyroid disease, medication causes, and colorectal cancer in older patients before labelling as functional.
Musculoskeletal / Abdominal Wall Pain
Carnett's test positive (pain worsens on tensing abdominal muscles) distinguishes abdominal wall from visceral pain. Often post-surgical, post-traumatic, or nerve entrapment. Reassurance + physiotherapy + topical NSAID.
Inflammatory Bowel Disease (Crohn's / UC)
Bloody diarrhoea, urgency, nocturnal symptoms, weight loss, elevated faecal calprotectin and CRP. Gastroenterology referral for colonoscopy and biopsy. Crohn's can affect any GI segment; UC is continuous colonic disease from rectum.
Coeliac Disease
Bloating, diarrhoea, abdominal pain, iron deficiency, fatigue. Positive anti-TTG IgA. Refer gastroenterology for duodenal biopsy confirmation. Do NOT start GFD before biopsy — histological villi will recover and give a false negative.
Gallstone Disease (Biliary Colic / Cholecystitis)
Right upper quadrant or epigastric colicky pain 1–4 hours post-fatty meal, nausea. USS confirmation. Elective surgical referral for cholecystectomy. If fever + positive Murphy's: acute cholecystitis — same-day surgical assessment.
Gynaecological Pathology
Cyclical pain, dysmenorrhoea, deep dyspareunia — endometriosis (average 7–9 year diagnostic delay in UK). Adnexal mass on USS — ovarian cyst; gynaecology referral. PID: cervical excitation, fever, discharge — same-day empirical treatment per BASHH guidelines.
Acute Appendicitis
Periumbilical pain migrating to RIF, anorexia, nausea, fever, rebound at McBurney's point. Same-day surgical assessment on clinical findings — the Alvarado score is not validated in primary care. Give analgesia, but do not send home. CT abdomen / USS confirms. Laparoscopic appendicectomy or IV antibiotics.
Ruptured Ectopic Pregnancy
Sudden lower abdominal pain, periumbilical or shoulder tip pain, haemodynamic instability, positive pregnancy test. 999 immediately. No intrauterine pregnancy on any previous USS does not exclude ectopic.
Ruptured / Leaking AAA
Tearing abdominal/back pain in age ≥60 with cardiovascular risk factors, pulsatile mass. 999. Mortality approaches 90% without emergency repair. Do not press firmly on a pulsatile mass.
Colorectal or Upper GI Malignancy
NICE NG12: FIT (NICE NG12) for change in bowel habit or IDA at any age, rectal bleeding with abdominal pain or weight loss under 50, rectal bleeding, abdominal pain or weight loss at 50+, or an abdominal mass → suspected cancer pathway referral if FIT ≥10 µg Hb/g; rectal mass → suspected cancer pathway referral without FIT. Dysphagia → upper GI suspected cancer pathway referral without waiting.
- Leaving without giving a working diagnosis or explanation of what tests are looking for
- Using terms like "just IBS" — this minimises a condition that significantly affects quality of life
- Failing to address the cancer fear explicitly when the patient has volunteered a family history
- Missing suspected cancer pathway referral criteria and managing as IBS without appropriate cancer screening
- Diagnosing IBS without checking faecal calprotectin where IBD is possible (NICE HTG320, formerly DG11)
- Using "I'm going to do a suspected cancer referral" without explaining what this means in plain language
- Delaying suspected cancer pathway referral to wait for investigation results when criteria are already met
- Not addressing the emotional impact of being told you need cancer screening
- Starting steroids before biopsy-confirmed IBD diagnosis
- Advising GFD before confirmatory duodenal biopsy in suspected coeliac disease
Validate — name their expectation
In abdominal pain with a family history of bowel cancer, the most common expectation is a colonoscopy or scan. Name it before managing it — don't pretend the expectation isn't there.
"I imagine part of you was hoping I'd send you for a scan straight away — especially with what happened with your mum. That's a completely understandable expectation to have."Explain — share your clinical reasoning
Explain why you are not immediately meeting the expectation. Frame the investigation plan as working toward the patient's goal, not away from it. Use the evidence: faecal calprotectin avoids unnecessary colonoscopy in 80% of IBS patients.
"The way I'd like to approach this is to start with some targeted tests that can tell us a lot about whether there is inflammation. If those come back indicating something needs further investigation, I will absolutely act on that quickly — including referring you for a camera test."Negotiate — offer something today
Always leave the patient with something meaningful: an investigation, a treatment to try, a named follow-up. A patient who leaves with nothing agreed will re-consult, seek private investigations, or attend A&E.
