Guidance: The practical management of the gastrointestinal symptoms of pelvic radiation disease.

BACKGROUND: A recent randomised trial suggested that an algorithmic approach to investigating and managing gastrointestinal symptoms of pelvic radiation disease (PRD) is beneficial and that specially trained nurses can manage patients as effectively as a gastroenterologist. AIMS: The aim of the development and peer review of the guide was to make the algorithm used in the trial accessible to all levels of clinician.
METHODS: Experts who manage patients with PRD were asked to review the guide, rating each section for agreement with the recommended measures and suggesting amendments if necessary. Specific comments were discussed and incorporated as appropriate, and this process was repeated for a second round of review.
RESULTS: 34 gastroenterologists, 10 nurses, 9 dietitians, 7 surgeons and 5 clinical oncologists participated in round one. Consensus (defined prospectively as 60% or more panellists selecting 'strongly agree' or 'agree') was reached for 27 of the original 28 sections in the guide, with a median of 75% of panellists agreeing with each section. 86% of panellists agreed that the guide was acceptable for publication or acceptable with minor revisions. 55 of the original 65 panellists participated in round two. 89% agreed it was acceptable for publication after the first revision. Further minor amendments were made in response to round two.
CONCLUSIONS: Development of the guide in response to feedback included ▸ improvement of occasional algorithmic steps ▸ a more user-friendly layout ▸ clearer timeframes for referral to other teams ▸ expansion of reference list ▸ addition of procedures to the appendix.

Introduction

This guide is designed mainly to aid clinical nurse specialists looking after patients with pelvic radiation disease (PRD) working in conjunction with a gastroenterologist. However, it might also help general practitioners and generalists in investigating and treating the gastrointestinal symptoms of patients following pelvic radiotherapy.

This guide defines best practice although not every investigation modality or treatment will be available in every trust.

Those using the guide, especially if non-medically qualified, should identify a senior gastroenterologist or other appropriately qualified and experienced professionals whom they can approach easily for advice if they are practising in an unsupervised clinic.

Practitioners should not use this guide outside the scope of their competency and must identify from whom they will seek advice about abnormal test results, which they do not fully understand before they start using the guide.

Where it is stated that ‘this is an emergency’, the user of this guide must discuss the issue with a suitably qualified person for immediate action.

Managing patients with PRD requires a different approach to those with other forms of bowel pathology. The guide also identifies test findings that may indicate that the underlying situation is potentially serious and that advice needs to be sought urgently.

Specific therapies are usually not listed by name but as a ‘class’ of potential drugs as different clinicians may have local constraints or preferences as to the medications available.

Important principles to consider when using the algorithms are

Patients may have up to 22 gastrointestinal (GI) symptoms after pelvic radiotherapy simultaneously.

Each symptom may have more than one cause.

Symptoms must be investigated systematically, otherwise causes may be missed.

Arranging all investigations at the first consultation reduces follow-up and allows directed treatment at all causes for symptoms at the earliest opportunity.

Patients who have had radiotherapy need a different approach to patients who have GI symptoms for other reasons.

Specialist centres only very rarely reach a new diagnosis of ‘irritable bowel syndrome’ in this patient group.

Endoscopic or surgical intervention in tissues exposed to radiotherapy carries increased risk of serious complications.

This guide has three parts:

Introduction, guide to blood tests, how to use the algorithm and taking a history.

An algorithm detailing the individual investigation and treatment of each of the 22 symptoms identified as particularly relevant to this patient group.

A brief description of the diagnosis, treatment and management techniques of common conditions found in patients with PRD.

▸ >11 mmol/L and ketones in urine: .

▸ >20 mmol/L and no ketones in urine: .

▸ If >3.0 mmol/L: .

▸ If <0.3 mmol/L: .

Identify the symptoms by systematic history taking.

Examine the patient appropriately.

Use the algorithm to plan investigations for troublesome/severe symptoms.

Most patients have more than one symptom and so investigations need to be requested for each symptom.

Usually all investigations are ordered at the same time and the patient reviewed with all the results.

When investigations should be ordered sequentially, the algorithm indicates this by stating first line, second line, etc.

Treatment options are generally offered sequentially but clinical judgement should be used.

Taking an appropriate history

Patients cannot be helped without an accurate history being taken.

Taking a history of GI symptoms is a skill that must be learnt.

Tools such as a Bristol Stool Chart can often clarify exactly what patients mean.

Specialist units find that symptom questionnaires completed by the patient before the consultation often help clarify which issues are really troubling the patient.

Taking a history needs to elicit:

What was bowel function like before the cancer emerged?

How have the symptoms changed over time?

Are key features indicative of reversible underlying pathology present, for example,

Steatorrhoea?

Nocturnal waking to defecate?

Rapid progressive worsening of symptoms?

Rapid weight loss?

Has the patient noticed any masses?

Patients and clinicians alike often miss the presence of intermittent steatorrhoea—ask:

Is there an oily film in the lavatory water?

Is the stool ever pale/putty-like/foul smelling/difficult to flush/floating?

A very clear definition of what a patient means when they use specific terms—for example, ‘diarrhoea’/‘loose stool’—what type on the Bristol Stool Chart?; ‘frequency’—true bowel opening or tenesmus and incomplete evacuation?

Is there a consistent impact of a specific component of diet on their symptoms, especially

Fibre: how much are they eating—too much/too little?

Fat: does this promote type 6–7 stool/steatorrhoea?

Lactose-containing foods?

Gluten-containing foods?

Alcohol intake?

Is there an association between the start of specific medication or increase in its dose and their symptoms—for example, metformin, proton pump inhibitor, β-blockers?

irradiated areas.

irradiated areas.

