GI · Full case

Irritable Bowel Syndrome

NICE CG61 BSG 2021

5–10%UK adult IBS prevalence

≥6 monthsMin. symptom duration (Rome IV)

≥1/weekAbdominal pain frequency (Rome IV)

<50 μg/gFaecal calprotectin: IBD unlikely

12 weeksMinimum FODMAP trial (supervised)

135mg TDSMebeverine dose (20 min before meals)

10mg nocteAmitriptyline starting dose (IBS pain)

70%FODMAP response rate (RCT evidence)

📋 Clinical Stem — Chronic Abdominal Pain with Altered Bowel Habit

A patient presents with recurrent crampy abdominal pain, bloating, and altered bowel habit causing significant functional impairment.

“A 28-year-old primary school teacher presents with a 9-month history of lower abdominal cramping, bloating, and alternating loose stools and constipation. Symptoms worsen during stressful periods at work and in the week before her period. She has tried cutting out dairy and gluten without clear benefit. She is increasingly anxious that she may have Crohn’s disease and has been researching symptoms online. She has taken three days off work in the past month. There is no rectal bleeding, no unintentional weight loss, and no nocturnal symptoms.”

This stem applies to any patient with chronic lower abdominal pain, altered bowel habit, or bloating with a functional pattern. Adapt demographics, IBS subtype (C/D/M/U), comorbid anxiety, occupational impact, and the patient’s hidden agenda (cancer or IBD fear).

Scenario A — IBS-D (Diarrhoea Predominant) 35-year-old male, post-meal urgency, loose stools ×4/day, social avoidance; hidden fear of bowel cancer after father’s diagnosis; wants colonoscopy

Scenario B — IBS-C (Constipation Predominant) 45-year-old woman, infrequent hard stools, straining, bloating; requesting strong laxatives; believes diet is entirely to blame

Scenario C — Post-Infectious IBS 24-year-old with ongoing loose stools 4 months after holiday gastroenteritis; worried it will never resolve; asking if antibiotics would help

Scenario D — IBS with Anxiety/Depression 32-year-old with known GAD, GI symptoms worsening under stress; resistant to psychological explanation; requesting CT scan and GI referral

Scenario E — Older First Presentation 52-year-old with 3-month altered bowel habit; requires active CRC/IBD exclusion before IBS diagnosis; hidden cancer fear

Key variables to adapt for IBS subtype (C/D/M/U), patient age, prior investigations, hidden agenda (cancer vs IBD vs “not being believed”), menstrual cycle link, occupational impact, degree of dietary restriction already attempted, specific psychosocial triggers

Steps:

Step 1

History Taking — Open Question First · Targeted Questions · ICE · Psychosocial Context

▲collapse

IBS is a positive clinical diagnosis based on Rome IV symptom criteria — not a label of exclusion when tests are normal. The GP’s history task is threefold: identify the Rome IV IBS pattern, actively screen for red flags mandating urgent action, and uncover the hidden agenda — in GI consultations almost always fear of cancer or IBD. The psychosocial history is diagnostically and therapeutically essential: stress, trauma, and psychiatric comorbidity are aetiological via the gut-brain axis.

🎓 Consultation opener — use existing information first

“I can see from your notes that you’ve been having problems with your tummy and bowels for some time now — I’d really like to understand what’s been going on for you. Could you tell me about it in your own words?”

Asking “How long have you had this?” when duration is documented in the notes wastes a Tasks mark and signals to the examiner you have not read the case. Reference pre-existing information, then open to new content. Scores in Relating to Others: patient-centred opener, no leading.

1A — Start with an open question: let the patient lead, then move to targeted questions

Question to ask	Why it matters clinically	Changes what?
🟩 OPEN QUESTION — always start here“Tell me about what’s been going on with your tummy and bowels — what has it been like for you?”	Allows the patient to lead with their own priority. In IBS, cancer or IBD fear often surfaces in the first 30 seconds if space is given. Closed questions suppress the hidden agenda.Scores RO domain: patient-centred opening, no leading questions, natural ICE emergence	DDxPsychosocialManagement
Pain character and location“Where exactly is the pain? Is it crampy or sharp? Does it come in waves or stay constant?”	IBS pain is typically lower abdominal or central, episodic, crampy, and related to defaecation. Constant severe pain, RUQ pain, or back radiation suggests organic pathology.Epigastric or RUQ pain shifts DDx towards upper GI or biliary disease	DDxReferral
Bowel habit pattern and stool consistency“How often are you opening your bowels? Has frequency changed? Are stools loose, formed, or hard?”	Defines IBS subtype (C/D/M/U) which directly determines pharmacological management. Bristol Stool types 1–2 = IBS-C; types 6–7 = IBS-D. Subtype identification is mandatory for appropriate drug choice.IBS-D → loperamide/TCA; IBS-C → ispaghula/linaclotide; IBS-M → antispasmodics first	DDxManagement
Relationship of pain to defaecation“Does opening your bowels make the pain better or worse? Does passing wind relieve it?”	Rome IV criterion 1: pain associated with defaecation. Relief of pain by opening the bowels is highly characteristic of IBS. Pain completely independent of defaecation points to organic disease.A positive answer satisfies one of the three Rome IV criteria needed for a positive diagnosis	DDx
Bloating and distension“Do you notice your tummy swelling or feeling bloated? When is it worst — morning, after meals, or by the evening?”	Bloating affects over 80% of IBS patients. Evening worsening after meals is typical of IBS. Objective distension on examination (not just the symptom) may indicate ascites or obstruction — organic causes.If bloating dominates without other IBS features, consider SIBO, coeliac, or bile acid malabsorption	DDxManagement
Active red flag screening“Have you noticed blood in your stools? Any significant weight loss without trying? Have symptoms ever woken you at night?”	Rectal bleeding, unintentional weight loss, and nocturnal symptoms are incompatible with IBS and mandate urgent action. These must be asked directly — patients often do not volunteer red flags unless specifically prompted.Never attribute rectal bleeding to haemorrhoids in a patient with altered bowel habit without CRC exclusion	999/UrgentReferralInvestigations
Symptom triggers“Does anything make symptoms better or worse — specific foods, stress, your period, or particular situations?”	Identifying triggers is simultaneously diagnostic and therapeutic. Stress triggers confirm gut-brain axis involvement. Menstrual cycle worsening is common in women. Specific food triggers guide FODMAP advice directly.High-FODMAP foods (onions, garlic, wheat, lactose, apples, legumes) guide dietary intervention	ManagementPsychosocial
Previous investigations and treatments“Have you had tests before — blood tests, scans, endoscopies? Have you tried anything for the symptoms?”	Avoids unnecessary duplication. If full workup done 18 months ago with normal results and no new red flags, repeat colonoscopy is not indicated. Prior dietary trials inform whether formal FODMAP supervision is needed.Document what was tested, when, and results — “I’ve had loads of tests” needs careful unpacking	InvestigationsManagement
Functional impact on daily life“How much is this affecting your work, social life, and daily activities? Are there things you are avoiding because of it?”	Functional impairment is a key component of IBS severity (IBS-SSS). Avoidance behaviours (not eating before meetings, staying near toilets, refusing restaurants) quantify disease impact and identify psychological complexity.Significant social avoidance → gut-directed CBT or hypnotherapy referral indicated alongside pharmacotherapy	ManagementPsychosocialReferral
Detailed dietary history“Walk me through a typical day of eating. How much fibre, fruit, vegetables? Coffee, alcohol, fizzy drinks?”	Dietary history directly informs the management plan. High-FODMAP intake, excessive insoluble fibre (bran), caffeine, and alcohol all exacerbate IBS. A 24-hour dietary recall is more useful than asking “do you eat healthily?”Bran and wheat bran cereals specifically worsen IBS — patients often increase these thinking they are helping	Management
Stress and mental health screening“How have you been feeling in yourself — mood and stress levels? Has anything significant been happening at home or work?”	40–60% of IBS patients have comorbid anxiety or depression. The gut-brain axis is central to IBS pathophysiology. Screening for psychiatric comorbidity changes the management plan and is required for a strong pass in SCA.Offer PHQ-9 and GAD-7 if any indication of mood or anxiety symptoms; document baseline before prescribing neuromodulator	ManagementPsychosocial

1B — Red flags: must not miss · must ask · must act

🚨

Red Flags — act before continuing history

Red flag	Why dangerous	Action
Rectal bleeding (any amount)	May indicate CRC, IBD, or ischaemic colitis. Never attribute to haemorrhoids in a patient with altered bowel habit without active exclusion. Age ≥40 with PR bleeding and changed bowel habit = 2WW under NICE NG12.	2WW CRC referral
Unintentional weight loss (>3 kg)	IBS never causes weight loss. Any significant unintentional weight loss alongside GI symptoms mandates urgent investigation for malignancy, IBD, or malabsorption. IBS diagnosis should not be made alongside unexplained weight loss.	Urgent investigation + 2WW
Nocturnal symptoms waking from sleep	IBS does not disrupt sleep architecture. Diarrhoea or severe pain waking the patient from sleep strongly suggests organic disease — IBD, microscopic colitis, or colorectal cancer. This symptom alone warrants urgent investigation.	Urgent GI investigation
Age ≥50 with new onset bowel symptoms	First presentation of IBS-type symptoms at age ≥50 has a significantly higher prior probability of CRC. IBS diagnosis should only be made in this age group after organic pathology has been actively excluded.	Investigate before IBS diagnosis
First-degree family history of CRC, IBD, or coeliac	First-degree FH of CRC doubles lifetime risk. FH of IBD increases individual risk 10–15×. Lower threshold for investigation and formal surveillance discussions.	Targeted investigations including colonoscopy
Raised inflammatory markers or iron deficiency anaemia	IBS does not cause systemic inflammation. Raised CRP or ESR alongside GI symptoms points to IBD, malignancy, or infective colitis. Iron deficiency anaemia mandates GI investigation as a priority.	Urgent GI referral and investigation
Palpable abdominal or rectal mass	A palpable mass in the context of bowel symptoms is cancer until proven otherwise. IBS produces no palpable abnormality on examination. This finding demands same-day assessment regardless of functional history.	Same-day assessment / 2WW

🛡️

Safeguarding Considerations — Consider in Every Consultation

IBS is significantly associated with a history of trauma and abuse. Studies show 30–50% of IBS patients referred to secondary care have a history of physical, sexual, or emotional abuse, frequently undisclosed in routine consultations. Chronic stress from domestic abuse or adverse childhood experiences directly dysregulates the gut-brain axis and manifests as IBS. High suspicion is appropriate in patients with frequent attendances, unexplained somatic symptoms, or resistance to psychological explanation.

🏠 Domestic Abuse / Intimate Partner Violence

Chronic stress and fear from IPV is a recognised precipitant of IBS via HPA axis dysregulation and altered gut motility
Pelvic and abdominal pain in women with frequent unexplained somatic symptoms may mask physical abuse injuries
Use SAFE questions if clinical suspicion is raised — routine enquiry is supported by NICE guidance
Safety planning, IDVA referral, DASH risk assessment, MARAC where indicated; document carefully
Patient consent to share information is not required when there is immediate risk of serious harm

👴 Older Adults / Carer-related Concern

New bowel symptoms in older adults in care settings may reflect neglect — poor nutrition, dehydration, or immobility
Carer-facilitated over-medication with laxatives or antimotility agents should be considered in new bowel habit changes
Social isolation may prevent accurate symptom reporting — collateral history from a trusted person is valuable
Cognitive decline as explanation for change in bowel habit or inability to describe symptoms should be considered

👦 Children in the Household

Parental IBS with high health anxiety may model illness behaviour and GI symptoms in children — a recognised paediatric presentation
Household stress or domestic abuse causing parental IBS may also be directly harming children in the household
If the consultation reveals severe parental anxiety or functional impairment, consider implications for dependent children
Children presenting with recurrent abdominal pain may reflect household dysfunction requiring wider safeguarding assessment

💊 Self-Harm / Medication Misuse Risk

Loperamide misuse is well-documented — high doses cause cardiac arrhythmia (prolonged QTc) and opioid-like psychoactive effects
Patients with comorbid anxiety, depression, or substance misuse and severe IBS-D may misuse loperamide to control anticipatory urgency
Prescribe loperamide with appropriate quantity limits; review regularly; do not prescribe large quantities without monitoring
Significant psychiatric comorbidity should be addressed concurrently with GI management

If a safeguarding concern is identified: Follow your practice safeguarding policy. The threshold is reasonable grounds to suspect harm — not certainty. Document clearly, discuss with your named safeguarding lead, and consider referral to MARAC or Adult/Children’s Social Care as appropriate. Use the DASH risk assessment tool for domestic abuse.