"I'm arranging those tests today, and I'd like to see you back in two to three weeks to go through the results together. In the meantime, I'm going to give you something that can help with the pain, and I'd like to talk through some dietary changes with really good evidence behind them."Soluble fibre (oats, psyllium husk, lentils) forms a gel in the gut, slowing transit and providing substrate for the microbiome. Insoluble fibre can worsen IBS bloating. The ratio matters: soluble preferred in IBS; total fibre crucial in constipation.
Start with 1 tablespoon psyllium husk (Fybogel) daily in water, increase slowly. Add porridge oats at breakfast. Introduce gradually over 4 weeks — too rapid an increase causes bloating initially.
FODMAPs are short-chain carbohydrates poorly absorbed in the small intestine. In IBS, they cause fermentation, gas production, osmotic fluid shifts, and pain. Restricting them reduces luminal contents and symptom load.
Requires trained dietitian guidance — self-directed low-FODMAP frequently leads to nutritional deficiencies. Three phases: elimination (4 weeks), systematic reintroduction (6–8 weeks), personalised long-term diet.
Exercise directly stimulates gut motility via the enteric nervous system and improves colonic transit time. Reduces HPA axis activation (stress response) and improves pain tolerance via endorphin release. Yoga has specific evidence for reducing IBS bloating.
Brisk walking 30 minutes five days per week is the minimum target. Avoid high-impact exercise immediately after meals. Yoga: 2–3 sessions per week specifically evidenced in IBS RCTs.
CBT for IBS directly targets the brain-gut axis by reducing visceral hypersensitivity and catastrophising. Gut-directed hypnotherapy (GDH) has some of the strongest trial evidence of the psychological therapies — 60–70% response rate, sustained at 5 years.
Refer to NHS Talking Therapies for CBT. Signpost to an app-delivered gut-directed hypnotherapy programme (e.g. Nerva; supported by RCT evidence). Mindfulness-based stress reduction also evidenced.
Inadequate fluid intake is the most common cause of constipation in UK adults. Irregular meal times impair gut motility rhythm (migrating motor complex requires predictable meal timing). Skipping meals then eating large volumes increases gas production.
Aim for 1.5–2 litres water daily. Take meals at consistent times. Eat slowly, avoid eating at a desk under time pressure. Reduce carbonated drinks (gas production) and coffee (gut stimulant) if symptoms worsen post-caffeine.
Alcohol increases gut permeability, disrupts the gut microbiome, worsens GORD, and can precipitate IBS flares. Caffeine accelerates colonic transit and precipitates diarrhoea-predominant IBS. Smoking doubles Crohn's disease risk and impairs peptic ulcer healing.
Use AUDIT-C to screen for alcohol excess. Advise CMO limits (14 units/week, 3+ alcohol-free days). Trial 4-week caffeine reduction — switch to decaffeinated and assess symptom change. Smoking cessation referral for all smokers with IBS or peptic disease.
IBS pain-predominant: antispasmodic first
- Mebeverine 135mg TDS before meals OR hyoscine butylbromide 10mg QDS
- Prescribe as regular course for 4–6 weeks, not PRN — PRN use is less effective
- IBS-C: macrogol (Movicol) 1–3 sachets/day — best evidence of all laxatives for IBS-C
- IBS-D: loperamide 2mg after each loose stool (max 12mg/day)
Low-dose amitriptyline: ATLANTIS trial evidence (2023)
- Amitriptyline 5–10mg nocte, titrate to no more than 30mg in primary care (higher doses only with specialist advice)
- Mechanism: central neuromodulation — reduces visceral hypersensitivity; anticholinergic effects also slow gut transit (useful in IBS-D)
- Counsel patient: this is not being used for depression; antidepressant doses are 5–10× higher; benefits take 4–6 weeks
- If amitriptyline not tolerated: nortriptyline (fewer anticholinergic effects); an SSRI only if a TCA has been ineffective (NICE CG61 third line)
Treat the organic cause specifically
- H. pylori positive: 7-day triple therapy (lansoprazole 30mg BD + clarithromycin 500mg BD + amoxicillin 1g BD), regimen per local guidance and prior antibiotic exposure; retest only if indicated (urea breath test ≥4 weeks after treatment)
- GORD / peptic: lansoprazole 30mg or omeprazole 20mg OD for 4–8 weeks; step down to on-demand once resolved
- IBD (following gastroenterology advice): mesalazine for UC; azathioprine/biologics for Crohn's — ALWAYS secondary care initiation
- Coeliac: strict gluten-free diet — no pharmacological treatment; annual review with tests as indicated; DEXA by risk
- IBS unresponsive to 12 months of best practice primary care → gastroenterology referral