If severe, —discuss immediately with a gastroenterologist.

GI symptoms

Borborygmi

(A rumbling/gurgling noise produced by the movement of fluid or gas through the intestine)

Investigations	Potential results	Clinical management plan: abnormal results
1st Line
Routine AND additional blood screen (pages 2–3)	Abnormal results	Follow treatment of abnormal blood results (pages 2–3).
OGD and duodenal aspirate and biopsies and/or glucose hydrogen methane breath tests	SIBO	Treatment for SIBO (page 17).
	Enteric infection	Treat as recommended by microbiologist.
Carbohydrate challenge	Carbohydrate malabsorption	Treatment for carbohydrate malabsorption (pages 16–17).
If borgorygmi are present in combination with other symptoms: flushing, abdominal pain, diarrhoea, wheezing, tachycardia or fluctuation in BP
2nd Line
Fasting gut hormones+ Urinary 5-HIAA + CT scan chest, abdomen and pelvis	Functioning NET, eg, carcinoid syndrome or pancreatic NET	Discuss and refer urgently to the appropriate neuroendocrine tumour team requesting an appointment within 2 weeks.
	If all tests are negative, but symptoms persist	Reassure.

OGD, oesophago-gastroduodenoscopy; NET, neuroendocrine tumour; SIBO, small intestinal bacterial overgrowth.

Diarrhoea (stool type 6–7 Bristol Stool Chart)

Also use this section if patient has ‘frequency of defecation’, ‘nocturnal defecation’ or ‘urgency of defecation’

Investigations	Potential results	Clinical management plan: abnormal results
Dietary/ lifestyle/ medications assessment	High dietary fat intakeLow/high fibre intakeHigh fizzy drink intakeHigh use of sorbitol-containing chewing gum or sweetsHigh caffeine intakeHigh alcohol intakeAnxietyDrug induced, eg, PPIs Laxatives β blockers Metformin	Dietary advice about healthy fibre and dietary fat intake. Referral to dietitian and ask patient to complete 7-day dietary diary beforehand. Lifestyle advice about smoking cessation. Consider referral for psychological support. Medications advice. Antidiarrhoeal ± bulk laxative.
Routine AND additional blood screen (pages 2–3)	Abnormal resultsMg2+ lowCoeliac disease	Follow treatment of abnormal blood results (pages 2–3). If IgA deficient, request IgG coeliac screen. Confirm with duodenal biopsy. Refer to dietitian for gluten free diet. Liaise with GP regarding long term monitoring of bone densitometry and referral to a coeliac clinic.
Stool sample: for microscopy, culture and Clostridium difficile toxin	Stool contains pathogen	Treat as recommended by the microbiologist and local protocols.
Stool sample: for faecal elastase	EPI	See EPI (page 16)
OGD with duodenal aspirate and biopsies and/or glucose hydrogen (methane) breath test	SIBO	Treatment for SIBO (page 17).
Carbohydrate challenge	Specific disaccharide intolerance	Appropriate treatment (pages 16–17).
SeHCAT scan	BAM	Treatment for BAM (page 16).
Abdominal X-ray	Faecal loading with overflow	Bulking agent.
1st Line
Flexible sigmoidoscopy with biopsies from non-irradiated bowel (avoid biopsies from areas obviously irradiated in sigmoid and rectum)	Radiation proctopathy and frequency of defecation	Pelvic floor and toileting exercises (page 18)—min. 6 weeks. Add stool bulking agent to pelvic floor exercise regimen. Antidiarrhoeal ± stool bulking agent.
	Radiation proctopathy/colopathy and pelvic floor dysfunction (page 17)	Antidiarrhoeal. ± stool bulking agent. ± pelvic floor and toileting exercises (page 18).
	Macroscopic colitis	Send stool culture. If mild or moderate, refer within 2 weeks to a gastroenterologist. If severe, this is an emergency—discuss immediately with a gastroenterologist.
	Microscopic colitis	Discuss with supervising clinician and refer to a gastroenterologist.
2nd Line
Colonoscopy with biopsies	Macroscopic or microscopic colitis	As above.
	Organic cause (eg, infection, inflammation, neoplastic)	Discuss with the appropriate clinical team within 24 h.
If diarrhoea is present in combination with other symptoms:flushing, abdominal pain, borborygmi, wheezing, tachycardia or fluctuation in BP
3rd Line
Gut hormones (Chromogranin A&B, gastrin, substance P, VIP, calcitonin, somatostatin, pancreatic polypeptide) and Urinary 5-HIAA and CT chest, abdomen and pelvis	Functioning NET, eg, carcinoid syndrome or pancreatic NET	Discuss and refer to the appropriate neuroendocrine tumour team requesting an appointment within 2 weeks.
	If all tests are negative, but symptoms persist	Reassure and suggest symptomatic treatment with antidiarrhoeal drugs.Trial of low-dose tricyclic antidepressants.Biofeedback.

Note: faecal calprotectin as a marker for bowel inflammation is too non-specific and hence not recommended in this population.

BAM, bile acid malabsorption; EPI, excocrine pancreatic insufficiency; GP, general practitioner; IgA, immunoglobulin A; IgG, immunoglobulin G; OGD, oesophago-gastroduodenoscopy; PPI, proton pump inhibitor; NET, neuroendocrine tumour; SIBO, small intestinal bacterial overgrowth.

If mild or moderate, refer within 2 weeks to a gastroenterologist. If severe, —discuss immediately with a gastroenterologist.