1C — PMH · FH · Drug history · Social history: management impact

🧬 PMH / FH — changes management

Factor	Why it matters	Management impact
IBD (Crohn’s / UC)	Can coexist with IBS-type functional symptoms; flares mimic IBS-D closely	Lower threshold for calprotectin and colonoscopy; gastroenterology review if flare suspected
Coeliac disease	Up to 5% of IBS-type presentations are undiagnosed coeliac — particularly IBS-D and IBS-M	tTG-IgA mandatory before any FODMAP or gluten restriction; biopsy confirmation required before label is changed
Thyroid disease	Hypothyroidism causes constipation; hyperthyroidism causes diarrhoea — both mimic IBS subtypes exactly	TSH in all new IBS presentations; treat thyroid disease first and reassess bowel symptoms at 3 months
Previous GI surgery (cholecystectomy)	Post-cholecystectomy bile acid diarrhoea exactly mimics IBS-D	Consider SeHCAT scan or empirical cholestyramine trial; do not attribute all post-surgical diarrhoea to IBS
Endometriosis	Cyclical bowel symptoms in women are frequently misdiagnosed as IBS for years — average diagnostic delay is 7–8 years	Refer to gynaecology if cyclical pain, dysmenorrhoea, or dyspareunia present alongside bowel symptoms
Anxiety / depression	Strongest predictor of IBS severity, chronicity, and treatment response via the gut-brain axis	Psychological therapy (CBT, gut-directed hypnotherapy) first-line for moderate-severe IBS; neuromodulator (TCA or SSRI)
Family history of CRC or IBD	Raises prior probability of organic disease; patient anxiety about this is clinically legitimate	Lower threshold for colonoscopy; formal cancer risk assessment; enhanced surveillance discussion
Childhood or previous trauma	Early life adversity is a recognised aetiological factor via altered HPA axis and gut-brain dysregulation	Trauma-informed care; psychological therapy; avoid dismissing symptoms without exploring contributory history

💊 Drug history · Social history — clinical impact

Factor	Why it matters	Management impact
NSAIDs / Aspirin	Cause GI mucosal damage, diarrhoea, and worsen IBS symptoms; can mask IBD activity	Review indication; switch to paracetamol; add PPI if NSAIDs essential; stop before attributing symptoms to IBS
Antibiotics (recent or frequent)	Dysbiosis from antibiotic use is a recognised precipitant of post-infectious IBS	Document antibiotic history; consider probiotics for dysbiosis; avoid unnecessary future courses
Metformin	Causes diarrhoea in 20–30% of users — easily mistaken for IBS-D	Switch to modified-release metformin; take with food; review if GI side effects are unacceptable to the patient
SSRIs / SNRIs	Can cause GI side effects that mimic or worsen IBS; relevant to neuromodulator prescribing decisions	Note current psychiatric medications; avoid duplicating serotonergic agents; review timing and dose
Alcohol intake	Direct GI irritant — worsens bloating, loose stools, and urgency; exacerbates IBS-D directly	Advise reduction if >14 units/week; include alcohol diary in symptom diary; quantify intake at each review
Caffeine intake	Direct colonic stimulant — increases motility and worsens urgency; energy drink use underreported in younger patients	Reduce to ≤3 caffeinated drinks/day; decaffeinated alternatives; peppermint tea has direct antispasmodic benefit
Occupation and work stress	High-stress occupations (teachers, healthcare, emergency services) have higher IBS prevalence	Occupational stress management; fit note if severity warrants; occupational health referral for high-impact roles
Smoking	Nicotine has direct colonic effects; cessation causes transient constipation; relevant to overall cancer risk	Cessation support; warn of short-term bowel changes; balance overall health benefit against transient GI effects

1D — ICE: Ideas · Concerns · Expectations — in every consultation, not just SCA

IBS is unusual in that the patient’s fear of serious disease is often the primary driver of the consultation, not the symptoms themselves. A patient convinced they have bowel cancer will not engage with a FODMAP diet until that fear is directly named and addressed. Studies show that patient-centred explanation of the IBS mechanism — including specifically naming and refuting the patient’s illness model — reduces IBS symptom severity scores even without pharmacological change. In the SCA, failure to explore ICE and address the cancer or IBD fear is the most common reason for a Relating to Others deduction in GI cases.

💭 Ideas

“What do you think might be causing all of this? Have you had any ideas or done any reading about what it could be?”

Most IBS patients arrive with a specific illness narrative — often cancer or Crohn’s disease. Uncovering this model allows you to address it directly with evidence and explanation rather than offering vague reassurance that the patient will not believe.

😟 Concerns

“Is there anything specific you are worried these symptoms might mean? Sometimes people have a concern they haven’t mentioned yet — like a serious illness.”

Cancer fear is the single most common hidden agenda in GI consultations and is rarely volunteered spontaneously. If not explicitly named — “It sounds like you might be worried this could be cancer or Crohn’s?” — the patient leaves with their fear intact regardless of what was said about IBS. This is a mark-scoring behaviour in the SCA.

🎯 Expectations

“What were you hoping we might be able to do for you today? Is there something specific — a test, a referral, or medication — that you were expecting?”

IBS patients frequently attend expecting colonoscopy or urgent GI referral. If this expectation is not explored, a management plan of dietary advice and antispasmodics will feel dismissive. Negotiating around the expectation is required for a patient-centred plan and a Relating to Others pass in the SCA.

1E — Psychosocial context: the person behind the IBS

IBS is a disorder of gut-brain interaction (Rome IV definition, 2016). Psychological and social factors directly activate the HPA axis, alter gut motility via the enteric nervous system, increase visceral hypersensitivity, and reduce the pain threshold for normal gut sensations. These factors must be explored as direct causes and perpetuators of the condition, not as secondary consequences. Addressing them is as clinically important as any pharmacological intervention.

😧 Anxiety and Psychological Stress

Chronic stress activates the HPA axis, raises cortisol, and directly alters gut motility and visceral sensitivity. Symptom monitoring creates a vicious cycle: the more the patient focuses on their gut, the worse the symptoms become.

“Has life been particularly stressful lately — at work or home? I ask because stress has a very direct physical effect on how the gut works.”

If anxiety is a major driver: gut-directed CBT or hypnotherapy referral; low-dose amitriptyline 10mg nocte or SSRI; PHQ-9 and GAD-7

🔬 Post-Infectious Trigger (PI-IBS)

PI-IBS develops in 10–25% of patients after acute gastroenteritis. The infection alters gut microbiome, increases intestinal permeability, and sensitises enteric neurons — producing persistent IBS symptoms after the infection resolves.

“Did these symptoms start around the time of a stomach bug? Sometimes an infection can trigger these symptoms even long after the bug itself has gone.”

PI-IBS has better prognosis than idiopathic IBS — symptoms often improve spontaneously over 12–24 months; this prognostic information is therapeutically useful

😴 Sleep Disturbance

Poor sleep quality directly worsens IBS symptoms. Sleep deprivation increases visceral sensitivity, lowers pain thresholds, and exacerbates anxiety that drives symptom amplification. The relationship is bidirectional.

“How is your sleep? People don’t always realise how closely sleep and gut symptoms are connected — poor sleep can make gut symptoms significantly worse.”

Important: nocturnal symptoms waking the patient are a red flag for organic disease, not a feature of IBS — clarify this distinction carefully

🏠 Adverse Life Events and Trauma History

History of childhood adversity, sexual abuse, or significant psychological trauma is present in up to 50% of IBS patients in secondary care. Early life stress programmes the gut-brain axis through epigenetic mechanisms, increasing lifelong IBS vulnerability.

“Sometimes gut problems can be connected to things that have happened in our past that were very difficult. Is that something that might be relevant, or that you’d feel comfortable talking about?”

Trauma-informed care: acknowledge, validate, offer psychological support; never dismiss symptoms as “just stress” without proper exploration

👩‍💼 Occupational and Social Functioning

IBS causes significant occupational impairment — absenteeism, presenteeism, avoidance of travel and meetings. Patients restrict diet severely, sometimes developing nutritional deficiencies or disordered eating patterns meeting criteria for ARFID.

“Is this affecting your work or the things you enjoy? Are you avoiding going out for meals or steering clear of situations because of worry about symptoms?”

Avoidance behaviours → CBT referral; significant functional impairment → fit note consideration; occupational health for high-impact roles

🍽️ Disordered Eating and Food Avoidance

Patients with IBS frequently develop highly restrictive food avoidance — eliminating entire food groups based on perceived triggers. Without dietetic guidance, this leads to nutritional inadequacy, social isolation, and food-related anxiety.

“Have you been cutting out a lot of foods? Sometimes I see people who’ve ended up on a very restricted diet — how many foods are you avoiding at the moment?”

Refer to FODMAP-trained dietitian for supervised approach; screen for ARFID or disordered eating; monitor BMI and micronutrient status

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

“It sounds like you might be worried this could be something serious — like Crohn’s disease or cancer. Is that on your mind?”

“I can see from your notes that... — tell me, what has changed or what has brought you in today?”

“The symptoms you are describing — particularly the way the pain relates to opening your bowels — follow a very recognisable pattern.”

“Has life been particularly stressful? Stress has a very direct physical effect on the gut — it is not just psychological.”

Deductions (examiner flags)

Asking “How long have you had this?” when the duration is documented in the notes
Jumping to diagnosis or investigations before exploring ICE — especially cancer or IBD fear
Not screening verbally for red flags (PR bleeding, weight loss, nocturnal symptoms)
Mentioning stress without linking it explicitly to gut physiology and the gut-brain axis
Overlooking trauma history as a potential aetiological factor in a GI consultation
Not asking about functional impact on work and social life

🔴 Red — failing

No open question · Jumping to tests or diagnosis · ICE not explored · Red flags not screened · No psychosocial history taken

🟠 Amber — borderline

Open question used but followed immediately by closed questions · ICE partially explored · One red flag missed · Stress mentioned but not connected to gut-brain physiology

🟢 Green — passing

Open question first · All red flags screened · ICE fully explored including specific cancer/Crohn’s fear · Gut-brain axis mentioned · Dietary and social history taken · Prior investigations reviewed before ordering new ones

Step 2

Triage Engine — Emergency · Urgent · Routine

▲collapse

The critical triage decision in any patient with GI symptoms is whether this is functional IBS (manageable in primary care) or organic disease (IBD, colorectal cancer, coeliac) requiring urgent investigation or referral. NICE CG61 red flag criteria must be systematically applied. Never confidently diagnose IBS in a patient aged ≥50 without first excluding organic pathology. Colorectal cancer is the fourth most common cancer in the UK and frequently presents with IBS-type symptoms.