- IBD requiring biologic therapy → secondary care initiation only
- Any new red flag developing at any point → expedited suspected cancer pathway referral regardless of previous reassuring investigations
- Chronic abdominal pain with significant psychosocial burden → pain clinic / psychology / liaison psychiatry
- IBS in pregnancy: avoid mebeverine (limited safety data); macrogol safe; CBT and dietary modification first-line
- Elderly patient with new abdominal pain: lower threshold for CT, suspected cancer pathway referral; consider mesenteric ischaemia and malignancy first
- Menstrual-related pain: consider endometriosis — mefenamic acid or COCP; gynaecology if refractory
- Post-infective IBS: commonly develops after Campylobacter or Salmonella — manage as IBS; most cases improve within 12–24 months
- IBS — diarrhoea-predominant
- IBS — constipation-predominant
- H. pylori positive
- GORD / dyspepsia symptoms
- Refractory IBS (≥6 months)
- NSAID-related GI symptoms
"Take mebeverine 20 minutes before meals — that's the most important timing. It helps relax the bowel before food arrives, which is when most people get their symptoms. Take it as a regular course rather than just when you have pain."
SCA pearl: Mebeverine is often incorrectly prescribed PRN only. Evidence supports regular dosing 20 minutes before meals for 4–6 weeks. Always explain the timing — it is counterintuitive and poor timing reduces effectiveness significantly.
"Take the PPI 30 minutes before your morning meal — that's when it's most effective, as it works best when the acid pump is being actively stimulated by food. If you're taking it for H. pylori eradication, take it twice a day with the antibiotics for a full week — completing the full course is really important."
SCA pearl: NICE CG184 recommends testing and treating H. pylori before commencing long-term PPI in dyspepsia. Starting PPI without testing is one of the most common prescribing errors in primary care and in the SCA — it misses a curable cause and leads to unnecessary medication dependency.
"Macrogol works by drawing water into the bowel to soften the stool and make it easier to pass. It's not habit-forming and is safe to use regularly. Dissolve the sachet in a full glass of water once a day to start — you can increase to up to three sachets a day if needed. It usually takes a day or two to start working."
SCA pearl: Macrogol is specifically preferred over lactulose in IBS-C because lactulose causes significant fermentation, bloating, and flatulence — worsening the patient's most troublesome symptoms. Prescribing lactulose for IBS-C is a commonly made prescribing error.
"I want to explain why I'm suggesting amitriptyline — not because I think your pain is in your mind, but because there's a well-proven connection between the brain and the gut. At this very low dose, it doesn't treat depression; it reduces the gut's oversensitivity to pain signals. It takes 4–6 weeks to work, and it will probably make you a bit drowsy at first — take it an hour before bed."
SCA pearl: The most important communication task when prescribing amitriptyline for IBS is pre-empting: "This is an antidepressant — does this mean you think it's all in my head?" Addressing this directly and empathetically before the patient says it is a high-scoring SCA communication skill that dramatically improves adherence.
"H. pylori is a bacterium that lives in the stomach lining and can cause inflammation and ulcers. These three medicines together — taken over 7 days — will clear it in about 90% of people. Complete the full course even if you feel better partway through. If your symptoms continue after finishing, we can do a breath test at least 4 weeks later to check it's gone."
SCA pearl: Stop PPI for 2 weeks (and antibiotics for 4 weeks) before testing for H. pylori — failure to do this causes false negative tests. This is one of the most common prescribing errors in primary care dyspepsia management and regularly appears in SCA cases.
"Loperamide slows down how quickly things move through your bowel, which helps reduce the urgency and the frequency of loose stools. Take one 2mg tablet after each loose bowel motion, up to a maximum of four a day. Don't use it if you have blood in your stools or a temperature — and always let me know if the diarrhoea is getting worse despite taking it."
SCA pearl: Loperamide is contraindicated in active IBD flare (risk of toxic megacolon). The key question to ask before prescribing is: "Have you noticed any blood or mucus in the diarrhoea?" If yes, treat as possible IBD, not IBS-D, until proven otherwise.