Faecal incontinence

(Soiling/leakage/using pads)

Investigations	Potential results	Clinical management plan: abnormal results
1st Line
Routine AND additional blood screen (pages 2–3)	Abnormal results	Follow treatment of abnormal blood results (pages 2–3).
Rectal examination AnoscopyFlexible sigmoidoscopy	Pelvic floor dysfunction (page 17) with radiation proctopathy and faecal incontinence/leakage ORAnal sphincter defect	Pelvic floor and toileting exercises (page 18). Stool bulking ± antidiarrhoeal agent. Antidiarrhoeal agent ± stimulant laxative suppositories/enemas. Topical sympathomimetic agent (eg, phenylephrine). Perianal skin care (pages 19–20). Referral for biofeedback. Consider referral to a specialist centre for sacral nerve stimulation. Consider referral to a specialist centre for defunctioning surgery/sphincter repair.
	Stool consistency: type 6–7	See ‘diarrhoea’ (page 7).
	Constipation with overflow diarrhoea	See ‘constipation’ (page 6).
	Mucus leakage	See ‘mucus discharge’ (page 9).
	Mucosal prolapse	Routine referral to a GI surgeon.
	Unrelated to radiotherapy (eg, childbirth, previous sphincter surgery, haemorrhoidectomy, idiopathic)	Refer to a specialist team for management of faecal incontinence.
2nd Line
Endo anal ultrasoundANDAnorectal physiology	Muscular incoordination or inadequate function	Pelvic floor and toileting exercises (page 18)Bulking agent (Normacol (Norgine, Harefield, UK) or loperamide.Biofeedback (page 18).
	Significant sphincter defect	Discuss with supervising clinician and routine referral to GI surgeon for consideration of sacral nerve or tibial nerve stimulation.

GI, gastrointestinal.

If severe, —discuss immediately with a gastroenterologist.

Loss of sensation

(Unable to discriminate between need to defecate and pass urine)

Investigations	Potential results	Clinical management plan: abnormal results
Neurological examination (including perianal sensation)	Abnormal examination (eg, suspected spinal cord compression, cauda equine syndrome, neurogenic bladder)	This is an emergencyDiscuss immediately with an oncology or neurology team.
Routine blood screen and ESR, vitamin B12, red cell folate	Abnormal results	Follow treatment of abnormal blood results (pages 2–3).
Consider MRI pelvis	Tumour recurrence or other cause for neurological dysfunction	Discuss immediately with supervising clinician.
	Related to radiotherapy or surgery	Pelvic floor and toileting exercises (page 18). Bulking agent ± antidiarrhoeal. Consider referral for biofeedback (page 18).

ESR, erythrocyte sedimentation rate.

If severe, —discuss immediately with a gastroenterologist.

If severe, —discuss immediately with a gastroenterologist.

Pain (anal/perianal/rectal): typical proctalgia fugax

(A sudden, severe pain in the anorectal region lasting less than 20 min, resolving spontaneously)

Investigations	Potential results	Clinical management plan: abnormal results
Symptom assessment	Spasm of the levator ani muscles	Treatment for rectal spasm Pelvic floor and toileting exercises (page 18). Consider a low dose antidepressant. Consider a trial of an inhaled β 2 agonist. Consider referral to a specialist centre for biofeedback (page 18). Consider referral for acupuncture.

Steatorrhoea

(the presence of excess fat in the stool)

Investigations	Potential results	Clinical management plan: abnormal results
1st Line
Stool sample for faecal elastase	EPI	See EPI (page 16).
Routine blood screen and additional blood screen	Addison's disease Coeliac diseaseThyroid dysfunction	Follow treatment abnormal blood results (pages 2–3).
SeHCAT scan	BAM	Treatment for BAM (page 16).
Glucose hydrogen (methane) breath test for bacterial overgrowth and/or OGD and D2 asp and biopsies	SIBO	Treatment for SIBO (page 17).
	Intestinal parasites	Treat with antibiotics within level of confidence or discuss with microbiologists and supervising clinician.
2nd Line
Gut hormones (Chromogranin A&B, gastrin, substance P, VIP, calcitonin, somatostatin, pancreatic polypeptide) and Urinary 5-HIAA and CT/MR liver and abdomen	Pancreatic neuroendocrine tumour	Discuss and refer urgently to the appropriate neuroendocrine tumour team, requesting an appointment within 2 weeks.
CT abdo pelvis/capsule endoscopy/MRI enteroclysis	Small intestinal disease other than radiotherapy induced (eg, lymphoma)	Discuss immediately and refer urgently to the appropriate team requesting an appointment within 2 weeks.
	If all tests are negative, but symptoms persist	Trial of empirical antibiotics to exclude test negative SIBO (page 17). Trial of low fat diet.

BAM, bile acid malabsorption; EPI, excocrine pancreatic insufficiency; OGD, oesophago-gastroduodenoscopy; SIBO, small intestinal bacterial overgrowth.

Tenesmus

(a feeling of constantly needing to pass stools, despite an empty rectum)

Investigations	Potential results	Clinical management plan: abnormal results
Flexible sigmoidoscopy	Radiation proctopathyAnterior resection syndrome	Pelvic floor and toileting exercises (page 18). Stool bulking agent. Low dose antidepressants. Consider referral to a specialist centre for biofeedback (page 18). Consider referral for acupuncture.
	Polyp	Arrange endoscopic/surgical removal.
	Newly diagnosed neoplasm	Refer urgently to the appropriate oncology team requesting an appointment within 2 weeks.
	Newly diagnosed IBD/infection	Send stool culture. If mild or moderate, refer within 2 weeks to a gastroenterologist. If severe, this is an emergency—discuss immediately with a gastroenterologist.