🔴 Emergency

999 or Same-Day Hospital

Call 999 / A&E now

Acute severe abdominal pain with peritonismRigid abdomen, guarding, rebound tenderness — perforation or obstruction until proven otherwise; call 999 immediately
Haemodynamically compromising rectal haemorrhageMajor GI bleed causing haemodynamic instability — immediate hospital admission via 999
Signs of toxic megacolonAcute colitis with fever >38.5°C, HR >120, abdominal distension — same-day hospital; do not manage in primary care
Clinical bowel obstructionAbsolute constipation, distension, vomiting, high-pitched or absent bowel sounds — A&E immediately
Sepsis with GI sourceNEWS2 ≥5 with abdominal symptoms — same-day hospital admission; activate sepsis pathway

🟠 Urgent

Same-Day GP / Urgent Referral

Days to 2 weeks

Rectal bleeding + altered bowel habit, age ≥402WW colorectal cancer referral under NICE NG12 — do not attribute to haemorrhoids without active CRC exclusion
Unintentional weight loss >3 kgUrgent investigation within 2 weeks; 2WW CRC consideration depending on associated features; never attribute to IBS
Palpable abdominal or rectal mass2WW CRC pathway even in a patient with known IBS history presenting with this new finding
Raised CRP / calprotectin >200 μg/gUrgent IBD or malignancy workup; fast-track GI referral for colonoscopy and biopsy
Iron deficiency anaemia alongside GI symptomsUrgent 2WW upper and/or lower GI endoscopy — do not attribute to IBS; investigate source of blood loss
First presentation of bowel symptoms, age ≥50Investigate before making IBS diagnosis — CRC prevalence requires active exclusion with blood tests and likely colonoscopy

🟢 Routine

Manage in Primary Care

GP practice

Typical IBS pattern, age <50, no red flags, normal investigationsPositive Rome IV criteria with normal FBC, CRP, calprotectin, and coeliac screen — manage confidently in primary care
Known IBS — symptom flare without new featuresReassess for new red flags; adjust management; review dietary and lifestyle adherence; document changes
Post-infectious IBS within 12 months, no red flagsReassure about prognosis; symptomatic management; review at 3 months
IBS with comorbid anxiety or depression, stableIntegrated GI and mental health management; psychological therapy referral; neuromodulator if appropriate
Routine dietary management and FODMAP referralRoutine referral to FODMAP-trained dietitian; not time-critical unless nutritional compromise is present

🎓 SCA Checkpoint — Step 2TasksRelating to OthersGlobal Skills

Key phrases that score

“I want to make sure we are not missing anything serious first — I will ask you a few important questions, then we can focus on the most likely cause.”

“Given what you have described, I do not think this needs emergency treatment today, but I want to do some targeted tests to be thorough.”

“There are certain symptoms — like blood in your stool or losing weight without trying — that would change what we need to do today. You do not have those, which is genuinely reassuring.”

Deductions (examiner flags)

Confidently diagnosing IBS in a patient aged ≥50 without any investigation to exclude organic disease
Dismissing rectal bleeding as haemorrhoidal without applying the 2WW criterion where indicated
Failing to acknowledge the importance of red flag symptoms verbally in the consultation
Making the patient feel their concern is trivial by rushing to reassurance before completing the assessment

🔴 Red — failing

IBS diagnosed in age ≥50 without investigation · Red flags not screened · 2WW not triggered when clinically indicated

🟠 Amber — borderline

Red flags screened but not acted upon appropriately · Triage decision correct but reasoning not shared with patient

🟢 Green — passing

All red flags systematically screened · Triage decision explained in plain language · 2WW pathway correctly identified when indicated · Age-appropriate investigation threshold applied

Step 3

Do I Need This Examination?

▲collapse

In IBS, examination is primarily used to exclude organic disease rather than confirm the diagnosis — IBS has no specific positive examination findings. The key findings that mandate a change in management are: palpable mass (cancer or IBD), peritonism (surgical emergency), signs of malnutrition or weight loss (malabsorption or malignancy), and clinical anaemia (organic GI blood loss). A normal examination, explained clearly to the patient, is itself a therapeutic intervention that reduces health anxiety.

Examination	Why it matters	What finding changes management	Changes management?
General inspection — weight, nutrition, pallor	IBS does not cause weight loss or malnutrition. Cachexia, muscle wasting, or pallor should prompt urgent investigation for malignancy or malabsorption. Document weight and BMI as a baseline for monitoring.Significant weight loss alongside GI symptoms = organic disease until proven otherwise	Weight loss >3 kg → urgent investigation and 2WW; cachexia → same-day hospital assessment	YES — if weight loss or cachexia
Abdominal examination — full IPPA	IBS may produce mild diffuse tenderness on palpation. A palpable mass, hepatomegaly, or organomegaly is not consistent with IBS and requires urgent investigation. Rebound tenderness and guarding indicate peritonism — a surgical emergency.Voluntary guarding from anxiety can mimic peritonism — check carefully with distraction technique	Palpable mass → 2WW · Peritonism → 999 · Hepatomegaly → liver disease workup	YES — if mass, organomegaly, or peritonism
Digital rectal examination (DRE)	Not required routinely in IBS, but indicated if: rectal bleeding reported, rectal mass suspected, constipation not responding to treatment, or patient aged ≥50 with new bowel symptoms. High sphincter tone may indicate pelvic floor dyssynergia.Rectal mass or blood on glove → 2WW CRC pathway; document clearly in notes	Mass or fresh blood on glove → 2WW · High sphincter tone → pelvic floor physiotherapy referral	Context — if indicated
Conjunctival pallor and signs of anaemia	Iron deficiency anaemia in a GI patient suggests organic blood loss and requires investigation of upper and lower GI tract. IBS never causes anaemia — its presence demands investigation regardless of the duration of functional symptoms.FBC should be checked if clinical anaemia is suspected; do not attribute anaemia to IBS alone	Clinical anaemia → FBC urgently + 2WW GI endoscopy regardless of IBS history	YES — if clinical anaemia present
Objective abdominal distension on examination	Bloating is a patient-reported symptom; objective distension on examination may indicate ascites, obstruction, or massive faecal loading. Shifting dullness on percussion points to ascites and liver disease — not IBS.Distinguishing patient-reported bloating (IBS) from objective clinical distension (organic) is clinically important	Ascites signs → urgent liver/oncology investigation · Massive faecal loading → disimpaction protocol	YES — if objective distension beyond gas
Perianal inspection	In patients with diarrhoea or perianal symptoms, inspection may identify fissures, fistulae, or skin tags consistent with Crohn’s disease. Perianal Crohn’s features demand urgent GI referral and revision of the IBS diagnosis.Perianal fistula or skin tags in a patient with diarrhoea → IBD referral; revise diagnosis away from IBS	Perianal Crohn’s features → urgent GI referral; revise IBS diagnosis to IBD suspected	Context — if Crohn’s suspected
Thyroid examination	Thyroid disease is a common and treatable cause of altered bowel habit. A goitre or thyroid nodule on examination should prompt urgent TSH testing before IBS is diagnosed in a patient with IBS-C or IBS-D.Particularly important in IBS-D and IBS-C where the symptom pattern mirrors thyroid dysfunction	Goitre or nodule → TSH urgently; treat thyroid disease first and reassess GI symptoms before IBS label applied	Context — if thyroid disease suspected
Skin examination — pyoderma, erythema nodosum, oral aphthous ulcers	Extraintestinal manifestations of IBD are frequently overlooked. Erythema nodosum, pyoderma gangrenosum, and oral aphthous ulcers are associated with IBD, not IBS. Their presence demands urgent GI referral and revision of the diagnosis.Any extraintestinal IBD feature → revise diagnosis; urgent gastroenterology referral; do not label as IBS	Any extraintestinal IBD feature → urgent GI referral; changes diagnosis from IBS to IBD suspected	YES — changes diagnosis if IBD features found

🎓 SCA Checkpoint — Step 3TasksRelating to OthersGlobal Skills

Key phrases that score

“I would like to examine your tummy today — it will help me rule out anything we need to be concerned about.”

“The examination is reassuringly normal — there is no mass or tenderness that would suggest something more serious going on.”

“I did not find any signs of anaemia or significant weight loss today, which is genuinely reassuring alongside the rest of the picture.”

Deductions (examiner flags)

Not offering examination to a patient presenting with new GI symptoms
Finding a palpable mass but attributing it to IBS without urgent investigation
Not explaining what you are examining for before you start
Attributing all examination findings to IBS without considering organic differentials

🔴 Red — failing

No examination offered · Palpable mass attributed to IBS without investigation

🟠 Amber — borderline

Examination done but findings not clearly communicated · Normal examination not used therapeutically to provide reassurance

🟢 Green — passing

Examination offered with explanation of purpose · Findings communicated clearly in plain language · Normal findings used to provide genuine targeted reassurance

Step 4

Do I Need This Investigation?

▲collapse

NICE CG61 recommends a targeted investigation screen in all new IBS presentations to exclude organic disease — but extensive investigation is not required and does not improve outcomes. The minimum screen is FBC, ESR/CRP, tTG-IgA coeliac antibodies, and faecal calprotectin. Colonoscopy is not indicated in typical IBS aged <50 with normal inflammatory markers and calprotectin. Investigations should be ordered purposefully and each test’s meaning explained to the patient in plain language.

Investigation	Clinical question it answers	What result changes management?
FBC (Full Blood Count)	Is there anaemia (organic GI blood loss), leucocytosis (infection or IBD), thrombocytosis (chronic inflammation or malignancy), or macrocytosis (folate/B12 deficiency suggesting malabsorption)?	Hb <110 g/L → 2WW GI endoscopy · MCV <80 with low ferritin → iron deficiency, investigate source · WBC >11 → exclude infection/IBD · Platelets >400 → screen for chronic inflammation/malignancy
CRP / ESR	Is there systemic inflammation pointing to IBD, malignancy, or infective colitis? IBS is a non-inflammatory condition — normal inflammatory markers support a functional diagnosis and are genuinely reassuring to the patient.	CRP >10 mg/L or ESR >20 mm/hr → investigate for IBD and malignancy; do not make an IBS diagnosis with raised markers without first excluding organic disease
tTG-IgA (Coeliac Screen)	Is this undiagnosed coeliac disease presenting as IBS? Coeliac affects up to 5% of IBS-type presentations and is entirely treatable with a gluten-free diet. Must be tested before any FODMAP trial or gluten restriction.	Positive tTG-IgA (on gluten-containing diet) → refer for duodenal biopsy before any dietary change; a positive result fundamentally changes the diagnosis and management plan
Faecal Calprotectin	Is there intestinal inflammation suggesting IBD? Calprotectin is a neutrophil protein released when the gut wall is inflamed — it is normal in functional IBS. The single most useful test to differentiate IBS from IBD in primary care.	<50 μg/g: IBD very unlikely → supports IBS diagnosis · 50–200 μg/g: borderline → repeat in 6 weeks · >200 μg/g: IBD likely → urgent GI referral for colonoscopy
TSH (Thyroid Stimulating Hormone)	Is thyroid dysfunction contributing to altered bowel habit? Hypothyroidism causes constipation; hyperthyroidism causes diarrhoea — both mimic IBS subtypes closely. Should be checked routinely in all new IBS presentations.	Abnormal TSH → treat thyroid condition first; reassess bowel symptoms at 3 months after thyroid treatment initiated; do not diagnose IBS until thyroid disease is controlled
Stool M/C/S (Microscopy, Culture, and Sensitivity)	Is there an ongoing infective cause for diarrhoea? Relevant in post-travel diarrhoea, acute-onset symptoms, immunocompromised patients, or failure to respond to initial IBS management.	Positive culture, ova, or cysts → treat specific infection; C. difficile toxin positive → refer; Giardia → metronidazole; do not diagnose IBS while active infection is present
Total serum IgA (if tTG-IgA negative but coeliac suspected)	IgA deficiency (1 in 500 people) causes falsely negative tTG-IgA serology. A patient with selective IgA deficiency and coeliac disease will test negative on the standard coeliac screen.	Low total IgA → request IgG-based coeliac antibodies (anti-DGP IgG) or refer directly for small bowel biopsy with appropriate clinical documentation
Colonoscopy / flexible sigmoidoscopy	Is there colorectal cancer, IBD, or microscopic colitis? Indicated when red flags are present or investigations suggest organic pathology — NOT required for typical IBS aged <50 with normal bloods and calprotectin.	Any structural lesion, dysplasia, or histological inflammation → changes diagnosis and management fundamentally; negative colonoscopy with normal biopsies → enables confident, evidence-based reassurance
Hydrogen breath test (lactose / SIBO)	Is small intestinal bacterial overgrowth or carbohydrate malabsorption contributing to symptoms? Relevant if bloating is the dominant complaint and FODMAP restriction under supervision has not provided adequate relief.	Positive SIBO test → consider antibiotic treatment (rifaximin used off-label in UK) · Positive lactose intolerance → targeted dietary restriction rather than full FODMAP elimination

🎓 SCA Checkpoint — Step 4TasksRelating to OthersGlobal Skills

Key phrases that score

“I would like to do some blood tests and a stool test to make sure we are not missing anything — including a test for coeliac disease and one specifically for gut inflammation.”

