Gastroenterology and Hepatology

Consider FIT-led colorectal cancer pathway and local IDA route

• Offer FIT in line with the current Kent and Medway / NICE symptomatic FIT pathway for IDA and other eligible colorectal-cancer features.
• FIT ≥10 micrograms Hb/g faeces — use the suspected colorectal cancer pathway.
• FIT <10, FIT not returned or FIT not obtainable — do not delay referral to an appropriate pathway if there is strong clinical concern, persistent unexplained symptoms, red flags or abnormal examination.
• Consider upper-GI investigation and whether cancer, gastroenterology or a local combined IDA pathway is the safest route, according to local governance.
• Post-menopausal bleeding with IDA — gynaecology 2WW; visible haematuria with IDA — urology 2WW.

Before you refer

• Recommend Examination of abdomen and ideally PR Exam if relevant history
• Urine dip for blood
• Ferritin, fasting transferrin saturation, coeliac serology (IgA & IgG tTG), FBC trend Ferritin is an acute-phase reactant. Where inflammation is active, or ferritin is raised as an inflammatory marker, use the fasting transferrin saturation to confirm iron deficiency — a normal or raised ferritin does not exclude it.
• Start oral iron and note response (e.g. ferrous sulphate 200mg PO OD)
• Determine relevant GI / menstrual / urinary history.

What you'll hear back

• Accepted & booked — routine or urgent
• Redirected (colorectal, gynaecology, urology) if a 2WW pathway fits
• Advice if a non-GI cause is more likely
• Where a test is omitted or outside an optimum time period, the SPoA will assess its clinical importance and determine whether a safe triage can be made. If not, the referrer will be advised what additional information or investigation is required.

Include: ferritin / FBC trend, transferrin saturation, coeliac result, urine dip and examination findings, response to iron, relevant GI / menstrual / urinary history.

Not this route: non-iron-deficient anaemia, or iron deficiency without anaemia.

GP resources

• Investigations | Diagnosis | Anaemia - iron deficiency | CKS | NICE
• Iron-Deficiency-Anaemia-in-Adults.pdf - BSG

Patient resources

Iron deficiency anaemia - NHS

Consider alternative referral pathway first — not via this SPOA

• Age 40+ with unexplained weight loss and abdominal pain — colorectal 2WW
• Age 55+ with unexplained weight loss, upper abdominal pain with reflux / dyspepsia / dysphagia — upper GI 2WW
• Age 40+ with jaundice and abdominal pain — upper GI 2WW → Age 60+ with weight loss and abdominal pain — urgent imaging / CT abdomen rather than direct 2WW
• Women 50+ with new IBS-type symptoms — CA-125 + pelvic USS; gynaecology 2WW if positive

Before you refer

• Recommend Examination of abdomen and ideally PR exam if relevant history.
• FBC, CRP, coeliac serology, renal, liver, bone & thyroid profiles
• qFIT if criteria met (see qFIT reference)
• Faecal calprotectin if IBD suspected (usually symptoms ≥6 weeks)
• Stool PCR if diarrhoea present ✓ H. pylori faecal antigen if upper abdominal discomfort / dyspepsia
• If negative, consider 1st-line management for functional dyspepsia / IBS by predominant symptom.
• FODMAP is dietitian-led per CKS — signpost patients to the Clinical Knowledge Summaries resources; do not require it before referral.

What you'll hear back

• Advice to continue in primary care (most likely functional / IBS)
• Accepted if red flags or diagnostic uncertainty
• Redirected (colorectal, upper GI or gynaecology) if a 2WW pathway fits.

Include: confirmation red flags excluded, faecal calprotectin if done, CA-125 / USS for women 50+, response to first-line management.

Resources

• Irritable bowel syndrome | Health topics A to Z | CKS | NICE
• Irritable bowel syndrome (IBS) and diet - BDA 

Patient resources

• Irritable bowel syndrome (IBS) - NHS
• Management of irritable bowel syndrome in primary care | British Journal of General Practice

Consider alternative referral pathway first — not via this SPOA

• Dysphagia at any age — upper GI 2WW
• Age ≥55 with weight loss plus dyspepsia, reflux or upper abdominal pain — upper GI 2WW
• Any age: significant acute upper GI bleeding — same-day specialist referral → Upper abdominal mass — direct-access USS / upper GI 2WW.