IBD, inflammatory bowel disease.

If severe, —discuss immediately with a gastroenterologist.

Routine:Full blood count, urea and electrolytes, liver function, glucose, calcium
Haemoglobin <80 g/L	→	▸ If Hb <80 g/L: consider blood transfusion (checking ferritin, transferrin saturation, RBC folate and vitamin B12 before transfusion).▸ If iron deficient: consider iron supplements.▸ If unexplained: consider OGD and colonoscopy/CT pneumocolon.
Anaemic but Hb >80 g/L	→	▸ Check ferritin, transferrin saturation, RBC folate and vitamin B12. Replace if necessary, monitor response. If unexplained consider OGD and colonoscopy.
Abnormal urea, electrolytes	→	▸ Discuss with supervising clinician within 24 h.▸ Consider appropriate IV fluid therapy/oral replacement.
Abnormal liver function tests	→	▸ Discuss with supervising clinician within 24 h. ▸ Patient will need a liver ultrasound and liver screen including hepatitis B and C serology, ferritin, α feta protein, α1 antitrypsin, liver autoantibodies, total Igs, cholesterol, triglycerides.
Abnormal glucose level	→	If no history of diabetes: ▸ Between 7–11 mmol/L: refer to GP. ▸ >11 mmol/L and ketones in urine: this is an emergency. ▸ >11–20 mmol and no ketones in urine: discuss with supervising clinician within 24 h. ▸ >20 mmol/L and no ketones in urine: this is an emergency. If known diabetic: ▸ Do not check glucose levels. ▸ Consider checking HbA1c.
Abnormal corrected calcium level	→	▸ If 2.6–2.9 mmol/L: discuss with supervising clinician within 24 h. ▸ If >3.0 mmol/L: this is an emergency.

GP, general practitioner; RBC, red blood cell; OGD, oesophago-gastroduodenoscopy.

Additional blood tests are indicated depending on the presenting GI symptoms and differential diagnoses as outlined in the algorithm. They potentially includeESR, CRP, red cell folate, iron studies, vitamin B12, thyroid function test, coeliac serology (TTG IgA), magnesium
Elevated ESR/CRP	→	Consider the following possibilities: ▸ Infection (including SIBO). ▸ Inflammation (including IBD). ▸ Recurrent malignancy. ▸ Non-GI causes (eg, rheumatoid arthritis, vasculitis, connective tissue disorders).
RBC folate deficiency	→	▸ Consider referral to dietitian for specialist dietetic advice/supplementation.
Iron deficiency: ferritin, % transferrin saturation, red cell indices	→	▸ If iron is low, discuss with supervising clinician and oncology team within 2 weeks. ▸ If intolerant of oral iron: consider IV iron infusion.
If excess iron	→	▸ Consider haemochromatosis: discuss with supervising clinician and consider genetic testing.
Low vitamin B12	→	▸ Exclude possibility of inadequate dietary intake—if this is the probable cause, consider trial of oral vitamin B12 supplements. ▸ Consider possibility of pernicious anaemia—check parietal cell antibody. ▸ Exclude SIBO (page 17). Recheck result after treatment with antibiotics. ▸ If confirmed on repeat testing and not treatable with oral replacement, ask GP to arrange lifelong intramuscular replacement.
Abnormal thyroid function tests	→	▸ If TSH suppressed (<0.5 mIU/L), recheck result with thyroid autoantibodies. ▸ If TSH suppression confirmed, request GP to organise/refer for radiological imaging and treatment.
	→	▸ If TSH elevated (>4.0 mIU/L). Re-check result. Also check morning cortisol if Na ≤135 mmol/L and K >4 mmol/L or raised urea or creatinine. ▸ If TSH elevation confirmed: start thyroid replacement medication. Request GP monitor long term. Review bowel function after 6–8 weeks.
Abnormal coeliac serology	→	▸ If IgA deficient, request IgG coeliac screen. ▸ If TTG elevated, confirm with duodenal biopsy. ▸ Refer for specialist dietetic advice.
Serum Mg2+	→	▸ If <0.3 mmol/L: this is an emergency. ▸ If 0.3–0.5, consider IV replacement if symptomatic or fall in Mg2 level has been acute. If oral replacement is given, check for response after 5–7 days with repeat blood tests. ▸ If oral replacement is used, Mg oxide or Mg aspartate provide better bioavailability and cause less diarrhoea than other Mg preparations.

CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; GI, gastrointestinal; GP, general practitioner; IBD, inflammatory bowel disease; IgA, immunoglobulin A; IgG, immunoglobulin G; RBC, red blood cell; SIBO, small intestinal bacterial overgrowth; TSH, thyroid stimulating hormone; TTG, tissue transglutaminase.

Specific blood tests are indicated depending on the symptoms/diagnosis as outlined in the algorithm:fat-soluble vitamins, trace elements, fasting gut hormones, INR, haematinics
Any malabsorptive syndromes, eg, ▸ BAM ▸ Pancreatic insufficiency ▸ Short bowel syndrome	→	▸ Check vitamins A–D–E, trace elements (selenium, copper and zinc) and INR. ▸ If deficient: start appropriate supplementation. ▸ Request yearly monitoring via GP.
If bleeding	→	▸ Check full blood count and INR. ▸ Discuss immediately with supervising clinician and gastroenterologist/GI surgeon.
When on a bile acid sequestrant	→	▸ Check triglyceride levels annually. ▸ Check fat-soluble vitamins A–D–E and INR (for vitamin K) annually. ▸ Check trace elements (selenium, zinc and copper) annually.
Cortisol level	→	▸ Morning level needed. If low, arrange synacthen test. If abnormal needs immediate discussion with endocrinologist.

