Gastroenterology for GPs: Your Essential Guide

From gut feelings to solid diagnoses — because every rumble tells a story

🥧 Tea-Friendly Learning 🥨 For GP Trainees Short on Time 🥩 Red Flag Focused

Clinical content reviewed: September 2026 · NICE-first, with named specialist guidance where NICE is silent

🔄 What changed in the September 2026 clinical update (click to expand)

Fatty liver on a scan: new step-by-step GP pathway. NICE NG49 fibrosis testing (ELF ≥10.51 = advanced fibrosis → refer) set alongside the BSG FIB-4 pathway. Referral cut-off corrected from FIB-4 >2.67 to >3.25 (BSG 2018), with age-adjusted lower cut-off 2.0 if over 65.
Monitoring NAFLD/MASLD: "annual LFT recall" replaced — LFTs cannot exclude fibrosis. NICE advises repeating fibrosis testing every 3 years in adults if advanced fibrosis is not found.
Abnormal LFTs: rebuilt around the BSG 2018 guideline (NICE has no dedicated guideline). Do an aetiology screen rather than simply repeating tests; standard vs extended panels updated. The ALT "×ULN" table is now labelled as a local-pathway example, not national guidance.
MASLD criteria: BMI criterion added; thresholds aligned to the 2023 multisociety definition; NICE NG49 is being updated and will adopt the term MASLD.
Upper GI cancer (NG12, May 2025): dysphagia, or age ≥55 with weight loss plus upper abdominal pain/reflux/dyspepsia, now = suspected cancer pathway referral (previously "urgent direct-access endoscopy").
IDA: referral now FIT-guided per NG12 (FIT for all adults with IDA), with BSG advice on upper GI assessment and local-pathway caveat.
FIT performance: figures re-labelled — they describe symptomatic FIT at 10 μg/g, not the 80 μg/g screening threshold.
Prescribing corrections: H. pylori penicillin-allergy regimen (clarithromycin 250 mg, not 500 mg); oral iron once daily for all salts; IBS amitriptyline start dose 5–10 mg; thiamine dose; peptic ulcer PPI duration; routine H. pylori re-testing not recommended; unverifiable tropical/parasitic doses removed and replaced with "specialist advice".
Language: "2WW" updated to "suspected cancer pathway referral" (28-day Faster Diagnosis Standard) per NICE NG12 definitions.
Unverified numbers removed: stage-specific survival figures and several prevalence percentages that could not be traced to a primary source were removed or replaced with sourced statements.

Executive Summary

Key Facts

Fatty liver

~4 in 10

adults in a UK primary-care cohort had fatty liver on ultrasound (BALLETS, cited in BSG 2018)

Bowel cancer

2nd

biggest cause of cancer death in England (Cancer Research UK, 2026)

Symptomatic FIT

≥10 μg/g

= suspected colorectal cancer pathway referral (NICE NG12)

Advanced fibrosis

ELF ≥10.51

NICE NG49 threshold — refer to hepatology

Downloads & Resources

Essential resources for ongoing learning and patient support

📁 Downloads

path: GASTROENTEROLOGY

🌐 Web Resources

MDCalc FIB-4 Calculator

First-line fibrosis risk score in NAFLD/MASLD (BSG 2018). Needs age, AST, ALT and platelets.

📋 National guidance (start here)

🫀 NICE NG49 — NAFLD: assessment and managementCurrent NICE guideline (update to MASLD in development).

🎗️ NICE NG12 — Suspected cancer: recognition and referralUpper GI recommendations amended May 2025; FIT criteria 2023.

📈 BSG — Management of abnormal liver blood tests (2018)The main UK guideline for abnormal LFTs — NICE has no dedicated guideline.

🔥 NICE CG184 — Dyspepsia and GORDPPI doses, H. pylori regimens, peptic ulcer management.

🗺️ Local pathway examples

🩸 Barnsley BEST — Iron Deficiency Anaemia PathwayExample local IDA pathway. Always check your own ICB pathway.

🔥 Barnsley BEST — Dyspepsia PathwayPractical history, alarm features and investigation algorithm.

📊 RUH Bath — LFT Guide for GPsPractical local guide to LFT patterns.