“The calprotectin test is particularly helpful because if it is normal, it makes an inflammatory condition like Crohn’s or colitis very unlikely — which should be genuinely reassuring.”

“I do not think you need a colonoscopy right now — let us see what the blood tests and stool test show first and review together.”

Deductions (examiner flags)

Not checking the coeliac screen before recommending a gluten-free or FODMAP diet
Ordering colonoscopy without a red flag indication in a typical IBS patient aged <50
Failing to explain the purpose and meaning of each investigation to the patient
Not ordering faecal calprotectin when IBD forms part of the differential diagnosis

🔴 Red — failing

No investigation offered · Coeliac screen omitted before dietary advice · Tests ordered without any explanation to patient

🟠 Amber — borderline

Minimum screen ordered but calprotectin omitted · Results interpretation not pre-explained · Colonoscopy ordered unnecessarily for typical uncomplicated IBS

🟢 Green — passing

NICE minimum screen ordered · Each test explained in plain language · Calprotectin ordered as IBD exclusion · Threshold for colonoscopy correctly calibrated · Meaning of results explained to patient including what they imply for the diagnosis

Step 5

Reaching a Diagnosis & DDx — Explained in Plain Language

▲collapse

IBS is a positive clinical diagnosis based on Rome IV criteria — not a default label. Patients need to understand what IBS actually is (a disorder of gut-brain communication, not structural damage), why the diagnosis is valid, and what it means for their life. Vague reassurance (“your tests are normal so it must be IBS”) scores very poorly in the SCA and is clinically inadequate. The diagnosis must be explained, not just named.

🗣️ Explaining the Diagnosis in Plain Language — say something like this

“What you have is called irritable bowel syndrome, or IBS. I want to be clear — this is a real, recognised condition, not something we say just because the tests are normal. IBS is caused by the way your gut and your brain communicate with each other. Think of it like a sensitive alarm system: your bowel is reacting too strongly to normal things like digestion, stress, or certain foods. There is nothing structurally wrong with your gut, it has not been damaged, and it will not turn into cancer. But that hypersensitivity causes very real pain, bloating, and changes in your bowel habits. The good news is that with the right approach — looking at diet, stress, and sometimes medication — most people significantly reduce their symptoms.”

💬 Addressing the patient’s own explanation — why it may not be the full picture

“I think I have got Crohn’s disease — I have been reading about it and my symptoms match.”
“I completely understand why you have been researching — these symptoms are distressing and it makes sense to want an explanation. Crohn’s disease does cause similar symptoms, which is exactly why I want to do the right tests. The key difference is that Crohn’s causes inflammation — which shows up in the blood tests and a stool test called calprotectin. If those are normal, we can be very confident this is not Crohn’s. IBS causes very similar symptoms but without any inflammation or structural damage.”

“But my tests have always come back normal — surely something is being missed?”
“Actually, with IBS, normal tests are exactly what we expect and they are genuinely reassuring rather than frustrating. The condition is real, but it works differently from diseases like IBD or cancer. The gut is oversensitive and reacting too strongly, but there is nothing structurally wrong. Normal scans and blood tests do not mean we have missed something — they actually help confirm the diagnosis.”

A — Diagnosable in Primary Care

GP can diagnose

IBS (all subtypes)

Rome IV positive: ≥6 months symptoms, ≥1 day/week abdominal pain for last 3 months, associated with ≥2 of: related to defaecation, change in stool frequency, change in stool form. Normal CRP, FBC, calprotectin, and coeliac screen.

Functional Bloating / Functional Abdominal Pain

Bloating or pain without meeting full Rome IV IBS criteria; normal investigations; managed similarly to IBS with dietary and lifestyle measures.

Lactose / Fructose Intolerance

Diagnosed by dietary exclusion and reintroduction, or hydrogen breath testing; part of FODMAP spectrum; managed with targeted dietary restriction.

B — Suspected — Refer

Refer for confirmation

IBD — Crohn’s Disease / Ulcerative Colitis

Raised CRP/ESR, faecal calprotectin >200 μg/g, bloody diarrhoea, weight loss, extraintestinal features (skin, joints, eyes); refer urgently to gastroenterology for colonoscopy and biopsy.

Coeliac Disease

Positive tTG-IgA serology (on gluten-containing diet), malabsorption features, iron deficiency, family history; refer for duodenal biopsy before any dietary change; gluten-free diet must not start before biopsy.

Bile Acid Malabsorption

Chronic watery diarrhoea after cholecystectomy or terminal ileal resection; consider SeHCAT scan; empirical cholestyramine trial reasonable if high suspicion.

Microscopic Colitis

Chronic watery non-bloody diarrhoea; typically middle-aged to older women; normal endoscopic appearance but abnormal histology; refer for colonoscopy with biopsies.

C — Emergency — Act Now

Diagnose & act

Colorectal Cancer

Rectal bleeding, altered bowel habit, weight loss, palpable mass, iron deficiency anaemia, age ≥50; 2WW CRC pathway — never attribute these features to IBS without organic exclusion.

Acute Intestinal Obstruction

Absolute constipation, vomiting, distension, tinkling or absent bowel sounds; 999 emergency; may present in a known IBS patient as a new, distinct acute event.

Toxic Megacolon / Severe Acute Colitis

Acute severe IBD flare with systemic toxicity, fever >38.5°C, tachycardia, distension; immediate hospital admission; do not manage in primary care under any circumstances.

📊 IBS Subtype Classification (Rome IV) — Determines Pharmacological Management

Subtype	Stool pattern (Bristol Scale)	Key symptoms	First-line pharmacological approach
IBS-C	Types 1–2 (>25% of stools)	Hard, lumpy stools; straining; incomplete evacuation; bloating	Ispaghula husk 1 sachet BD (soluble fibre); avoid insoluble fibre (bran); linaclotide 290mcg OD if inadequate response
IBS-D	Types 6–7 (>25% of stools)	Loose/watery stools; urgency; frequency; post-prandial urgency	Loperamide 2–4mg PRN (max 16mg/day); antispasmodics for pain; low-dose amitriptyline 10mg nocte if first-line fails
IBS-M	Types 1–2 AND 6–7 (>25% each)	Alternating diarrhoea and constipation; crampy pain; bloating	Antispasmodics as first-line for pain; address dominant bowel symptom; dietary management is central
IBS-U (Unclassified)	Does not meet IBS-C, D, or M criteria	Abdominal pain with altered habit but inconsistent stool pattern	Antispasmodics for pain; dietary management; reassess at 4–6 weeks with stool diary review
⚠ Rome IV criteria (positive diagnosis): Recurrent abdominal pain, on average ≥1 day/week in the last 3 months, associated with ≥2 of: (1) related to defaecation, (2) associated with change in stool frequency, (3) associated with change in stool form/appearance. Symptom onset at least 6 months ago. All three criteria must be met.

🎓 SCA Checkpoint — Step 5TasksRelating to OthersGlobal Skills

Key phrases that score

“The diagnosis is called IBS — irritable bowel syndrome. I want to be clear: this is a real condition, not just a label for when we cannot find anything.”

“Your gut is more sensitive than it should be — it is reacting too strongly to normal things like food and stress. There is no damage, no inflammation, and it will not turn into cancer.”

“I can see why you were worried about Crohn’s — the symptoms do look similar. The key difference is that Crohn’s causes inflammation which we can test for, and your tests are normal.”

Deductions (examiner flags)

“Your tests are all normal, so there is nothing wrong” — this invalidates the diagnosis and damages trust
Failing to explain the gut-brain axis mechanism in any form to the patient
Not addressing the patient’s specific illness belief (Crohn’s/cancer fear)
Not identifying the IBS subtype or its implications for management

🔴 Red — failing

IBS presented only as a diagnosis of exclusion · No mechanism explained · Cancer/IBD fear not addressed · Subtype not identified

🟠 Amber — borderline

Diagnosis named but mechanism not explained in plain language · DDx addressed but patient’s specific fear not directly named

🟢 Green — passing

Positive Rome IV diagnosis explained · Gut-brain axis mechanism explained with analogy · Patient’s specific fear named and addressed · Subtype identified and management implications stated

Step 6

If Referral Is Needed — What the GP Does Before & During

▲collapse

Most IBS is managed entirely in primary care. Referral is required when red flags are present, the diagnosis is uncertain, symptoms are refractory to adequate primary care management, or psychological complexity warrants specialist input. The GP must be clear about what is being referred for and what has already been tried, and must communicate the referral plan to the patient in a way that does not undermine confidence in the IBS diagnosis.

Condition	Urgency	What GP does before referral	What GP must NOT do
Rectal bleeding + changed bowel habit ± age ≥40	2WW CRC	Complete 2WW referral form with red flag trigger documented; advise patient about timeline and what to expect; do not wait for any test results before making the referral	Do not wait for IBS treatment response before referring; do not attribute rectal bleeding to IBS or haemorrhoids without CRC exclusion
Suspected IBD (raised calprotectin >200, raised CRP, bloody diarrhoea)	Urgent GI	Check FBC, CRP, calprotectin, stool cultures; start haematinics if anaemic; document symptom duration and character in referral letter; advise patient not to start empirical steroids	Do not start steroids before confirmed IBD diagnosis; do not delay referral waiting for all results to return; do not diagnose IBS alongside raised inflammatory markers
Suspected coeliac disease (positive tTG-IgA)	Routine GI / Dietitian	Confirm patient remains on a gluten-containing diet; check FBC, folate, ferritin, vitamin D, B12; advise patient explicitly not to start gluten-free diet before biopsy; explain the importance of this	Do not advise gluten-free diet before duodenal biopsy; do not check tTG-IgA serology if patient is already eating gluten-free — the test will be falsely negative
Refractory IBS — failed 2+ drug classes and supervised dietary management	Routine GI	Document all treatments tried and documented responses; ensure FODMAP was properly supervised by a dietitian; check for missed diagnoses (SIBO, bile acid malabsorption, endometriosis); include IBS-SSS in referral	Do not refer without completing a supervised FODMAP trial first; do not refer without documenting baseline symptom severity using a validated tool
Psychological therapy — CBT, gut-directed hypnotherapy	Routine Psychology / NHS Talking Therapies	Screen with PHQ-9 and GAD-7; explain the gut-brain link to the patient in positive terms; offer NHS Talking Therapies self-referral as a first step; document patient acceptance or resistance to psychological component	Do not frame the referral as “this is all in your head”; do not withhold the referral because the patient is resistant — explore their concern first, then offer again
Specialist dietitian (FODMAP-trained)	Routine Dietetics	Advise patient not to start unsupervised FODMAP before the appointment; provide a detailed dietary history and IBS subtype in the referral; advise which foods are currently being avoided	Do not advise unsupervised FODMAP without dietitian support — nutritional deficiencies and overly restrictive diets are recognised complications without professional guidance
Gynaecology — suspected endometriosis	Urgent Gynae	Document cyclical nature of symptoms, dysmenorrhoea, dyspareunia; advise patient about endometriosis as a possible diagnosis alongside IBS; refer concurrently rather than sequentially	Do not diagnose IBS in a woman with cyclical bowel symptoms and dysmenorrhoea without gynaecological assessment for endometriosis — average diagnostic delay is 7–8 years

🎓 SCA Checkpoint — Step 6TasksRelating to OthersGlobal Skills

Key phrases that score

“I think we can manage this well in the practice, but I do want to refer you to a specialist dietitian who has expertise in exactly this type of gut problem.”

“Given the symptoms, I need to refer you to the hospital quite quickly under a two-week wait pathway — this is a precautionary measure we take with these features.”

“The psychological therapy I am recommending is not because this is all in your head — it is because we know the gut and brain are closely connected, and this therapy specifically targets that link.”