Before you refer

• H. pylori stool antigen — ideally undertake a 2-week PPI washout (to avoid a false negative) — treat if positive
• FBC — check for iron deficiency if anaemia is found
• Liver profile and USS if hepatobiliary disease suspected
• Coeliac serology if overlapping IBS-type symptoms
• If <55 without alarm symptoms: offer guideline-based first-line dyspepsia management, including lifestyle advice, H. pylori testing/treatment where appropriate, and an appropriate-dose PPI trial. In selected patients with likely functional dyspepsia, consider a low-dose tricyclic neuromodulator after review of contraindications, interactions and patient preference; this is not a prerequisite for referral where there is diagnostic uncertainty or clinical concern.

What you'll hear back

• Advice / accepted for endoscopy or clinic as appropriate
• Redirected to upper GI 2WW if red flags
• Request further information if H. pylori status or PPI trial not documented.

Include: H. pylori status and treatment, PPI trial and response where appropriate, dysphagia / weight loss / bleeding excluded, USS result if done, and any reason referral is still needed despite first-line management.

BSG guidelines (2013) (5) state that endoscopic screening is not feasible or justified for an unselected population with GORD but endoscopic screening can be considered in patients with chronic GORD symptoms (>15yrs) and at least three of:

• Age ≥50 years;
• White race; Male sex;
• Obesity

The threshold for screening should be lowered if positive family history of at least one first degree relative with Barrett's or Oesophageal adenocarcinoma.

Resources:

• Dyspepsia - unidentified cause | Health topics A to Z | CKS | NICE
• Dyspepsia - proven GORD | Health topics A to Z | CKS | NICE.

Consider alternative referral pathway first — not via this SPOA

• Suspected cancer (weight loss, rectal bleeding, mass) — colorectal 2WW
• Bloody diarrhoea + systemically unwell — urgent GI (≥6 bloody stools + systemic upset: fever >37.8, pulse >90, anaemia, CRP >40) — same-day on-call medical team.

Before you refer

• Stool PCR / C. diff antigen
• Stool for ova, cysts & parasites if relevant foreign travel history
• FBC, CRP, renal, liver, bone & thyroid profile, coeliac serology, vitamin B12 / folate, ferritin
• Faecal calprotectin (ideally off NSAIDs / PPI 4-6 weeks); if 100-250 mcg/g, repeat at 4 weeks.

If steatorrhoea with a significant alcohol history suggests chronic pancreatitis, also complete the ARLD workup:

• AUDIT-C; renal bloods, liver screen + USS
• Prophylactic oral thiamine
• Refer to community alcohol services; consider dietetics.

What you'll hear back

• Accepted & booked (routine or urgent)
• Moved to IBD route if calprotectin raised
• Urgent gastro if chronic pancreatitis suspected (+ CT, faecal elastase) requested by the SPOA, not a pre-referral requirement
• Redirected to the hepatology SPOA (alcohol-related liver disease route) if liver disease predominates
• Redirected to colorectal 2WW if red flags.

Include: stool and calprotectin results, coeliac serology, and whether onset 45+, nocturnal/continuous, weight loss, or family history of GI disease. If alcohol is a factor: AUDIT-C and units/week, LFTs, USS, thiamine given, and alcohol-service referral status.

Consider alternative referral pathway first — not via this SPOA

• Acute severe colitis (≥6 bloody stools + systemic upset: fever >37.8, pulse >90, anaemia, CRP >40) — same-day on-call medical team
• Perianal sepsis (hot fluctuant swelling) or signs of obstruction — on-call surgical team.

Before you refer

• Stool PCR / C. diff antigen
• Stool for ova, cysts & parasites if relevant foreign travel history
• FBC, CRP, renal, liver, bone & thyroid profile, coeliac serology, vitamin B12 / folate, ferritin.
• Faecal calprotectin if age 16-60. Consider withholding NSAIDs / PPI before testing only where clinically safe and appropriate. Repeat calprotectin is for clinically stable patients with an equivocal result (100-250 mcg/g); it is not a prerequisite for referral where symptoms, examination, blood results or clinical trajectory raise significant concern.
• Known flare: check adherence, stop NSAIDs, encourage patients to contact local IBD advice line.