🔬 Faecal Calprotectin Care PathwayPrimary-care pathway for IBS vs IBD (NICE DG11-based).

💊 Derbyshire — Primary Care IBS ManagementStep-by-step local IBS prescribing guide.

🫀 Liver & primary care

🫀 British Liver Trust — Primary Care ToolkitTesting, pathways and audit tools.

🏥 Primary Care Sheffield — GastroenterologyReal-world referral guidance from GP specialists.

🩺 Primary Care Society for GastroenterologyGP-focused gastro education and updates.

🎓 CPD, exams & patients

📚 BMJ Learning — Gastroenterology ModulesShort modules on IBS, IBD and dyspepsia.

🎓 RCGP Curriculum — GastroenterologyWhat GPs should know and manage in GI medicine.

💚 Guts UK — Digestive Health CharityHigh-quality patient information.

Quick Navigation

GP Role Red Flags IDA Investigations Abnormal LFTs FIT Test Upper GI Lower GI IBD GI Cancers Fatty Liver on Scan Other Liver

🧠 Brainy Bites

Quick-fire clinical pearls and mnemonics for busy GPs

ALARMS — Upper GI Red Flags

A memory aid for alarm features in dyspepsia. Use it to prompt your history — then apply the NICE NG12 criteria (see GI Cancers) to decide on referral.

A — Anaemia (iron deficiency)
L — Loss of weight (unintentional)
A — Anorexia
R — Recent onset of progressive symptoms
M — Melaena / haematemesis
S — Swallowing difficulty (dysphagia)

Note: ALARMS is a teaching mnemonic, not a NICE tool. For example, NG12 recommends a suspected cancer pathway referral for dysphagia at any age, but only non-urgent direct-access endoscopy for haematemesis (acute bleeding needs emergency assessment, not a referral).

Diagnosing IBS — NICE first, Rome IV second

NICE CG61: consider IBS if ≥6 months of abdominal pain/discomfort, bloating or change in bowel habit. Diagnose if pain is relieved by defecation or linked to altered stool frequency or form, plus ≥2 of:

Altered stool passage (straining, urgency, incomplete evacuation)
Abdominal bloating, distension, tension or hardness
Symptoms made worse by eating
Passage of mucus

Rome IV (used in research and specialist practice): recurrent pain ≥1 day/week for 3 months, onset ≥6 months ago, with ≥2 of — related to defecation, change in frequency, change in form.

Before labelling IBS: NICE recommends FBC, ESR, CRP and coeliac serology, and faecal calprotectin (NICE DG11) when IBD is in the differential. New IBS-type symptoms in a woman aged 50+ → check CA125 (NICE NG12 1.5.5).

NICE CG61; NICE NG12; NICE DG11

1️⃣ Role of the GP in Gastroenterology

Your scope of practice — from first contact to specialist referral

Diagnosis

Recognise common GI presentations
Differentiate functional from organic disease
Identify symptoms that meet NICE NG12 suspected cancer criteria
Arrange appropriate first-line investigations (including symptomatic FIT)

Management

Initiate treatment for common conditions (GORD, IBS, constipation)
Prescribe safely (PPIs, laxatives, antispasmodics) and review long-term PPIs
Provide lifestyle and dietary advice
Monitor chronic conditions (IBD, coeliac disease, NAFLD/MASLD fibrosis risk)

Emergencies

Recognise the acute abdomen requiring emergency admission
Identify GI bleeding and assess severity
Recognise bowel obstruction, perforation and acute severe colitis
Initiate resuscitation and arrange urgent transfer

Coordination

Refer appropriately to gastroenterology, hepatology or surgery
Coordinate care between primary and secondary care; use advice & guidance
Manage post-discharge follow-up
Liaise with dietitians, IBD nurses, stoma nurses and alcohol services

Prevention

Promote bowel cancer screening uptake (ages 50–74 in England)
Advise on alcohol reduction (UK guideline: no more than 14 units/week) and healthy diet
Identify and manage metabolic risk factors (obesity, diabetes, hypertension, dyslipidaemia)
Test and treat H. pylori where indicated

2️⃣ Red Flag Symptoms & Emergencies

Recognise these immediately — they need urgent action

Upper GI (NICE NG12)