Food Fear & Social Dining
Many patients develop food anxiety — restricting their diet beyond what is clinically necessary, avoiding social eating, and cancelling meals out to maintain access to familiar toilets.
Ask: "Do you find yourself avoiding eating before events?" "Have you stopped going to restaurants?"
Clinical response: Dietitian-guided low-FODMAP reintroduction phase specifically addresses food fear by scientifically testing tolerance. Avoid validating excessive restriction without dietitian guidance.
"I want to make sure the dietary advice we give is targeted, not a blanket food ban — a dietitian can help you identify exactly which foods affect you, rather than cutting everything out."Work Attendance & Career
IBS is one of the leading causes of GI-related workplace absenteeism in the UK. Patients in physical jobs or without toilet access (drivers, construction, teachers) experience disproportionate impact.
Ask: "Has this affected your ability to do your job? Have you had to take time off?"
Clinical response: Fit Note with workplace accommodations (toilet access, flexible breaks). Consider occupational health referral for ongoing attendance difficulties.
"I can support you with a Fit Note if you need one, and I can write to your employer to suggest some practical adjustments that might make work much more manageable."Relationships & Intimacy
Abdominal bloating, unpredictable bowel symptoms, and the psychological burden of chronic pain all impact intimate relationships. Deep dyspareunia alongside IBS symptoms raises the possibility of endometriosis.
Ask: "Has this condition affected any of your personal relationships or home life?"
Clinical response: If sexual pain (dyspareunia) reported alongside IBS symptoms, reconsider endometriosis as a diagnosis and refer gynaecology.
"It's completely understandable that something that affects you every day would have an impact on your relationships too. Have you been able to talk to your partner about how this has been affecting you?"Travel, Leisure & Public Space
The unpredictability of IBS-D causes profound restrictions on travel, public transport, and leisure activity. Patients frequently plan journeys around toilet availability and decline social invitations.
Ask: "Have you found yourself avoiding travelling or going places? Do you plan around toilet availability?"
Clinical response: The Bladder and Bowel Community's "Can't Wait" card scheme is a practical UK resource. Normalise its use.
"There's a scheme called the Can't Wait card — it gives you access to toilets urgently in shops and public spaces. Patients often say it completely changes how they feel about going out."Mental Health & Health Anxiety
There is bidirectional causality between IBS and mental health. Health anxiety — specifically fear of undiagnosed cancer — is common in patients with a family history of GI malignancy. Repeated investigations to reassure do NOT reduce health anxiety — they reinforce it.
Ask: "Have you found that worrying about what's causing this has been taking up a lot of your thinking?"
Clinical response: NHS Talking Therapies referral for CBT-based health anxiety treatment specifically designed for this context.
"There are specific psychological therapies that are very effective for this kind of worry — and they work just as well for the gut symptoms too, because of the connection between the brain and the bowel."Medication Concerns & Stigma
Starting amitriptyline for gut symptoms triggers significant anxiety about being labelled as having a psychiatric diagnosis. This concern, if not proactively addressed, is the most common reason for non-adherence to the most effective pharmacological treatment for refractory IBS.
Ask: "How do you feel about the idea of medication to help with this? Any concerns about the treatment I'm suggesting?"
Clinical response: Pre-empt the stigma concern when prescribing amitriptyline — this single explanation dramatically improves adherence.
"Some people feel hesitant when I mention amitriptyline because it's technically an antidepressant — but at this very low dose, it's being used specifically for pain and gut sensitivity, not for mood. It's one of the best-evidenced treatments we have for this."2–3 weeks: investigation results review
Review FBC, CRP, coeliac antibodies, faecal calprotectin, FIT (change in bowel habit — NG12) and H. pylori result if tested. Confirm or revise working diagnosis. Initiate first-line pharmacotherapy if not already started. Check suspected cancer pathway referral appointment has been made if applicable.
6 weeks: treatment response review
Assess response to antispasmodics, laxatives, or PPI. Review dietary modification adherence. Check H. pylori response; retest only if indicated (peptic ulcer or persisting symptoms). Consider low-dose amitriptyline if first-line treatment has failed. Review IBD referral outcome if referred.
3 months: sustained response assessment
If on amitriptyline — review response and side effects; titrate if partial response. Assess dietitian progress (low-FODMAP reintroduction phase). NHS Talking Therapies/CBT outcome if referred. If suspected cancer pathway investigations normal — formally diagnose IBS and communicate clearly. Recheck for any new red flags.