What you'll hear back

• Accepted & booked to IBD
• Request a repeat calprotectin only if the patient is clinically stable and the result is equivocal (100-250 mcg/g); referral should not be delayed where high suspicion or significant concern is stated.
• Redirected to surgery for perianal sepsis / obstruction.

Include: calprotectin result(s), PCR / C. diff antigen, IBD type and disease location, current treatment or immunosuppressant / biologic — these may lower the referral threshold or influence urgency.

Resources:

• Diagnosing IBD RCGP toolkit
• Managing IBD Flares RCGP toolkit
•  Supporting patients with IBD RCGP toolkit
• Flare pathways launched to help GPs from Crohn's and colitis.

Consider alternative referral pathway first — not via this SPOA

• Suspected cancer — relevant 2WW pathway
• Acute GI bleeding — A&E.

Before you refer

• Recommend Examination of abdomen and ideally PR Exam if relevant history
• FBC, CRP, renal, liver, bone & thyroid profile, coeliac serology, vitamin B12 / folate, ferritin — add a fasting transferrin saturation where inflammation is active, or where ferritin may be raised as an acute-phase reactant
• Consider both colorectal-cancer risk and inflammatory bowel disease: use FIT in accordance with the current Kent and Medway / NICE symptomatic FIT pathway and faecal calprotectin where IBD is suspected. A positive FIT does not distinguish cancer from other causes of gastrointestinal bleeding. Do not delay urgent referral solely to await either test where there is significant clinical concern.

What you'll hear back

• Advice to manage in primary care
• Accepted & booked, or directed to a specific route above
• Request further information if the clinical question or results are incomplete.

Include: a clear clinical question, relevant results, and what has already been tried.

Faecal calprotectin testing

Recommended as an option to support the differential diagnosis of IBD or IBS in adults with recent-onset lower GI symptoms for whom specialist assessment is being considered (NICE DG11).

Consider in:

• Adults aged 16-60 years
• Patients with lower GI symptoms in whom you suspect IBS or IBD
• Lower GI symptoms of >4 weeks duration
• If screening for IBD, also check FBC, renal, liver, bone & thyroid profiles, coeliac serology, B12 / folate, ferritin, CRP.

Exclude if:

• Patient using NSAIDs within past 4-6 weeks
• Colorectal cancer suspected, or diagnostic uncertainty.

Interpretation:

• <100 mcg/g — IBS 98% likely; treat as IBS and review at 6 weeks
• 100-250 mcg/g — IBD 12% likely; repeat at 4-6 weeks; refer to gastroenterology if concern over presentation
• >250 mcg/g — IBD 48% likely; refer to gastroenterology urgently.

References: shared criteria used across the routes above.

This guide draws on the EROS pathway, the local directory of service (routing and investigations), NICE, GIRFT, RCGP, BSG and specialty specific guidelines.

Response times: (indicative SPOA response time) Routine referral within 5 Days. Urgent referral within 48 hrs. (aligned to NHSE guidance).

Consider alternative referral pathway first — not via this SPOA

• Suspicion of cancer — 2WW with urgent imaging
• ALT >300 — acute liver screen + urgent USS, urgent hepatology via SPoA- urgent referral
• Synthetic failure - Coagulopathy, low albumin or high bilirubin — discuss with on-call.

Before you refer

• Liver screen baseline + USS
• Address risk factors (alcohol, metabolic, medication, BMI)
• If metabolic: Metabolic associated fatty liver disease (MAFLD) route.
• If >14 units/week: Alcohol related liver disease (ARLD) route
• Recheck at 2-4 weeks, then 3-monthly.

What you'll hear back

• Advice + lifestyle/recheck plan
• Accepted (routine or urgent), Fibroscan Clinic
• Fibroscan is requested by the SPOA — not a pre-referral requirement for primary care
• A&G available at any stage

Include: Liver screen / NILS, ALT level and trend, USS result, alcohol units, metabolic risk factors.

Resources

• Management of abnormal LFTs NUB RCGP
• NAFLD NUB RCGP
• Alcohol and cirrhosis NUB RCGP
• Guidelines on the management of abnormal liver blood tests BSG, includes disease specific pathways ( Alcohol related liver disease & MASLD) and generic abnormal LFT pathways ( hepatitis / cholestatic / isolated bilirubin & synthetic failure)

Patient resources
British Liver Trust - Pioneering Liver Health

Consider alternative referral pathway first — not via this SPOA

• Weight loss, epigastric or bone pain, new diabetes — upper GI 2WW with urgent imaging.