BAM, bile acid malabsorption; GI, gastrointestinal; GP, general practitioner; INR, International Normalised Ratio.

Investigations	Potential results	Clinical management plan: abnormal results
Check haemoglobin, RBC indices and plateletsCheck clotting and haematinics if heavy bleeding has occurred	Abnormal	Follow treatment for abnormal blood results (pages 2–3).
Flexible sigmoidoscopy	Radiation proctopathy with bleeding from telangiectasia	Do not biopsy irradiated areas. Optimise bowel function and stool consistency. If bleeding is not affecting quality of life, reassure. If bleeding affects quality of life, stop/reduce anti-coagulants if possible and consider sucralfate enemas (page 19). Discuss referral to a specialist centre for treatment to ablate telangiectasia (pages 18–19): a. hyperbaric oxygen therapy b. intra-rectal formalin b. thermal therapy, eg, APC Consider referral to a specialist centre for experimental therapy within the context of a clinical trial: thalidomide, vitamin A, tranexamic acid, RFA.
	Haemorrhoidal bleeding	If not affecting quality of life, reassure.Consider local treatment of haemorrhoids (diet, topical creams).Consider surgical referral for 3rd degree haemorrhoids.
	Primary inflammatory bowel disease	Send stool culture. If mild or moderate, refer within 2 weeks to a gastroenterologist.If severe, this is an emergency—discuss immediately with a gastroenterologist.
	Diverticular bleeding	This is an emergencyDiscuss immediately with a GI surgeon
	Viral infection (eg, CMV)	This is an emergencyDiscuss immediately with a gastroenterologist.
	Newly diagnosed neoplasia second primary/tumour recurrence/advanced polyp	Refer urgently to the appropriate oncology team requesting an appointment within 2 weeks.
	If all tests are negative, but symptoms persist	Consider colonoscopy. Optimise bowel function and stool consistency. Reassure and request GP to check Hb as clinically indicated.

APC, argon plasma coagulation; CMV, cytomegalovirus; GI, gastrointestinal; GP, general practitioner; RBC, red blood cell; RFA, radiofrequency ablation.

Investigations	Potential results	Clinical management plan: abnormal results
Check haemoglobin and RBC indicesCheck clotting and haematinics if heavy bleeding has occurred	Abnormal	Follow treatment for abnormal blood results (pages 2–3).
OGD and colonoscopy	Radiation-induced telangiectasia in the colon or terminal ileum	Do not biopsy irradiated areas. Optimise bowel function and stool consistency. If bleeding is not affecting quality of life, reassure. If bleeding affects quality of life, stop/reduce anticoagulants if possible and consider oral sucralfate. Discuss and refer to a specialist centre for treatment to ablate telangiectasia: hyperbaric oxygen therapy thermal therapy, eg, APC Consider referral to a specialist centre for experimental therapy within the context of a clinical trial: thalidomide, vitamin A, tranexamic acid, RFA.
	Primary inflammatory bowel disease	Send stool culture. If mild or moderate, refer within 2 weeks to a gastroenterologist. If severe, this is an emergency—discuss immediately with a gastroenterologist.
	Diverticular bleeding	This is an emergencyDiscuss immediately with a GI surgeon.
	Upper GI source for bleeding	This is an emergencyDiscuss immediately with a gastroenterologist.
	Newly diagnosed neoplasia2nd primary/tumour recurrence/advanced polyp	Refer urgently to the appropriate oncology team requesting an appointment within 2 weeks.
	If all tests are negative, but symptoms persist	Discuss with supervising gastroenterologist. Consider capsule endoscopy (following use of a patency capsule—high risk of strictures). Consider angiography. Ask GP to monitor Hb as clinically indicated.

APC, argon plasma coagulation; GI, gastrointestinal; GP, general practitioner; OGD, oesophago-gastroduodenoscopy; RBC, red blood cell; RFA, radiofrequency ablation.

Investigations	Potential results	Clinical management plan: abnormal results
1st Line
Routine ANDadditional blood screen (pages 2–3)	Abnormal results	Follow treatment of abnormal blood results (pages 2–3).
Abdominal X-ray	Severe faecal loading	Full bowel clearance, ie, Picolax (Ferring Pharmaceuticals Ltd, West Drayton, UK), Klean-Prep (Norgine Limited, Harefield, UK), Moviprep (Norgine Limited, Harefield, UK). Maintenance bulk laxative. Correct positioning on lavatory and pelvic floor exercises (page 18).
Dietary history	Inadequate fluid Inadequate/excessive fibre intakeExcessive sorbitolExcessive caffeine	Dietary advice. Referral to dietitian and ask patient to complete 7 day dietary diary.
Drug history/medications assessment		Consider stopping opiate drugs/metformin/statins/non-steroidal anti-inflammatory drugs.
2nd Line
OGD and duodenal aspirate and/or glucose hydrogen methane breath test	SIBO	Treatment for SIBO (page 17).
Stool for faecal elastase	EPI	Treatment for EPI (page 16).
Dietary history± challenge test for carbohydrate malabsorption	Carbohydrate intolerance	Treatment for carbohydrate malabsorption (pages 16–17).
Ultrasound of biliary tree and abdomen and pelvis (and small bowel if no CT scan of abdomen and pelvis in the time symptoms have been present/last 3 months)	Suggestive of gallstones, inflammatory bowel disease, tumour recurrence, other	Discuss with supervising clinician and refer as clinically appropriate to a GI surgeon/gastroenterologist/oncology team.
MRI small bowel	Small bowel stenosis	Discuss with supervising clinician and refer as clinically appropriate to a GI surgeon/gastroenterologist/oncology team.
	If all tests are negative, but symptoms persist	Reassure. Antispasmodics. Low-dose antidepressants. Consider referral for low FODMAPs diet. Agent for neuropathic pain if pain severe. Refer to pain clinic if pain severe. Consider a referral for acupuncture. Consider a referral for hypnotherapy.