6 months: consolidation and ongoing management plan
Review whether step-down in medication is appropriate. Assess psychosocial impact — has work, relationships, and social participation improved? Arrange annual review for patients on ongoing medication. Refer to gastroenterology if symptoms remain poorly controlled.
Annual: surveillance and rechecking for red flags
Check weight, ask about new red flags (weight loss, rectal bleeding, change in bowel habit character). Review medication need. Colonoscopic surveillance for patients with FH of colorectal cancer in a first-degree relative <50 — one-off colonoscopy at age 55 (BSG/ACPGBI/UKCGG 2019, Monahan et al. Gut 2020).
Memory rule — monitoring in abdominal pain and IBS
Anaemia check (FBC annually if risk factors for GI blood loss); Bowel cancer surveillance (colonoscopy per FH protocol — first-degree relative <50: colonoscopy at 55); Calprotectin if symptoms change (reconsider IBD); Diet review (annual dietitian if on low-FODMAP); Eradication retested only if indicated — urea breath test ≥4 weeks post H. pylori treatment, PPI off 2 weeks before testing
⚠ Three scenario-specific phrases — use these verbatim
Why safety-netting matters beyond clinical care
- Not summarising the agreed plan — patient leaves unsure what is happening next
- Failing to ask a closing question ("anything else?") — misses any remaining unvoiced concerns
- Not giving specific safety-net symptoms for the abdominal pain context
- Not revisiting the cancer concern at closing — it must be woven throughout, not just mentioned at step 1
- Going over time without completing the management plan — data gathering took too long
- Not naming a specific follow-up timepoint — "come back in a few weeks" is inadequate
- History: systematic, complete, open question first, red flags screened, ICE fully explored
- Investigations: appropriate, individually justified, results linked to plan, pregnancy test if indicated
- Diagnosis: shared in plain language, provisional flag given if tests pending, DDx acknowledged
- Management: cause-directed, biopsychosocial approach, stepped-care structure, lifestyle included
- Safety-netting: specific named symptoms, specific timeframe, emergency pathway made clear
- Open question used first in the consultation without exception
- All three ICE components explicitly named and addressed in the management plan
- Cancer fear named directly and empathetically throughout — not just at step 1
- Diagnosis explained without jargon using an accessible analogy (oversensitive bowel muscle)
- Shared decision making demonstrated — plan agreed, not imposed
- Closing question asked and patient's response genuinely explored
Who you are
Mrs D, 42, secondary school teacher. Lives with husband and two teenage children. Generally well, no significant past medical history. Mum was diagnosed with bowel cancer 8 months ago and is currently undergoing chemotherapy. You try to downplay your symptoms throughout but are clearly worried underneath. You came in mainly because your husband insisted.
Hidden agenda
You are terrified you have bowel cancer like your mum. You have been googling your symptoms for three months and convinced yourself it is cancer. However, you are too scared to say this directly because you feel "stupid" for worrying and are frightened of what the answer might be. If the candidate names cancer directly and empathetically, you will visibly relax and become much more engaged in the consultation.
Symptoms if asked directly
- Crampy lower abdominal pain, 4–5/10 severity, 2–3 times per week
- Worse after meals and when stressed at work (exam season currently)
- Relieved by opening your bowels approximately 50% of the time
- Bowel habit alternates between loose (2–3 times/day for a week) and constipated (nothing for 3 days)
- No blood in stool or on paper — you have specifically been checking
- No weight loss — you haven't weighed yourself but clothes still fit
- Some bloating, especially in the evenings; pass wind more than usual
- No nocturnal pain, no fever, no nausea or vomiting
- Last period was normal, not pregnant
Lifestyle + bonus details
- Significant work stress — exam season, year 11 parent complaints, school inspection coming up in 6 weeks
- Drinks 2 cups of coffee in the morning and 1–2 glasses of wine most evenings
- Diet is mostly processed food and ready meals due to time pressure; low in fibre
- Exercise: minimal — walks to school occasionally but nothing regular since lockdown
- Bonus detail (only if specifically asked about stress impact on body): "Actually, I did notice the pain got much worse during parents' evening — I was in agony for two days afterwards."