Before you refer

• Check GGT — if raised, liver screen baseline + USS
• A normal GGT does not exclude a hepatic cause — a space-occupying liver lesion (for example a tumour or haemangioma) can present with an isolated raised ALP and a normal GGT. Consider liver USS.
• If GGT normal, consider bone source: bone profile, vitamin D (often rejected), CRP, PTH, PSA
• Myeloma screen removed from the routine bone-source panel — an isolated raised ALP without hypercalcaemia is not a typical presentation of myeloma. Request only where there are additional red flag features.
• ALP isoenzymes are not recommended — largely superseded by more specific bone formation markers (for example P1NP). Complete the investigation of an isolated raised ALP, including bone causes, before requesting further specialist tests.

What you'll hear back

• Accepted to hepatology if hepatobiliary
• Redirected (rheumatology, urology, metabolic bone clinic where a bone origin is confirmed or suspected; haematology only where the myeloma screen is abnormal) if bone/other source
• Advice / manage in primary care if normal workup.

ESR is no longer requested — CRP alone is the preferred inflammatory marker (laboratory advice: lower cost, less manual processing, and test accuracy can be monitored more reliably).

Include: Liver screen, ALP and GGT levels, bilirubin (normal), and bone-source results if non-hepatic cause suspected.

Resources

Management of abnormal LFTs NUB RCGP
Guidelines on the management of abnormal liver blood tests BSG, includes disease specific pathways ( Alcohol related liver disease & MASLD) and generic abnormal LFT pathways ( hepatitis / cholestatic / isolated bilirubin & synthetic failure).

Higher concern

• Ferritin >1000 — hepatology

Before you refer

• Confirm threshold (male >300, female >200)
• LFTs, FBC, CRP, fasting transferrin saturation
• HFE gene test if TSat >45% or family history of haemochromatosis — record the full HFE genotype in the referral so that type 1 (HFE-related) hereditary haemochromatosis can be confirmed
• If TSat <45%: repeat ferritin; consider alcohol, inflammation, Hepatitis C, metabolic syndrome.

What you'll hear back

• Routine haematology where there is evidence of type 1 (HFE-related) hereditary haemochromatosis — the SPOA redirects; no separate GP referral needed (genotype criteria per the local haematology guideline on elevated ferritin and testing for hereditary haemochromatosis — link to be inserted)
• A&G (hepatology/gastro) for other patterns
• Advice to treat underlying cause in primary care.

Include: ferritin (and repeat), fasting transferrin saturation, HFE result, family history of haemochromatosis, alcohol/inflammatory context.

Consider alternative referral pathway first — not via this SPOA

• Bilirubin >2× ULN, ALT >300, or ALP >500 — urgent hepatology via SPoA urgent referral
• Suspicion of cancer — upper GI 2WW.

Before you refer

• Liver screen baseline + USS
• Address risk factors.

What you'll hear back

• Accepted (routine or urgent)
• Redirected to 2WW if cancer suspected
• A&G available at any stage.

Include: Liver screen, USS result, and risk factors (BMI & alcohol history).

Resources

• Guidelines on the management of abnormal liver blood tests
• Combination of LFT abnormalities RCGP toolkit.

Exclude first

• Confirm alcohol intake is not the driver (ARLD route if >14 units/week).

Before you refer

• Calculate FIB-4 score (< 1.3 significant fibrosis excluded, > 2.67)
• Lifestyle advice; address metabolic risk factors
• Record BMI

What you'll hear back

• Low FIB-4: advice + re-stratify in 2 years
• Fibroscan <10.0 kPa — only re-refer for Fibroscan after 3 years if significant deterioration; 10-11.9 kPa — hepatology recall for repeat scan in 2 years
• Intermediate/high: accepted routine hepatology (Fibroscan)
• A&G available.

Include: FIB-4 score, BMI, metabolic risk factors, alcohol units.

Resources

• Guidelines on the management of abnormal liver blood tests
• MASLD RCGP toolkit.