EPI, exocrine pancreatic insufficiency; FODMAPs, fermentable oligo-, di- and mono-saccharides and polyols; GI, gastrointestinal; OGD, oesophago-gastroduodenoscopy; SIBO, small intestinal bacterial overgrowth.

Investigations	Potential results	Clinical management plan: abnormal results
Dietary/lifestyle/medications assessment	Inadequate fibre intakeReduced general exerciseDrug induced, eg, opioid ondanestron antimuscarinic loperamide iron supplement Chronic constipation/evacuation disorder	Dietary advice about healthy fibre and fluid intake. Lifestyle advice about daily exercise. Making time to have a toileting routine, correct positioning on the lavatory. Medications advice. Rectal evacuant (eg, glycerine suppositories). Bulk laxative ± rectal evacuant. Consider referral for biofeedback therapy (page 18). Consider use of probiotics.
Abdominal/rectal examination	Anal fissure	Topical healing agent, eg, GTN or diltiazem gel (for 8 weeks). Stool bulking/softening agent ± short term topical local anaesthetic. If recurrent, consider referral for botulinum toxin treatment. If fissure not healed after 2 months, refer for surgical opinion.
Routine blood screen and additional blood screen	Dehydration	Encourage oral fluid intake.
	Hypothyroidism	Repeat thyroid function test. Inform GP and follow management (pages 2–3).
	Elevated calcium	Follow management (page 2).
Abdominal X-ray	Faecal loading/faecal impaction	Full bowel clearance, eg, Picolax, Klean-Prep. Maintenance bulk laxative. Correct positioning on lavatory and pelvic floor exercises (page 18).
Transit study	Slow GI transit	Discuss and refer to a gastroenterologist routinely.
Colonoscopy/CT pneumocolon if new onsetFlexible sigmoidoscopy for longstanding problems	Newly diagnosed neoplasm	Discuss and refer to oncology team, requesting appointment within 2 weeks.
	Newly diagnosed IBD	If mild or moderate, refer within 2 weeks to a gastroenterologist. If severe, this is an emergency—discuss immediately with a gastroenterologist.
	Anastomotic stricturing	Discuss with supervising clinician.
	Anterior resection syndrome	Pelvic floor exercises (page 18). Bulking agent. Antidiarrhoeal medication. Low-dose tricyclic/SSRI antidepressant. Consider referral for sacral nerve/tibial nerve stimulation. Consider referral to a GI surgeon for stoma formation.

GI, gastrointestinal; GP, general practitioner; GTN, glyceril trinitrate; IBD, inflammatory bowel disease.

Investigations	Potential results	Clinical management plan: abnormal results
1st Line
Dietary assessment	High intake of fizzy drinks	Reduce intake of fizzy drinks and discuss alternatives.
2nd Line
Abdominal X-ray	Faecal loading	See ‘constipation’ (page 6).
OGD and D2 aspirate and/or glucose hydrogen (methane) breath test	SIBO	Treatment for SIBO (page 17).
	If all tests are negative, but symptoms persist	Discuss ‘aerophagia’ with patient.

OGD, oesophago-gastroduodenoscopy; SIBO, small intestinal bacterial overgrowth.

Investigations	Potential results	Clinical management plan: abnormal results
1st Line
Dietary assessment	Excess/deficient fibre intake/resistant starchInadequate fluids	Referral to dietitian and ask patient to complete 7 day dietary diary in advance. Dietitian to assess food diary to determine dietary fibre intake.Give appropriate advice.
2nd Line
Abdominal X-ray	Constipation	See ‘constipation’ (page 6).
	Faecal loading	Full bowel clearance, eg, Picolax, Klean-Prep, Moviprep. Maintenance bulk laxative. Correct positioning on lavatory and pelvic floor exercises (page 18).
OGD and D2 aspirate and/or glucose hydrogen (methane) breath test	SIBO	Treatment for SIBO (page 17).
Flexible sigmoidoscopy	Newly diagnosed neoplasm	Refer urgently to the appropriate oncology team, requesting an appointment within 2 weeks.
	Newly diagnosed IBD	Send stool culture. If mild or moderate, refer within 2 weeks to a gastroenterologist. If severe, this is an emergency—discuss immediately with a gastroenterologist.
Rectal examination	Pelvic floor dysfunction (page 17)Lax sphincter muscle	Pelvic floor and toileting exercises (page 18). Stool bulking ± antidiarrhoeal agent. Antidiarrhoeal agent ± stimulant laxative suppositories/enemas. Referral for biofeedback (page 18).

IBD, inflammatory bowel disease; OGD, oesophago-gastroduodenoscopy; SIBO, small intestinal bacterial overgrowth.