Dysphagia — any age → suspected cancer pathway referral
Age ≥55 with weight loss + upper abdominal pain, reflux or dyspepsia → suspected cancer pathway referral
Upper abdominal mass consistent with stomach cancer → consider suspected cancer pathway referral
Jaundice at age ≥40 → suspected cancer pathway referral (pancreatic)
Haematemesis → consider non-urgent direct-access OGD (acute bleed = emergency assessment)

Lower GI (NICE NG12 — offer FIT)

Abdominal mass, change in bowel habit or iron-deficiency anaemia (any adult)
Age ≥40: unexplained weight loss + abdominal pain
Age <50: rectal bleeding + unexplained abdominal pain or weight loss
Age ≥50: unexplained rectal bleeding, abdominal pain or weight loss
Age ≥60: anaemia even without iron deficiency
FIT ≥10 μg Hb/g → suspected cancer pathway referral
Rectal mass, or unexplained anal mass/ulceration → consider referral without FIT

Acute Abdomen / Emergencies

Severe abdominal pain with peritonism
Absolute constipation (no flatus or stool) with distension or vomiting
Haemodynamic instability or active GI bleeding
Sepsis
Suspected acute severe colitis (≥6 bloody stools/day plus systemic features)

NICE NG12 (last updated January 2026; upper GI recommendations amended May 2025)

🩸 Iron Deficiency Anaemia — The Golden Rule

In adults, IDA = GI blood loss or malabsorption until proven otherwise. Do not assume diet.

🔑 The One Rule You Must Remember

Iron deficiency anaemia in an adult needs an explanation — you must exclude occult GI bleeding (colorectal and upper GI cancer) and coeliac disease before blaming diet or periods.

Why this matters — even if the patient says:

"I don't eat much red meat"
"I'm vegetarian"
"My diet isn't great"

⚡ What NICE says — FIT-guided referral (NICE NG12, 2023)

Step	Action
All adults with IDA	Offer FIT (NG12 1.3.1). FIT is offered even if the person had a negative screening FIT.
FIT ≥10 μg Hb/g	Refer using a suspected colorectal cancer pathway referral (NG12 1.3.2).
FIT <10 or not returned	Safety-net, and do not delay referral if strong clinical concern persists (NG12 1.3.3). The IDA still needs explaining — see below.
Age ≥60 with anaemia (even without iron deficiency)	Offer FIT (NG12 1.3.1).

Specialist guidance & local pathways: the BSG 2021 IDA guideline recommends bidirectional endoscopy (OGD + colonoscopy) for men and post-menopausal women with IDA, and many ICB pathways refer all IDA to the lower GI pathway regardless of the FIT result (anaemia can reduce FIT accuracy). FIT only assesses the lower GI tract — upper GI causes still need considering. Follow your local pathway.

Typical GP work-up for IDA

Confirm iron deficiency: FBC and ferritin. Ferritin rises in inflammation, so a "normal" ferritin does not exclude iron deficiency if CRP is raised — transferrin saturation helps.
FIT (as above) — and examine: abdominal and rectal examination. NICE warns of false-negative faecal occult blood tests (NG12 1.15.1), and rectal/anal masses are referred without FIT.
Coeliac serology (tTG IgA + total IgA) — NICE NG20 recommends testing in unexplained IDA.
Menstrual history and urine dip for haematuria.
Refer per NG12 / local pathway; consider upper GI endoscopy as advised by BSG.

What to say to patients:

"Iron deficiency in adults often comes from slow bleeding from the stomach or bowel — bleeding you might not even notice. It doesn't mean you have cancer, but we always check carefully to make sure."

For menstruating women (if cause unclear):

"Heavy periods can cause low iron, but we still like to check for other causes too — such as coeliac disease or a problem in the stomach or bowel — so we don't miss anything."

💊 Oral Iron Replacement — start while investigating

Drug	Dose	Frequency	Duration / Notes
Ferrous sulfate	200 mg tablet	Once daily	One tablet once daily of any of these salts. Continue for 3 months after iron deficiency is corrected, to replenish stores.
Ferrous fumarate	210 mg tablet	Once daily
Ferrous gluconate	300 mg tablet	Once daily

Monitoring: check Hb within about 4 weeks — expect a rise of at least 20 g/L over 3–4 weeks. If not tolerated, try another salt; many local formularies then suggest the same dose on alternate days, or taking it with food. Vitamin C co-prescription is not needed (BSG).