Deductions (examiner flags)

Framing psychological therapy in a way that invalidates the physical symptoms
Failing to refer for 2WW when rectal bleeding is present alongside altered bowel habit
Referring to gastroenterology before adequately completing primary care management
Advising unsupervised FODMAP restriction without dietitian involvement

🔴 Red — failing

2WW not triggered for PR bleeding · Psychological referral not offered when indicated · Referral reasons not communicated to patient

🟠 Amber — borderline

Referral initiated but reason not explained · Psychological therapy mentioned but not offered concretely · Timing not communicated to patient

🟢 Green — passing

Referral pathway correctly identified and explained · 2WW triggered when indicated · Psychological referral framed positively around gut-brain science · Specialist dietitian role explained · What to expect from referral communicated clearly

Step 7

Management — Expectation · Goals · Lifestyle · Drug Selector · Drug Cards · Psychosocial · Follow-Up · Safety-Netting

▲collapse

IBS management is multimodal and patient-centred — dietary management, lifestyle modification, and psychological therapy are first-line before or alongside pharmacotherapy. No single intervention works for all patients. The management plan must be negotiated, specific, and tailored to the patient’s IBS subtype, comorbidities, and personal priorities.

7A — Address the patient’s expectation first: validate → explain → negotiate

🤝

Never dismiss the expectation — acknowledge it, share your reasoning, then agree a shared plan

Validate — name their expectation

Many IBS patients expect colonoscopy or urgent referral. Naming this without dismissing it is essential for shared decision-making.

“I can hear how much you have been worried — it makes complete sense that you would want a scope to be absolutely certain. Let me tell you what I am thinking.”

Explain — share your clinical reasoning

The patient needs to understand why the proposed tests are appropriate and why colonoscopy is not the first step in typical IBS with normal bloods and calprotectin.

“The tests I am recommending are specifically designed to pick up the conditions you might be worried about. If they are normal — which I am expecting — that is actually very helpful and reassuring information.”

Negotiate — offer something today

Never leave a patient with nothing agreed. A concrete plan — even just tests and a follow-up date — maintains the therapeutic relationship.

“What I would like to do today is start the tests, give you some dietary information that can make a real difference straight away, and bring you back in four weeks to go through the results together.”

Key principle: The patient who feels heard, whose concern has been named and addressed, and who leaves with a clear plan is far more likely to engage with dietary and lifestyle changes than one who receives only vague reassurance.

7B — Why treatment matters: goals tailored to this patient

Treatment goals for IBS

Reduce IBS-SSS by ≥50 points (clinically significant response) Achieve ≥3 pain-free days per week Normalise bowel habit to Bristol types 3–5 Reduce urgency episodes by ≥50% Return to full occupational and social functioning Restore dietary variety after supervised FODMAP reintroduction PHQ-9/GAD-7 reassessment at 3 months if psychiatric comorbidity present Named follow-up in 4–6 weeks with symptom diary review

Motivational language — tailored to the patient

“Research shows that people who complete a supervised FODMAP diet have about a 70% chance of significant symptom improvement — better than most IBS medications.”

“I know this has been affecting your work and social life. Most people with IBS who engage with the right treatment get to a point where they can eat out, travel, and live normally — that is absolutely an achievable goal for you.”

7C — Non-medication management: mechanism + evidence + tailored advice

Never give generic lifestyle advice. Every recommendation must be linked to its mechanism, quantified where possible, and tailored to the patient’s IBS subtype. The FODMAP diet has the strongest evidence (70% response rate in RCTs) but requires supervised reintroduction to be safe and effective.

🥖

Low FODMAP Diet

6-week supervised elimination then systematic reintroduction

Mechanism

FODMAPs are poorly absorbed in the small intestine and rapidly fermented by colonic bacteria, producing gas, osmotic fluid shifts, and visceral distension — directly triggering IBS symptoms.

Practical

Must be supervised by a FODMAP-trained dietitian. Phase 1 (6 weeks): eliminate high-FODMAP foods. Phase 2 (8–12 weeks): systematic reintroduction of individual FODMAP subgroups. Phase 3: personalised diet.

70% response rate in RCTs — better than most IBS medications

🍽️

Regular Meal Pattern

3 meals/day at regular times; eat slowly

Mechanism

Irregular eating disrupts the migrating motor complex. Erratic meal timing and large portion sizes increase colonic fermentation and symptom burden.

Practical

3 regular meals at similar times. Smaller portions. Eat slowly — chew thoroughly to reduce swallowed air. At least 20 minutes per meal. Avoid eating on the move.

Reduces bloating and post-prandial urgency in 50–60% of patients

💧

Fluid and Caffeine Management

2L water/day; ≤3 caffeinated drinks/day

Mechanism

Adequate hydration supports stool consistency. Caffeine is a direct colonic stimulant that worsens urgency. Fizzy drinks increase swallowed gas.

Practical

8 glasses non-caffeinated fluid daily. Limit coffee/tea/energy drinks to ≤3/day. Switch to herbal or peppermint tea (direct antispasmodic benefit). Avoid fizzy drinks.

Caffeine reduction reduces urgency episodes by 30–40% in IBS-D

🧐

Stress Management

Daily relaxation practice; address identifiable stressors

Mechanism

Psychological stress activates the HPA axis and directly alters gut motility and visceral sensitivity. Chronic stress perpetuates IBS independently of any mood disorder.

Practical

Daily mindfulness or progressive muscle relaxation 10–15 minutes. Gut-directed hypnotherapy (Monash protocol). Diaphragmatic breathing for bloating. NHS Talking Therapies referral if indicated.

CBT and hypnotherapy: 50–70% sustained symptom improvement at 12 months

🏃

Physical Activity

150 min/week moderate aerobic exercise

Mechanism

Exercise promotes gut transit (IBS-C), reduces visceral sensitivity through endorphin release, and has anxiolytic and antidepressant effects that directly benefit the gut-brain axis.

Practical

150 minutes/week moderate aerobic activity. For IBS-D, avoid high-impact exercise after meals. Yoga has specific IBS evidence. Aim for 30 minutes daily.

Regular exercise reduces IBS severity scores by 20–30%

🦠

Probiotics

Single strain; minimum 4-week trial

Mechanism

IBS is associated with gut microbiome dysbiosis. Specific strains can reduce visceral hypersensitivity and gas production. Evidence is strain-specific.

Practical

Lactobacillus plantarum 299v (bloating, IBS-D) or Bifidobacterium infantis 35624. 4-week trial; stop if no response. Avoid multi-strain products. NICE supports time-limited trial.

30–40% symptom improvement in RCTs; best evidence for bloating and pain

7D — Prescribing guide: what to start, in what order, and why

IBS pharmacotherapy is subtype-directed and adjunctive. First-line agents are chosen based on dominant symptom. NICE CG61 explicitly recommends against polypharmacy before adequately trialling single agents at adequate dose.

Step 1 — Symptom-targeted monotherapy

Match drug class to dominant symptom and IBS subtype.

Pain/cramps (all subtypes): Mebeverine 135mg TDS (20 min before meals) or hyoscine 20mg QDS
IBS-D: Loperamide 2mg PRN (max 16mg/day); titrate using stool diary
IBS-C: Ispaghula husk 1 sachet BD; soluble fibre only; explicitly avoid bran
Bloating (any): Peppermint oil 0.2ml enteric-coated TDS (Colpermin)

Review at 4 weeks; optimise dose before adding second agent

Step 2 — Low-dose neuromodulator

If first-line fails or refractory pain dominates.

TCA: Amitriptyline 10mg nocte; titrate by 10mg/4 weeks to max 30mg; IBS-D preferred (slows transit)
SSRI: Citalopram 10mg OD; if IBS-C or anxiety (accelerates transit, anxiolytic)
Always explain: prescribed at gut pain modulation dose, not antidepressant dose

Review at 6–8 weeks; if no benefit, switch class or refer

Step 3 — Specialist / second-line

Refractory IBS-C after Steps 1–2 and dietary management.

Linaclotide 290mcg OD (30 min before first meal); NICE TA488; discontinue if no response at 4 weeks
Gut-directed hypnotherapy or CBT if not yet accessed
Gastroenterology referral if diagnosis uncertain

Linaclotide: 4-week discontinuation rule (NICE TA488)

Step 4 — Refractory IBS / Specialist Input

Gastroenterology referral: hydrogen breath test (SIBO), SeHCAT (bile acid malabsorption), consider rifaximin off-label
Gut-directed hypnotherapy (Monash protocol): 70% sustained response at 5 years
Pain clinic if centrally mediated pain predominates; reassess diagnosis

Special Cases — Comorbidities Changing Management

IBS + depression: SSRI first (dual benefit); avoid TCA in low mood (overdose risk)
IBS + anxiety: Low-dose TCA or SSRI + gut-directed CBT referral
IBS-C + pregnancy: Ispaghula safe; linaclotide and TCAs contraindicated
IBS in elderly: Start TCA at 5mg; prefer nortriptyline; loperamide generally safe
IBS + endometriosis: Refer to gynaecology concurrently; treat both conditions

⚙ Interactive Medication Chooser — tick the patient profile, options re-tier live against NICE / BNF

A live, topic-scoped version of the standalone Medication Chooser. The static selector and reference cards below are unchanged.

7E — Medication selection tool

Select patient characteristics — IBS medication guidance below

IBS-D (diarrhoea predominant) IBS-C (constipation predominant) IBS-M (mixed) Abdominal pain dominant Anxiety or depression comorbidity Refractory to first-line therapy

IBS medication quick reference

IBS-D: Loperamide 2mg PRN + Mebeverine 135mg TDS for pain
IBS-C: Ispaghula husk 1 sachet BD → Linaclotide 290mcg OD if inadequate
IBS-M / Pain: Mebeverine 135mg TDS or Colpermin TDS
Anxiety/Depression: Amitriptyline 10mg nocte (IBS-D) or Citalopram 10mg OD (IBS-C)
Refractory: Refer gastroenterology; gut-directed hypnotherapy

7F — Drug reference cards: IBS pharmacotherapy by class

Antispasmodics

Mebeverine 135mg · Hyoscine butylbromide 20mg · Alverine 60mg

✓ Recommended

Step 1135mg TDS / 20mg QDS

✓ Prefer when

Pain and cramping are the dominant symptoms in any IBS subtype

Post-prandial pain — mebeverine taken 20 min before meals to pre-empt cramping

IBS-M when neither constipation nor diarrhoea predominates strongly

First-line as PRN or regular use depending on symptom pattern

✗ Avoid if

Paralytic ileus or mechanical bowel obstruction — absolutely contraindicated

Hyoscine: myasthenia gravis, narrow-angle glaucoma, urinary retention

Hyoscine in elderly — anticholinergic burden; prefer mebeverine

⚠ Side effects

Mebeverine: very well tolerated; rare allergic reactions; minimal side effect profile

Hyoscine: dry mouth, blurred vision, urinary hesitancy, constipation, tachycardia

🔬 Monitor

No routine monitoring required for mebeverine — safest antispasmodic overall

Reassess symptom response at 4 weeks; if no improvement, consider dose optimisation or class change

💬 Counselling

“This tablet helps relax the muscles in your gut causing the cramping pain. Take it about 20 minutes before meals. It is very well tolerated and you can take it regularly or just when you need it.”

SCA pearl: Mebeverine has no drug interactions and no monitoring requirements. Prescribing hyoscine to an elderly patient with urinary symptoms would be scored as a clinical error by the examiner.

Loperamide

Imodium · generic loperamide hydrochloride

✓ Recommended

Step 1 (IBS-D)2mg PRN, max 16mg/day

✓ Prefer when

IBS-D — diarrhoea, urgency, and frequency are dominant

Situational urgency — prophylactically before stressful events, travel, meals out

Post-infectious IBS with ongoing loose stools

✗ Avoid if

Acute dysentery or infectious diarrhoea — risk of toxic megacolon; exclude infection first

IBS-C — will worsen constipation severely

History of loperamide misuse — cardiac arrhythmia risk; prescribe with quantity limits

⚠ Side effects

Constipation — most common; titrate carefully using stool diary

Abdominal bloating and cramping if dose too high

🔬 Monitor

Stool diary at 4 weeks — target Bristol types 3–4; adjust dose accordingly

Quantity limits for patients with known misuse risk

💬 Counselling

“This tablet slows down your bowel movements. Start with 2mg when needed; take another 2mg after each loose stool up to 8mg/day normally. Do not take it during a stomach bug with vomiting and fever.”