Investigations	Potential results		Clinical management plan: abnormal results
Dietary assessment	Excessive dietary fibre intake		Refer to dietitian for detailed dietary review and advice. Pelvic floor and toileting exercises (page 18).
Rectal examination	Haemorrhoids		Stool bulking/softening agent.± short-term topical local anaesthetic.
	Anal lesion Rectal lesion		Refer urgently to a GI surgeon.
			Refer for a flexible sigmoidoscopy within 2 weeks.
Flexible sigmoidoscopy	Anorectal ulcer		Determine patient is not on nicorandil for angina.
	Neoplastic		Refer urgently to the appropriate oncology team requesting an appointment within 2 weeks.
	Rectal mucosal prolapse		Refer to a GI surgeon.
	Traumatic ulceration/solitary rectal ulcer syndrome		Refer to a gastroenterologist.
	If radiation-ulceration related		Do not biopsy Sucralfate enemas. Consider stool bulking/softening agent. Antibiotics. Consider hyperbaric oxygen therapy. Refer to a specialist centre.
	Carpet villous adenoma		Refer for endoscopic removal.
	Newly diagnosed neoplasm		Refer to the appropriate oncology team requesting an appointment within 2 weeks.
	IBD		Send stool culture. If mild or moderate, refer within 2 weeks to a gastroenterologist. If severe, this is an emergency—discuss immediately with a gastroenterologist.
OGD and D2 aspirate and/or glucose hydrogen (methane) breath test	SIBO		Treatment for SIBO (page 17).

GI, gastrointestinal; IBD, inflammatory bowel disease; OGD, oesophago-gastroduodenoscopy; SIBO, small intestinal bacterial overgrowth.

Investigations	Potential results	Clinical management plan: abnormal results
Fundoscopy	Raised ICP	This is an emergencyDiscuss immediately with supervising clinician and the oncology or neurology team.
Trial of PPI	Inflammatory (acid related)	Reassess after 2–4 weeks as clinically indicated.
Blood screen+morning cortisol level	Metabolic abnormality	Discuss immediately with supervising clinician and consider referral to endocrinology within 24 h.
	Liver/biliary abnormality	Discuss with supervising clinician within 24 h.
	Suggestive of infection	Treat with antibiotics within level of confidence or discuss with microbiologists and supervising clinician.
Urine analysis	Metabolic abnormality, eg, glucosuria, ketonuria	Discuss immediately with supervising clinician.
	Infection	Treat with antibiotics within level of confidence or discuss with microbiologists and supervising clinician within 24 h.
OGD± assessment for Helicobacter pylori	Inflammatory/ulcerative disease	PPI and helicobacter eradication therapy. Sucralfate. Promotility agents. Discuss with supervising clinician need for future repeat endoscopy.
	Gastric dysmotility	Consider a prokinetic medication (page 20) (eg, domperidone, metoclopramide, erythromycin).
Glucose hydrogen (methane) breath test	SIBO	Treatment for SIBO (page 17).
Hepatic and pancreatic ultrasound	Biliary/hepatic/pancreatic aetiology	Discuss with gastroenterologist or hepatology team.If acute jaundice/cholangitis: this is an emergency.
CXR/CT/MRI(including CNS)	Local or distal infection	Treat with antibiotics within level of confidence or discuss with microbiologists and supervising clinician.
	Central nervous system pathology	This is an emergencyDiscuss immediately with supervising clinician and the oncology or neurology team.
	Bowel obstruction	This is an emergencyDiscuss immediately with a GI surgeon.
	If all tests are negative, but symptoms persist	Consider contributing psychological factors. Consider referral for psychological support if there is a possible underlying eating disorder. Consider a routine referral to a gastroenterologist for further management.

GI, gastrointestinal; OGD, oesophago-gastroduodenoscopy; PPI, ; SIBO, small intestinal bacterial overgrowth.

Investigations	Potential results	Clinical management plan: abnormal results
1st Line
Dietary assessment	Inappropriate fluid and fibre intakeExcessive sorbitolExcessive caffeine	Dietary advice about healthy fibre and general dietary intake.
Medication assessment	Drug induced, eg, opioid ondansetron anti-muscarinics loperamide iron supplement statin metformin	Medications advice.
Routine blood tests and calcium, ESR, CRP	Abnormal results	Follow treatment of abnormal blood results (pages 2–3).
Abdominal X-ray	Faecal loading/faecal impaction	Full bowel clearance, eg, Picolax, Klean-Prep. Maintenance bulk laxative. Correct positioning on lavatory (toileting exercises) (page 18).
2nd Line
OGD and duodenal aspirate ± glucose hydrogen (methane) breath tests	SIBO	Treatment for SIBO (page 17).
Flexible sigmoidoscopy	Newly diagnosed IBD	Send stool culture. If mild or moderate, refer within 2 weeks to a gastroenterologist. If severe, this is an emergency—discuss immediately with a gastroenterologist.
Ultrasound of biliary tree and small bowel (if no recent CT scan of abdomen and pelvis)	Suggestive of gallstones, IBD, tumour recurrence, other	Discuss with supervising clinician within 24 h and refer as clinically appropriate to a GI surgeon/gastroenterologist/oncology team.
	If all tests are negative, but symptoms persist	Consider CT abdomen and pelvis. Consider lower GI endoscopic assessment. Refer to a specialist pain team for further assessment. Consider antispasmodics. Consider low-dose antidepressants. Consider agent for neuropathic pain. Consider referral for acupuncture.

CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; GI, gastrointestinal; IBD, inflammatory bowel disease; OGD, oesophago-gastroduodenoscopy; SIBO, small intestinal bacterial overgrowth.