Resolution: Mrs D will accept the plan if the candidate (1) names her cancer fear explicitly and empathetically by name, not euphemism; (2) explains clearly why blood and stool tests are the appropriate first step and what will happen if they are abnormal — including that a camera test will follow; and (3) gives her a specific follow-up appointment time rather than "I'll be in touch." She does not need to be given a colonoscopy today — she needs to feel heard and to understand there is a clear, monitored plan.
- Peritonism: guarding, rebound, rigid abdomen
- Ruptured AAA: tearing pain + pulsatile mass + haemodynamic instability
- Ruptured ectopic: lower abdominal pain + positive pregnancy test + instability
- Acute mesenteric ischaemia: pain out of proportion to examination findings in AF patient
- Strangulated hernia / SBO with vascular compromise
- Suspected appendicitis: RIF pain, fever, anorexia — same-day surgical assessment
- Acute cholecystitis: RUQ pain + fever + positive Murphy's
- NICE NG12: FIT for habit change or IDA (any age), bleeding + pain or weight loss (under 50), bleeding, pain or weight loss (50+), abdominal mass → suspected cancer pathway referral if FIT ≥10; rectal mass or dysphagia → suspected cancer pathway referral
- Severe IBD flare: bloody diarrhoea ≥6/day + fever + tachycardia
- Stable ectopic suspected: lower abdominal pain + positive pregnancy test
- IBS / functional: Rome IV criteria met, no red flags, normal examination
- Constipation: infrequent hard stools, straining, lower abdominal discomfort
- GORD / peptic (no red flags, age <55): epigastric burning, post-prandial, responds to antacids
- Stable biliary colic: episodic RUQ pain, no fever, no jaundice
- Related to defaecation (better or worse)
- Change in stool frequency
- Change in stool form/appearance
- FBC (anaemia, infection, eosinophilia)
- CRP / ESR (systemic inflammation)
- LFTs (biliary / hepatic cause)
- Faecal calprotectin where IBD is possible (IBD vs IBS — NICE HTG320, formerly DG11)
- FIT if change in bowel habit at any age (NG12); CA-125 if woman ≥40 with persistent bloating
- Anti-TTG IgA + total IgA (coeliac screen)
- H. pylori stool antigen (if dyspeptic features)
- Urine dipstick (UTI / haematuria)
- Pregnancy test (reproductive-age women — mandatory)
Step 1 — IBS-C: Macrogol (Movicol) 1–3 sachets daily (not lactulose — worsens bloating)
Step 1 — IBS-D: Loperamide 2mg after each loose stool (max 12mg/day)
Step 2 — Refractory: Amitriptyline 5–10mg nocte → titrate to max 30mg in primary care (CG61; ATLANTIS RCT 2023)
Step 2 alternative: Nortriptyline if anticholinergic side effects problematic; SSRI only if a TCA has been ineffective (CG61)
GORD / peptic (no red flags, <55): Omeprazole 20mg OD or Lansoprazole 30mg OD × 4–8 weeks
Coeliac: Strict gluten-free diet — gastroenterology first; no pharmacological treatment
IBD: Mesalazine (UC) / azathioprine / biologics — secondary care initiation only; never independently in primary care
| Treatment / Condition | Monitor | Timing | Action threshold |
|---|---|---|---|
| H. pylori eradication | ¹³C urea breath test — only if indicated | ≥4 weeks post-treatment (PPI off 2 wks) | Positive → second-line regimen per CG184/local guidance; gastroenterology if second-line fails |
| Long-term PPI (>6 months) | Serum magnesium; DEXA if ≥5 years + osteoporosis risk | Annual; Mg 6-monthly with diuretics | Mg <0.7 mmol/L → supplement. Step down PPI to lowest effective dose annually |
| Amitriptyline (IBS) | Symptom response; side effects; QTc if cardiac history | 4 wks, 3 months, 6 months, annually | No response at 3 months → switch class; consider gastroenterology referral |
| IBD (shared care) | FBC, CRP, albumin, vitamin D, faecal calprotectin | 6-monthly when stable | Calprotectin >250 + symptoms → gastroenterology re: flare management |
| Coeliac disease | Anti-TTG IgA; haematinics (Hb, iron, folate, B12, vit D); DEXA by risk | Annual review; tests as indicated | Raised antibodies on GFD → dietitian review (dietary non-compliance) |
| Any age ≥50 with GI symptoms | Weight, rectal bleeding, change in bowel habit character | Every appointment | Any new red flag → suspected cancer pathway referral regardless of previous normal investigations |