SCA pearl: Loperamide misuse is well-documented. In the SCA, a patient with anxiety and IBS-D requesting large quantities should prompt discussion about anxiety management and strict quantity limits on prescriptions.

Ispaghula Husk (Soluble Fibre)

Fybogel · Regulan · Ispagel Orange

✓ Recommended

Step 1 (IBS-C)1 sachet (3.5g) BD

✓ Prefer when

IBS-C — hard stools, straining, infrequent defaecation, incomplete evacuation

Safe in pregnancy and elderly — no systemic absorption, no drug interactions

✗ Avoid if

Known or suspected bowel obstruction — absolutely contraindicated

Difficulty swallowing — oesophageal impaction risk without adequate fluid

Bran / insoluble fibre — specifically AVOID in all IBS subtypes; worsens symptoms

⚠ Side effects

Initial bloating and flatulence in first 2 weeks — warn patient; usually settles

Must be taken with at least 200ml of fluid — oesophageal impaction risk if taken dry

🔬 Monitor

Review stool frequency and consistency at 4 weeks — target 3–5 formed stools/week in IBS-C

If no response after 4 weeks: step up to linaclotide 290mcg OD (NICE TA488)

Ensure adequate hydration (≥2L/day) — fibre without fluid worsens constipation

💬 Counselling

“This is a soluble fibre supplement that helps bulk up and soften the stool gradually. Mix it in a full glass of water and drink it straight away. Expect some bloating in the first two weeks — this will settle. Take it 2 hours away from other medications.”

SCA pearl: The examiner will penalise recommending bran or insoluble fibre for IBS. Specifically name ispaghula husk (soluble fibre) and explain why insoluble fibre (bran, wheat bran cereals) worsens IBS symptoms across all subtypes.

Low-dose TCA

Amitriptyline 10mg · Nortriptyline 10mg (less sedating)

✓ Recommended

Step 210mg nocte (titrate to 30mg)

✓ Prefer when

Refractory pain — antispasmodics and dietary management have failed to control pain

IBS-D with prominent pain — constipating side effect is beneficial in this subtype

IBS with anxiety or sleep disturbance — sedating effect at low dose aids sleep quality

✗ Avoid if

IBS-C — anticholinergic effect worsens constipation severely; use SSRI instead

Recent MI or cardiac arrhythmia — TCA cardiac toxicity risk even at low IBS doses

Active suicidal ideation — fatal in overdose; SSRI is safer in this context

⚠ Side effects

Morning sedation — improves within 2 weeks; take at bedtime

Dry mouth, constipation, urinary hesitancy (anticholinergic effects)

🔬 Monitor

Review at 6–8 weeks: pain response, side effects, mood (baseline PHQ-9 before starting)

ECG before starting if cardiac history; titrate by 10mg every 4 weeks to max 30mg nocte

💬 Counselling

“I am prescribing this at a very low dose — much lower than used for depression. At this dose it works directly on the pain nerve signals in your gut. It is not being used as an antidepressant. Take it at night as it can cause some drowsiness. Give it 6 weeks to notice a meaningful difference.”

SCA pearl: Critical to explain that the TCA is for gut pain modulation at sub-antidepressant dose. Failure to do this leads to non-adherence. If the patient has active low mood, prefer an SSRI for patient safety.

SSRIs

Citalopram 10–20mg · Fluoxetine 10–20mg

✓ Recommended

Step 210mg OD titrate to 20mg

✓ Prefer when

IBS-C — SSRIs accelerate gut transit (prokinetic effect), unlike TCAs which slow transit

Anxiety or depression comorbidity — dual benefit on mood and gut symptoms

IBS where TCA is contraindicated (cardiac disease, constipation, active suicidality)

✗ Avoid if

IBS-D — SSRIs worsen diarrhoea and urgency via prokinetic effect; use TCA instead

Concurrent SSRI/SNRI/TCA — serotonin syndrome risk

⚠ Side effects

Initial nausea and diarrhoea — warn patient; usually resolves within 2 weeks

SSRI discontinuation syndrome — taper gradually; never stop abruptly

🔬 Monitor

PHQ-9/GAD-7 at baseline; repeat at 6–8 weeks

Serum sodium at 4 weeks if elderly or on diuretics

💬 Counselling

“This medication can help with both anxiety and bowel symptoms, particularly constipation. Some nausea or loose stools in the first 2 weeks — almost always settles. Takes 4–6 weeks for full benefit on the gut. Never stop it suddenly.”

SCA pearl: The pivot between SSRI and TCA is the IBS subtype. IBS-C → SSRI (accelerates transit); IBS-D → TCA (slows transit). Stating this subtype-directed rationale scores in the Tasks domain.

Linaclotide

Constella 290mcg capsules

✓ Recommended

Step 3 (IBS-C)290mcg OD (30 min before breakfast)

✓ Prefer when

Moderate-to-severe IBS-C failing laxatives and ispaghula after adequate dietary management

NICE TA488 (2019): recommended for IBS-C where laxative treatment has been inadequate

Visceral pain prominent alongside constipation — direct analgesic effect via guanylate cyclase-C

✗ Avoid if

Children under 18 — contraindicated absolutely

Known or suspected mechanical bowel obstruction

IBS-D — will cause profuse diarrhoea; absolutely contraindicated

⚠ Side effects

Diarrhoea — most common; up to 20% of patients; usually mild and transient

Abdominal pain and flatulence at initiation; usually improves within 2–4 weeks

🔬 Monitor

Review at 4 weeks — discontinue if no clinical improvement (NICE TA488)

FODMAP dietitian assessment should be in progress before or alongside starting

💬 Counselling

“This capsule helps the gut produce more fluid and reduces pain signals. Take on an empty stomach, 30 min before your first meal. Some loose stools initially — usually settles. If severe diarrhoea, stop it and contact us.”

SCA pearl: Linaclotide requires NICE TA488 criteria — document laxatives and dietary management tried and failed before prescribing. The 4-week discontinuation rule if no response scores in the Tasks domain.

7G — Psychosocial impact of the diagnosis: work, travel, relationships & daily life

🤝

Living with IBS — addressing the full impact of the condition and its treatment

IBS has a disproportionate impact on quality of life relative to its “functional” label. Patients restrict their diet, avoid social situations, miss work, limit travel, and damage relationships because of unpredictable symptoms. A GP who addresses only the gut symptoms without exploring these consequences is missing the most clinically significant aspect of the condition for many patients. Proactively discussing these domains is a mark-scoring behaviour in the SCA and demonstrates genuine patient-centred care.

💼

Work and Occupational Impact

IBS causes significant absenteeism and presenteeism. Patients avoid client meetings, presentations, and travel due to urgency. Teachers, healthcare workers, and customer-facing roles are particularly affected.

Proactively advise that symptoms can be managed to a level where occupational functioning is restored. Offer a fit note if severe impairment is documented. Document work impact for severity assessment using IBS-SSS.

Occupational health referral may be appropriate for high-impact roles. Anxiety about work performance directly worsens gut symptoms through the gut-brain axis.

“Has this been affecting your work? I want to make sure we help you get to a point where it is not holding you back professionally.”

✈️

Travel and Social Activities

IBS-D patients frequently limit or avoid travel due to urgency and fear of incontinence in public. Social eating becomes a source of significant anxiety — patients either over-restrict their diet or avoid restaurants entirely.

Advise on practical strategies: pre-travel loperamide, identifying accessible toilets, planning meals around IBS-safe foods. Encourage gradual re-engagement with social activities as a specific treatment target.

Social avoidance perpetuates anxiety and worsens long-term IBS outcomes. Address it explicitly as a therapeutic goal, not an incidental consequence.

“Are you avoiding going out for meals or travelling? Let’s specifically address that as part of your treatment plan — it is a very achievable goal.”

🧠

Mental Health and Wellbeing

Up to 70% of patients with moderate-to-severe IBS have clinically significant anxiety or depression. The relationship is bidirectional — IBS worsens mood, and poor mood worsens IBS. Addressing one without the other is inadequate management.

Screen with PHQ-9 and GAD-7. Offer psychological therapy — gut-directed CBT or hypnotherapy — as first-line for moderate-to-severe IBS regardless of whether formal psychiatric diagnoses are present.

Frame psychological intervention around gut-brain science, not “this is all in your head.” Failure to frame this correctly damages the therapeutic alliance and leads to non-attendance.

“How has all of this been affecting your mood? Living with these symptoms every day takes a real toll — I would like to check in on that specifically.”

💑

Relationships and Intimacy

IBS affects intimate relationships — urgency, bloating, and unpredictability cause embarrassment, and abdominal pain reduces sexual desire and spontaneity. Partners may not understand the condition.

Proactively acknowledge this impact. Advise on timing (e.g. antispasmodic before intimate occasions, avoiding large meals beforehand). Sexual dysfunction from amitriptyline or SSRIs should be discussed before prescribing.

In severely affected relationships, couples or sex therapy may occasionally be relevant — normalise the referral pathway.

“Sometimes IBS can affect relationships and intimacy — is that something that has been an issue? I want to make sure we address every aspect of how this is affecting you.”

🍳️

Nutritional Impact of Over-Restriction

Without dietitian guidance, IBS patients develop highly restrictive diets — eliminating grains, dairy, vegetables, and legumes — leading to inadequate caloric intake, micronutrient deficiencies (B12, D, calcium, iron), and disordered eating patterns.

FODMAP diets without supervised reintroduction permanently restrict large numbers of foods without evidence of benefit for that specific patient. All eliminated foods should be systematically reintroduced in Phase 2.

Screen for significant weight loss or nutritional deficiency and refer to FODMAP-trained dietitian for all patients attempting dietary restriction of any kind.

“Can you tell me what you are currently eating? I want to make sure the diet you are on is not causing any nutritional problems alongside the IBS.”

🌎

Health Anxiety and Reassurance-Seeking

IBS patients with health anxiety may have had multiple normal investigations across different practices and hospitals, presenting repeatedly seeking further tests. This cycle of reassurance-seeking is self-perpetuating and does not improve outcomes — it reinforces illness behaviour.

The GP’s role is to break this cycle: provide a confident positive diagnosis (not just a diagnosis of exclusion), explain the mechanism, set clear follow-up criteria, and avoid reflexive investigation requests.

Health anxiety about IBS should be specifically targeted in psychological therapy. Excessive investigation worsens health anxiety and is not clinically beneficial in typical IBS.

“I notice you have had quite a few tests over the past few years. I would like to help you move forward rather than continuing down that road — let me explain what I think is going on and what we can do differently.”

7H — Follow-up schedule

4–6 weeks — First review (results and initial treatment response)

Review investigation results (FBC, CRP, calprotectin, tTG-IgA, TSH) in plain language with the patient. Assess initial response to dietary and lifestyle changes. If medication started, review tolerability and side effects. If calprotectin is raised (>200), escalate referral to gastroenterology urgently.

Results reviewMedication review

3 months — Symptom severity and treatment response

IBS Symptom Severity Score (IBS-SSS) — compare to baseline to quantify response. Review FODMAP progress (dietitian review should be completed or in progress). Reassess psychological comorbidity with PHQ-9/GAD-7. If first-line treatment failing, step up medication or refer for psychological therapy. Review occupational and social functioning explicitly.

IBS-SSS assessmentPHQ-9 / GAD-7

6 months — FODMAP reintroduction phase and medication optimisation

FODMAP reintroduction (Phase 2) should be underway or completed by this point. Review and personalise the dietary plan with dietitian feedback. If medication started at first visit, assess 6-month response. Consider neuromodulator (TCA or SSRI) if antispasmodics alone are insufficient. Confirm psychological therapy referral has been received.

Dietetic reviewMedication step-up if needed

12 months — Annual review

Annual IBS review — assess overall symptom control, quality of life, and occupational functioning. Review ongoing medication need (aim to step down where possible). Screen for new red flag symptoms (new rectal bleeding, weight loss, nocturnal symptoms) — an IBS diagnosis does not make a patient immune to developing organic disease. Check PHQ-9/GAD-7 if not recently done.