Investigations	Potential results	Clinical management plan: abnormal results
Neurological examination (including perianal sensation)	Abnormal examination (eg, suspected spinal cord compression)	This is an emergencyDiscuss immediately with an oncology or neurology team.
Symptom assessment	Pain over the renal angle	Consider pyelonephritis kidney infection/stone/urinary tract infection. Urine dip stick and urine sample for culture and sensitivity. Consider renal ultrasound.
	Pain in the lower flank	Consider constipation, faecal loading and faecal impaction (page 6).
	Pain in the lower back	Consider lower back fracture. Request a spinal (thoracic/lumbar) X-ray. Consider MRI.
	Bone pain	Consider a bone scan and myeloma screen.
Routine blood screen and additional blood screen	Abnormal results suggesting cancer relapse	Discuss immediately with supervising clinician.
CT/MRI/PET scan abdomen and pelvis	Colonic faecal loading	See ‘constipation’ (page 6).
	Acute bowel obstruction	This is an emergencyDiscuss immediately with a GI surgeon.
	Spinal fracture	Discuss immediately with supervising clinician.

GI, gastrointestinal; PET, position emission tomography.

Investigations	Potential results	Clinical management plan: abnormal results
Medication assessment	On nicorandil	Liaise with cardiology team and GP to offer alternative medication.
Visual assessment1st LineAnoscopy and flexible sigmoidoscopy2nd LineMRI	Haemorrhoids	Stool bulking/softening agent ± short-term topical local anaesthetic. Consider referral for surgical review for grade 3 or 4 haemorrhoids.
	Anal fissure	Topical healing agent, eg, GTN or diltiazem gel (for 8 weeks). Stool bulking/softening agent ± short-term topical local anaesthetic. If fissure not healed after 2 months, refer for surgical opinion.
	Anorectal fistula	Pelvic MRI. Refer to a colorectal surgeon.
	Anorectal abscess	This is an emergencyDiscuss immediately with a colorectal surgeon regarding treatment with antibiotics and/or drainage.
	Anorectal ulcer	Check patient is not on nicorandil.
	Mucosal prolapse/solitary rectal ulcer	Refer to GI surgeon/gastroenterologist.
	Neoplastic ulcer	Refer urgently to appropriate oncology team requesting an appointment within 2 weeks.
	If radiation-ulceration related	Do not biopsy Sucralfate enemas. Consider stool bulking/softening agent. Antibiotics. Consider hyperbaric oxygen therapy. Refer to a specialist centre.
	If all tests are negative, but symptoms persist	Consider investigation under anaesthesia. Pelvic floor and toileting exercises (page 18). Stool bulking agent ± laxative. Consider a referral for acupuncture. Consider referral to a specialist pain team. Consider a low-dose antidepressant. Consider an agent for neuropathic pain. Consider referral for a urological/gynaecological opinion.

GI, gastrointestinal; GP, general practitioner; GTN, glyceril trinitrate.

Investigations	Potential results	Clinical management plan: abnormal results
Symptom assessment	Perianal pruritus mainly present during the night	Consider enterobiosis (eggs are not visible with the naked eye and stool samples are only positive in 5–15%). Send a sample of transparent adhesive tape (eg, Scotch Tape) applied on the anal area for microscopic analysis.
	Due to excess pancreatic enzyme replacement	Alter dose.
Visual assessment	Changes due to radiotherapy	If soiling see guidance for faecal incontinence (page 8). If loose stool/diarrhoea present investigate for possible causes (page 7). Perianal skin care (pages 19–20). Topical barrier agent. Topical corticosteroids (Trimovate (GlaxoSmithKline UK, Uxbridge, UK)). Consider referral to dermatologist.
	No changes due to radiotherapy	Perianal skin care (pages 19–20). Consider referral to dermatologist.
Protoscopy/flexible sigmoidoscopy	Haemorrhoids	Stool bulking/softening agent ± short-term topical local anaesthetic. Consider referral for surgical review for grade 3 or 4 haemorrhoids.
	Anal fissure	Topical healing agent, eg, GTN or diltiazem gel (for 8 weeks). Stool bulking/softening agent ± short-term topical local anaesthetic. If fissure not healed after 2 months, refer for surgical opinion.
	Anorectal fistula	Pelvic MRI. Refer to a colorectal surgeon.
	Anorectal abscess	This is an emergencyDiscuss immediately with a GI surgeon regarding treatment with antibiotics and/or drainage.
	Anorectal ulcer	Check patient is not on nicorandil.
	If radiation related	Do not biopsy Sucralfate enemas. Consider stool bulking/softening agent. Antibiotics. Consider hyperbaric oxygen therapy. Refer to a specialist centre.
	Mucosal prolapse/solitary rectal ulcer	Refer to colorectal surgeon/gastroenterologist.
	Neoplastic ulcer	Refer urgently to appropriate oncology team requesting an appointment within 2 weeks.

GI, gastrointestinal; GTN, glyceril trinitrate.

Investigations	Potential results	Clinical management plan: abnormal results
Dietary assessment	Inadequate dietary intake	Dietary advice and consider oral nutritional supplements. Refer for specialist dietetic assessment and advice.
Symptom assessment	No other GI symptoms present	Discuss with supervising clinician or Request OGD, colonoscopy, CT chest, abdomen and pelvis.
	If GI symptoms present	Follow algorithm.
Routine and additional blood screen (pages 2–3) and myeloma screen	Abnormal results, eg, thyrotoxicosis, new onset diabetes mellitus, Addison's disease	Follow treatment of abnormal results (pages 2–3).
OGDColonoscopyCT chest abdomen and pelvis	Organic cause (eg, infection, inflammation, neoplastic)	Discuss with supervising clinician within 24 h.
	No organic cause identified	Refer to dietitian and review regularly.Consider psychological causes, eg, depression/eating disorder.Refer to appropriate cancer MDT for consideration of PET scan.

GI, gastrointestinal; OGD, oesophago-gastroduodenoscopy; PET, position emission tomography.

10–15%	Mild BAM
5–10%	Moderate BAM
<5%	Severe BAM