Consider alternative referral pathway first — not via this SPOA

• Unwell, fever, suspected cholangitis or encephalopathy, bilirubin >100, abnormal clotting/renal, abdominal pain, GI blood loss, suspected paracetamol overdose — admit.

Before you refer

• Split (conjugated/unconjugated) bilirubin, FBC
• If haemolysis: reticulocytes, LDH, haptoglobins, blood film (request as a manual white cell differential) and DAT (direct antiglobulin test)
• Liver screen baseline + USS if chronic liver disease possible.

What you'll hear back

• Advice (likely Gilbert's — reassure, manage in primary care)
• Accepted hepatology (conjugated) or haematology (haemolysis)
• 2WW if cancer suspected.

Include: split bilirubin, FBC and haemolysis screen (including blood film and DAT), USS result, and symptom status.

Resources

Guidelines on the management of abnormal liver blood tests.

Consider alternative referral pathway first — not via this SPOA

• Acute withdrawal at high risk of seizures or DTs, withdrawal seizure, overt jaundice, or suspected Wernicke's — A&E.

Before you refer

• AUDIT-C; renal bloods, liver screen + USS
• Prophylactic oral thiamine
• Refer to community alcohol services; consider dietetics
• If steatorrhoea / persistent diarrhoea is the reason chronic pancreatitis is suspected, also complete the chronic diarrhoea workup:
  • Stool PCR / C. diff - FBC, renal, liver, bone & thyroid profile
  • Coeliac serology; B12, folate, ferritin
  • Faecal calprotectin off PPI/NSAIDs (16-60).

What you'll hear back

• Routine gastro (abnormal LFTs / decompensation)
• Urgent gastro if chronic pancreatitis suspected (+ CT, faecal elastase) — requested by the SPOA, not a pre-referral requirement
• If calprotectin raised — moved to the IBD route, as per the chronic diarrhoea card • Redirected to colorectal 2WW if red flags emerge
• Advice + community alcohol services.

Include: AUDIT-C and units/week, LFTs, USS, thiamine given, and alcohol-service referral status. If diarrhoea present: stool and calprotectin results, coeliac serology, and whether onset 45+, nocturnal/continuous, weight loss, or family history of GI disease.

Resources

• Alcohol and cirrhosis RCGP toolkit
• Guidelines on the management of abnormal liver blood tests.

Patient

Drug & Alcohol Wellbeing Service - West Kent | Change Grow Live.

Urgent - Consider alternative referral pathway first — not via this SPOA

• Fatigue, jaundice, dark urine, abdominal pain or signs of liver failure — urgent gastro/hepatology.

Before you refer

• Liver screen baseline + USS
• HBV DNA, HIV, hepatitis A immunity
• State HBsAg / anti-HBc / anti-HBs status.

What you'll hear back

• Accepted / A&G if HBsAg positive
• A&G if immunosuppression/chemo planned (reactivation risk)
• Advice + contact tracing if cleared infection.

Include: full hepatitis B serology, HBV DNA, any planned immunosuppression, and clinical concerns.

Resources

• Hepatitis B RCGP toolkit.

Urgent- Consider alternative referral pathway first — not via this SPOA

• Fatigue, jaundice, dark urine, abdominal pain or signs of liver failure / suspected acute hepatitis C — same-day assessment.

Before you refer

• HCV antibody; if positive, HCV RNA and Genotype
• Urgent liver USS + liver screen baseline
• Coinfection screen: hepatitis B, HIV, hepatitis A immunity.

What you'll hear back

• Accepted to nurse led Viral hepatitis clinic if RNA positive (treatment, surveillance)
• A&G + contact tracing if RNA negative
• Same-day assessment if red flags.

Include: HCV antibody, HCV RNA and genotype, USS, and coinfection results.

Resources

• Hepatitis C RCGP toolkit.

Consider alternative referral pathway first — not via this SPOA

• Suspected cancer (incl. complex cysts) — 2WW
• Gallstones / gallbladder polyps — general surgery pathway
• Focal fat sparing — NAFLD route.

Before you refer

• Attach the imaging report
• Liver screen baseline
• State whether the finding is symptomatic.

What you'll hear back

• Advice / primary care for asymptomatic benign findings
• Accepted routine gastro if symptomatic, or adenoma
• Redirected (surgery, NAFLD route, cardiology) as appropriate.

Include: the imaging report and finding, symptom status, and liver screen results.