Red flag re-screenAnnual review

As needed — Open access for new or worsening symptoms

Provide explicit safety-netting about symptoms warranting a new consultation rather than waiting for the annual review: new rectal bleeding, significant weight loss, symptoms waking from sleep, systemic symptoms. An IBS diagnosis does not make a patient immune to developing organic disease. Review promptly if any new red flags emerge at any point in follow-up.

Safety-net review

7I — Monitoring: the FODMAP + FLAGS framework

Memory rule

IBS monitoring follows the FODMAP + FLAGS framework: FODMAP reintroduction at 3 months · Outcome score (IBS-SSS) at every visit · Dietary review at 6 months · Medication response at 4–8 weeks · Annual red flag re-screen · Psychological assessment (PHQ-9/GAD-7) at 3 months. FLAGS: Fresh rectal bleeding = new 2WW · Loss of weight = urgent investigation · Anaemia = urgent GI workup · Gut nocturnal symptoms = organic disease until excluded · Systemic inflammation (raised CRP) = change the management plan immediately.

Drug / Intervention	Monitoring parameter	Timing	Action threshold
All medications	IBS-SSS (Symptom Severity Score)	Baseline then every 3 months	Score >300 = severe · <175 = mild; target ≥50-point reduction for clinically significant response
Amitriptyline (TCA)	PHQ-9/GAD-7 · Anticholinergic side effects · ECG if >30mg or cardiac history	6–8 weeks then 3-monthly	PHQ-9 worsening → reassess suitability; ECG if dose increasing in elderly or those with cardiac risk
SSRI (Citalopram, Fluoxetine)	PHQ-9/GAD-7 · Serum sodium in elderly · Suicidal ideation screen at initiation	Sodium at 2–4 weeks (if elderly) · Efficacy at 6–8 weeks	Na <130: withhold and review · Worsening mood or suicidal ideation at 2 weeks: urgent review required
Linaclotide	Stool diary (consistency and frequency) · Diarrhoea development	4 weeks (NICE TA488 discontinuation decision point)	No response at 4 weeks → discontinue per NICE; severe diarrhoea → hold and review urgently
FODMAP diet	IBS-SSS · Nutritional adequacy · Body weight	Phase 1 review at 6 weeks; Phase 2 assessment at 3–6 months	Nutritional deficiency (low B12, D, calcium) → dietitian urgent review; significant weight loss → investigate for malabsorption

Patient context	IBS-SSS target	Treatment goal
Mild IBS (IBS-SSS <175)	Maintain <175	Dietary management ± PRN antispasmodic; no regular pharmacotherapy usually needed
Moderate IBS (IBS-SSS 175–300)	Reduce by ≥50 points to <175	Dietary + antispasmodic or loperamide + consider neuromodulator at 3 months if inadequate
Severe IBS (IBS-SSS >300)	Reduce to <300; target <175 longer term	Multidisciplinary: diet, pharmacotherapy, psychological therapy; gastroenterology referral if refractory
IBS-D response target	Bristol types 3–4; ≤3 urgency episodes/week	Loperamide titration; TCA if pain prominent; reassess at 3 months with stool diary
IBS-C response target	Bristol types 3–5; ≥3 complete bowel movements/week	Ispaghula → linaclotide if inadequate; reassess FODMAP compliance at every visit
Post-infectious IBS	Aim for symptom resolution within 12–24 months	Better prognosis than idiopathic IBS; share this information therapeutically with patient

7J — Safety-netting: exact phrases + medico-legal rationale

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

Documents that the GP recognised the possibility of organic disease and communicated this clearly to the patient at the time of the IBS diagnosis

Reduces medicolegal risk in cases where IBS is later found to have masked a colorectal cancer diagnosis in a younger patient

Satisfies GMC Good Medical Practice duty to ensure safe information sharing and patient education at every consultation

Improves patient engagement with follow-up and reduces missed diagnoses through patient empowerment

IBS is associated with missed CRC diagnoses — safety-netting is specifically recommended in NICE CG61 as a clinical standard

Demonstrates patient-centred practice and shared responsibility — scored directly in the SCA Relating to Others domain

4–6 weeksReview investigation results, medication tolerability, and initial dietary changes

3 monthsIBS-SSS, PHQ-9/GAD-7, FODMAP progress with dietitian

AnytimeNew red flags: PR bleeding, weight loss, nocturnal symptoms, systemic symptoms

🎓 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills

Closing the consultation

“Before I let you go — is there anything I have said today that you would like me to go over again, or anything you are still worried about?”

“What we have agreed today is: blood tests including a coeliac screen and a gut inflammation test, some dietary information about the FODMAP approach, and a prescription for mebeverine to take before meals.”

“I want to be clear — this is a real condition that we take seriously. With the right approach, most people get to a point where symptoms are well controlled and not holding them back.”

“Please come back straightaway if you notice blood in your stools, lose weight unexpectedly, or have symptoms waking you from sleep.”

“I will see you in four weeks to go through the results together. You can also call the practice if you have any concerns before then.”

Deductions — closing

No closing question asked (“Is there anything else?”)
Not summarising the agreed plan before ending the consultation
Vague safety-netting (“come back if worried”) without naming specific red flag symptoms
Leaving the patient with only reassurance and no actionable management plan
Prescribing medication without explaining indication or potential side effects
Not addressing the patient’s original concern (cancer or Crohn’s fear) at the close of the consultation

Tasks domain — full criteria

Rome IV criteria for IBS correctly applied and subtype identified
Appropriate investigation screen ordered (FBC, CRP, calprotectin, tTG-IgA, TSH)
IBS subtype identified and pharmacological management correctly tailored to subtype
Red flags actively screened and 2WW triggered if indicated by clinical features
First-line non-pharmacological management (FODMAP, lifestyle) offered before or alongside pharmacotherapy

Relating to Others — full criteria

ICE fully explored — cancer/Crohn’s fear specifically named and addressed by the GP
Gut-brain axis explained in patient-friendly language without invalidating the physical symptoms
Psychological intervention framed positively around gut-brain science, not “all in your head”
Management plan negotiated and agreed with patient, not imposed without discussion
Closing question asked and patient’s remaining concerns addressed before ending
Empathy demonstrated for the impact of IBS on daily life, work, and social activities

🔴 Red — failing

IBS as diagnosis of exclusion only · No lifestyle management offered · ICE not explored · Cancer fear not addressed · No specific safety-netting

🟠 Amber — borderline

Diagnosis explained but mechanism absent · ICE partially explored · Medication prescribed without counselling · Safety-netting vague (“come back if worried”)

🟢 Green — passing

Positive Rome IV diagnosis with mechanism explained · ICE fully addressed · Subtype-specific management · FODMAP and psychological therapy offered · Specific named red flag safety-netting · Closing question asked

“I have been having terrible stomach problems for nearly a year now and I am really worried it could be something serious — like Crohn’s disease.”

Who you are

Sarah, 28-year-old primary school teacher. You have had crampy lower abdominal pain, bloating, and alternating loose stools and constipation for 9 months. Symptoms are worse before your period and during stressful work periods (especially before Ofsted inspections). You have tried cutting out dairy and gluten without clear benefit. You have taken 3 days off work in the past month. No blood in stools, no weight loss, no night symptoms.

Hidden agenda

You are frightened this could be Crohn’s disease. Your older brother was diagnosed with Crohn’s last year and has had surgery, and you have been researching your symptoms online. You have not mentioned this because you feel embarrassed about self-diagnosing from the internet. You want to be referred to a gastroenterologist for a colonoscopy to “rule out” Crohn’s. You are also secretly worried about cancer but have not said this aloud.

Symptoms if asked directly

Pain: lower abdomen, crampy, comes and goes — definitely worse before opening bowels
Stools: alternating — sometimes loose 3–4 times a day, other times hard and difficult
Bloating: worst by evening after eating; embarrassing at work
No rectal bleeding — answer “no” clearly if asked
No weight loss — weight is stable
No night symptoms — sleep is normal when not stressed
Period-related worsening: symptoms definitely worse in week before period

Lifestyle and bonus details

Diet: mostly healthy but eats a lot of garlic, onions, apples, and wholegrain bread
Coffee: 3–4 cups per day (this is a trigger but you have not connected it)
Alcohol: 6–8 units per week at weekends
Exercise: minimal at the moment due to fatigue and embarrassment
Stress: very high at work — difficult class, Ofsted likely
Bonus: if asked about stress in a non-judgmental way, you will disclose that you cried at school last week and feel overwhelmed; this opens the psychological discussion

“But how can you be sure it is not Crohn’s if you have not done a colonoscopy? My brother was told he was fine for years before they found it. Can you not just refer me to a specialist to be certain?”

Resolution: You will accept the plan if the clinician: (1) specifically names your Crohn’s fear and addresses it with evidence (the calprotectin test explanation is particularly reassuring); (2) acknowledges your brother’s diagnosis is a legitimate reason for your concern; (3) gives a clear follow-up plan with a specific timepoint; and (4) either offers a referral pathway or explains convincingly why the blood tests and calprotectin are the correct first step. You remain anxious if the clinician dismisses your concern without engaging with your specific fear.

🏥

Clinic Quick Reference

IBS — Clinical Decision Framework

NICE CG61 (updated 2015) · CKS 2023 · First Presentation and Follow-Up

▼expand

🚨 1 — Triage System

Patient presents with recurrent abdominal pain, altered bowel habit, or bloating

↓

🔴 Emergency / 2WW

Rectal bleeding + altered bowel habit, age ≥40 → 2WW CRC
Peritonism / obstruction → 999
Palpable abdominal or rectal mass → 2WW
Unintentional weight loss >3 kg → urgent investigation
Iron deficiency anaemia → 2WW endoscopy

Act immediately — do not manage in primary care

🟠 Urgent Investigation

Age ≥50, first presentation → investigate before IBS label
Calprotectin >200 μg/g → urgent GI referral
Raised CRP/ESR → exclude IBD and malignancy
Nocturnal symptoms → organic disease until excluded
First-degree FH of CRC or IBD → lower threshold for colonoscopy

Investigate urgently before IBS diagnosis

🟢 Primary Care IBS Management

Age <50, typical pattern, no red flags
Normal FBC, CRP, calprotectin <50, tTG-IgA negative, TSH normal
Rome IV criteria met (positive diagnosis)
Known IBS — symptom flare without new features

Manage in primary care; lifestyle + pharmacotherapy

🔬 2 — Diagnostic Pathway

Rome IV Criteria (all three required)

Recurrent abdominal pain ≥1 day/week for last 3 months
Plus ≥2 of:
• Related to defaecation
• Change in stool frequency
• Change in stool form/appearance
Symptom onset ≥6 months ago

Minimum Investigation Screen (NICE CG61)

FBC · CRP/ESR · tTG-IgA (on gluten diet) · Faecal calprotectin · TSH
Colonoscopy NOT required if age <50, no red flags, calprotectin <50 μg/g
Check total IgA if negative tTG-IgA but coeliac still suspected

📊 3 — Key Numbers

<50

Calprotectin (μg/g): IBD very unlikely

70%

FODMAP response rate (RCT evidence)

33pts

IBS-SSS <175 = mild; target reduction ≥50pts

≥6 months

Min. symptom duration (Rome IV)

≥1/week

Pain frequency required (Rome IV)

5–10%

UK adult IBS prevalence

135mg TDS

Mebeverine dose (20 min before meals)

10mg nocte

Amitriptyline start dose (IBS pain)

290mcg OD

Linaclotide dose (30 min before breakfast)

4 weeks

Review point for linaclotide and antispasmodics

50–70%

CBT / gut hypnotherapy sustained response

10–25%

Post-infectious IBS after gastroenteritis

💊 4 — Medication Decision by IBS Subtype

Step therapy by subtype

IBS-D dominant

→

Loperamide 2mg PRN

IBS-C dominant

→

Ispaghula 1 sachet BD

Pain dominant (all)

→

Mebeverine 135mg TDS

Bloating dominant

→

Colpermin TDS

Step 2 — Neuromodulators

IBS-D + pain fails step 1

→

Amitriptyline 10mg nocte

IBS-C + anxiety fails step 1

→

SSRI (citalopram 10mg)

Refractory IBS-C

→

Linaclotide 290mcg

Critical prescribing rules

🔴 Never prescribe TCA for IBS-C — causes severe constipation
🔴 Never prescribe SSRI for IBS-D — worsens diarrhoea (prokinetic)
🔴 Never recommend bran/insoluble fibre — worsens all IBS subtypes
⚠ Linaclotide requires NICE TA488 criteria; 4-week response check
⚠ Loperamide: quantity limits for misuse risk; not in active infection
✅ Ispaghula safe in pregnancy; linaclotide and TCAs contraindicated
✅ Mebeverine: no interactions, no monitoring — safest antispasmodic

⚠ 5 — Safety Netting & Follow-Up

Follow-up timeline

4–6 weeks: Results review; medication tolerability; initial dietary response

3 months: IBS-SSS; PHQ-9/GAD-7; FODMAP progress; step up if needed

6 months: FODMAP reintroduction review; medication optimisation

12 months: Annual review; red flag re-screen; step-down medication

Open access: PR bleeding, weight loss, nocturnal symptoms → urgent

📌 IBS diagnosis does not prevent organic disease — re-screen red flags at every review

🔬 6 — Monitoring & Red Flags

Drug / Intervention	Parameter	Timing	Action threshold
All IBS management	IBS-SSS score	Every visit	Target ≥50-point reduction; <175 = mild; >300 = severe → escalate
Amitriptyline	PHQ-9, side effects, ECG (if >30mg or cardiac Hx)	6–8 weeks then 3-monthly	Worsening PHQ-9 → reassess; ECG if escalating dose in elderly
SSRI	PHQ-9/GAD-7, serum sodium (elderly), suicidal ideation at 2 weeks	2–4 weeks Na; 6–8 weeks efficacy	Na <130 → withhold; worsening mood at 2 weeks → urgent review
Linaclotide	Stool diary (consistency, frequency), diarrhoea	4 weeks (NICE discontinuation point)	No response at 4 weeks → discontinue; severe diarrhoea → hold immediately
FODMAP diet	IBS-SSS, body weight, nutritional status (B12, D, Ca)	Phase 1 at 6 weeks; Phase 2 at 3–6 months	Nutritional deficiency → urgent dietitian review; weight loss → investigate malabsorption
Any new symptom	Red flag re-screen	At every consultation	PR bleeding, weight loss, nocturnal symptoms → 2WW; raised CRP → urgent investigation

🔴 Red flags requiring urgent action: Rectal bleeding · Unintentional weight loss >3kg · Nocturnal symptoms · Age ≥50 first presentation · Palpable mass · Iron deficiency anaemia · Raised CRP · Calprotectin >200 μg/g · FH of CRC or IBD

🛡️ Safeguarding: IBS associated with 30–50% trauma/abuse history in secondary care cohorts · Screen for domestic abuse (SAFE questions) · Loperamide misuse risk · Children in household of severely impaired parent · Document and refer per local safeguarding policy

🎓

SCA Exam Quick Reference

SCA Consultation Blueprint

Tasks · Relating to Others · Global Skills · RAG guide

▼expand

🕐 12-Minute Consultation Flow — with Domain Scoring

0–2 min

Open + Use Existing Information

“I can see from your notes that... — tell me, what has been going on for you?”

Reference notes first, then open broadly. Never ask for information already documented — this wastes a Tasks mark.

Allow 60–90 seconds of uninterrupted patient narrative. Cancer/IBD fear often surfaces here unprompted.

Relating to Others Global Skills

✗ Asking documented info · Interrupting the patient within 30 seconds

2–5 min

Targeted History + Red Flag Screen

“Have you noticed any blood in your stools? Any weight loss? Have symptoms ever woken you at night?”

Rome IV criteria: ask about defaecation relationship, stool frequency, stool form. Define subtype (C/D/M/U).

Ask about triggers (food, stress, menstrual cycle) to establish gut-brain link and dietary targets.

Tasks Global Skills

✗ Skipping red flag screen · Not asking about bowel habit frequency/consistency · Failing to establish IBS subtype

5–7 min

ICE + Psychosocial + Examination

“It sounds like you might be worried this could be Crohn’s or cancer — is that on your mind?”

ICE: name the cancer/Crohn’s fear explicitly. Ask about stress, sleep, and occupational impact.

Offer abdominal examination; explain purpose; use normal findings therapeutically to provide reassurance.

Relating to Others Tasks

✗ Not naming the specific fear · No examination offered · Skipping psychosocial history entirely

7–10 min

Diagnosis Explanation + Investigations

“What you have is called IBS — it is a real condition caused by the way your gut and brain communicate. There is no damage and it will not turn into cancer.”

Explain Rome IV positive diagnosis. Address Crohn’s/cancer fear with the calprotectin explanation.

Order minimum NICE screen: FBC, CRP, calprotectin, tTG-IgA, TSH. Explain each test’s purpose.

Tasks Relating to Others

✗ “Tests are normal so it must be IBS” · Not explaining the gut-brain mechanism · Omitting calprotectin · Ordering colonoscopy without indication

10–12 min

Management Plan + Safety-Netting + Close

“What we have agreed today is... Come back straight away if you notice blood in your stools, lose weight, or have night symptoms.”

Subtype-specific medication + FODMAP referral + lifestyle advice. Offer psychological therapy framed around gut-brain axis.

Closing question: “Is there anything else you wanted to ask?” Named follow-up at 4–6 weeks.

Tasks Relating to Others Global Skills

✗ Vague safety-netting · No closing question · No follow-up timepoint · Plan not summarised

🔴🟠🟢 RAG Scoring — All 3 Domains

Tasks Domain

🟢

Rome IV criteria applied · Subtype identified · Correct investigations · Subtype-specific medication · Specific safety-netting

🟠

Diagnosis named but mechanism absent · Investigation screen incomplete · Safety-netting vague · Medication correct but not counselled

🔴

IBS by exclusion only · Red flags not screened · Age ≥50 not investigated · Wrong medication for subtype · No FODMAP offered

Relating to Others

🟢

Open question first · Cancer/Crohn’s fear named · ICE fully explored · Gut-brain explained · Plan negotiated · Closing question asked

🟠

ICE partially explored · Fear not explicitly named · Psychological therapy framed poorly · Plan imposed rather than negotiated

🔴

No open question · ICE not explored · Fear not acknowledged · Patient left without plan or remaining concerns unaddressed

Global Skills

🟢

Systematic structure · Data gathering by 7 min · Plain language · Patient agenda prioritised · Reasoning shared · Summary given

🟠

Structure present but data gathering slow · Some jargon uncorrected · Summary incomplete · Patient agenda occasionally overridden

🔴

No clear structure · Data gathering not complete before management · Jargon throughout · No summary · Patient’s concerns dismissed

💬 Key Phrases — ICE, Diagnosis & Plan

Ideas — elicit illness model

“What do you think might be causing this? Have you done any reading about what it could be?”

Concerns — name the fear explicitly

“It sounds like you might be worried this could be something serious — like Crohn’s or cancer. Is that on your mind?”

Expectations — elicit the request

“What were you hoping we might be able to do today — a test, a referral, or medication?”

Validate — acknowledge before explaining

“I completely understand why you have been worried — your brother’s diagnosis makes this feel very real.”

Explain — gut-brain mechanism

“IBS is caused by the way your gut and brain communicate — your bowel is reacting too strongly, like a sensitive alarm system. There is no damage and it will not turn into cancer.”

Close — safety-net and check

“Come back straight away if you notice blood, lose weight, or have night symptoms. Is there anything else on your mind?”

🚫 9 Danger Zones — Instant Deductions

✗

Starting with closed questions→ Always open: “Tell me what has been going on.”

✗

Asking documented information again→ Reference notes: “I can see from your notes that...”

✗

Not naming the cancer or Crohn’s fear explicitly→ Say it: “Are you worried this could be Crohn’s or cancer?”

✗

IBS diagnosed in age ≥50 without any investigation→ Always investigate before IBS label at age ≥50

✗

Recommending bran or insoluble fibre for IBS→ Ispaghula husk (soluble fibre) only; bran worsens IBS

✗

Prescribing TCA for IBS-C→ TCA worsens constipation; use SSRI for IBS-C with neuromodulator need

✗

Framing psychological therapy as “all in your head”→ Frame around gut-brain axis science; not psychological weakness

✗

Vague safety-netting (“come back if worried”)→ Name specific symptoms: PR bleeding, weight loss, nocturnal symptoms

✗

Advising unsupervised FODMAP without dietitian→ Always recommend supervised FODMAP with a trained dietitian

💊 Drug Quick-Pick

IBS-D + urgency

→

Loperamide 2mg PRN

Max 16mg/day

IBS-D + pain

→

Mebeverine 135mg TDS

20 min AC meals

IBS-C

→

Ispaghula 1 sachet BD

With 200ml fluid

IBS-C refractory

→

Linaclotide 290mcg

NICE TA488; 4-wk check

Pain refractory (IBS-D)

→

Amitriptyline 10mg nocte

NOT for IBS-C

IBS-C + anxiety/depression

→

SSRI (citalopram 10mg)

NOT for IBS-D

Bloating (all subtypes)

→

Colpermin TDS

Peppermint oil capsules

🚫 TCA → IBS-D only · SSRI → IBS-C/anxiety only · Bran = NEVER · Linaclotide = NICE TA488 criteria

Irritable Bowel Syndrome · GP Clinical Reasoning Framework v2 · NICE CG61 (2008, updated 2015) · NICE CKS IBS (2023) · NICE TA488 Linaclotide (2019) · Rome IV Criteria (2016) · NICE NG12 Colorectal Cancer Referral (2015)

v2: Clinical stem · Open Q first · ICE in all modes · Psychosocial (1E + 7G) · Lay language DDx (Step 5) · Safeguarding (Step 1) · Expectation management (7A) · SCA RAG checkpoints after every step · SCA Scorecard as standalone section · Dual tailored summaries (Clinic + SCA) with visual algorithms

Teaching clinicians why each step matters — not just what to do · Always consult current BNF/SPC before prescribing · Clinical judgement takes precedence over any framework · For patient safety, always apply red flag criteria at every consultation regardless of IBS diagnosis duration

Irritable Bowel Syndrome

Red Flags — act before continuing history

Safeguarding Considerations — Consider in Every Consultation

🏠 Domestic Abuse / Intimate Partner Violence

👴 Older Adults / Carer-related Concern

👦 Children in the Household

💊 Self-Harm / Medication Misuse Risk

😧 Anxiety and Psychological Stress

🔬 Post-Infectious Trigger (PI-IBS)

😴 Sleep Disturbance

🏠 Adverse Life Events and Trauma History

👩‍💼 Occupational and Social Functioning

🍽️ Disordered Eating and Food Avoidance

999 or Same-Day Hospital

Same-Day GP / Urgent Referral

Manage in Primary Care

IBS (all subtypes)

Functional Bloating / Functional Abdominal Pain

Lactose / Fructose Intolerance

IBD — Crohn’s Disease / Ulcerative Colitis

Coeliac Disease

Bile Acid Malabsorption

Microscopic Colitis

Colorectal Cancer

Acute Intestinal Obstruction

Toxic Megacolon / Severe Acute Colitis

Validate — name their expectation

Explain — share your clinical reasoning

Negotiate — offer something today

Select patient characteristics — IBS medication guidance below

Work and Occupational Impact

Travel and Social Activities

Mental Health and Wellbeing

Relationships and Intimacy

Nutritional Impact of Over-Restriction

Health Anxiety and Reassurance-Seeking

4–6 weeks — First review (results and initial treatment response)

3 months — Symptom severity and treatment response

6 months — FODMAP reintroduction phase and medication optimisation

12 months — Annual review

As needed — Open access for new or worsening symptoms

Memory rule

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

🎭 Patient actor brief — click to practise

Who you are

Hidden agenda

Symptoms if asked directly

Lifestyle and bonus details