NICE CKS Anaemia – iron deficiency (once-daily dosing, 3-month continuation, as quoted in NHS Somerset and NHS Dorset formularies); NHS Scotland Right Decisions IDA guideline (Hb response); BSG 2021 IDA guideline

Verification note: the NICE CKS page could not be opened directly during this update (access blocked); doses were cross-checked against NHS formularies that quote CKS. Re-check against CKS/BNF before publishing.

🎓 AKT Pearl

Ferritin is an acute-phase reactant — it can be normal or high in inflammation even with true iron deficiency. Interpret it alongside CRP and transferrin saturation.

🔬 Investigations & Screening

First-line tests and screening programmes in gastroenterology

Blood Tests

FBC

Anaemia (iron deficiency, B12/folate deficiency)
Macrocytosis (alcohol, B12/folate deficiency)
Low platelets — a marker of advanced liver fibrosis/portal hypertension (BSG 2018); also used in FIB-4

Liver blood tests

BSG initial panel: bilirubin, albumin, ALT, ALP, GGT (+ FBC if none in last 12 months)
ALT/AST = hepatocellular injury; ALP/GGT = cholestasis; bilirubin, albumin, INR = liver function
Add AST if you need to calculate FIB-4

Inflammatory markers

CRP/ESR — IBD, infection, malignancy (part of NICE CG61 IBS work-up)

Coeliac serology

tTG IgA + total IgA. If IgA-deficient, use an IgG-based test (IgG tTG, IgG EMA or IgG DGP) — NICE NG20
Patient must be eating gluten in more than one meal every day for at least 6 weeks before testing (NG20)

Stool Tests

🔴 FIT (Faecal Immunochemical Test)

Quantifies human haemoglobin in faeces — used to triage symptomatic patients
Symptomatic threshold: ≥10 μg Hb/g → suspected colorectal cancer pathway referral (NICE NG12 / DG56)
Not needed before referral for rectal mass, or unexplained anal mass or ulceration (NG12 1.3.1)
Screening programme FIT uses a different, higher threshold — see Screening

🟡 Faecal Calprotectin

🧠 One-liner: FIT helps rule out cancer · Calprotectin helps rule out IBD. Both are most useful when negative (high negative predictive value).

Neutrophil-derived protein — a marker of intestinal inflammation
NICE DG11: supports distinguishing IBD from non-inflammatory causes such as IBS in adults with recent-onset lower GI symptoms, when cancer is not suspected
Cut-offs and "grey zone" retesting vary by laboratory — use your local lab's reference range and pathway
Raised results also occur with GI infection, NSAIDs, diverticular disease, colorectal cancer and polyps — so a positive result needs further assessment, not an automatic IBD label

🟢 Normal result — what to say

"A normal calprotectin makes inflammatory bowel disease very unlikely, which is reassuring."

🟡 Raised result — what to say

"This suggests there may be some inflammation in the bowel, but it doesn't necessarily mean inflammatory bowel disease. We'll arrange further tests to find out more."

Removed in this update: the previous sensitivity/specificity/PPV figures for calprotectin could not be traced to a primary source, so they have been taken out.

Stool Culture (MC&S)

Bacterial pathogens (Campylobacter, Salmonella, Shigella, E. coli O157)
Ova, cysts and parasites — if recent travel
C. difficile toxin — if recent antibiotics or hospitalisation

Imaging

Abdominal ultrasound

Part of the BSG standard liver aetiology screen; gallstones, biliary obstruction, focal lesions
Detects steatosis but not fibrosis — a "fatty liver" report says nothing about scarring. Ultrasound is also insensitive to milder steatosis (BSG 2018)

CT

Acute abdomen, suspected perforation or obstruction (secondary care)
Urgent direct-access CT for suspected pancreatic cancer — age ≥60 with weight loss + specified symptoms (NG12 1.2.5)

Endoscopy

OGD: dysphagia and upper GI cancer symptoms (via suspected cancer pathway), treatment-resistant dyspepsia age ≥55 (non-urgent direct access)
Colonoscopy/CT colonography: FIT-positive, lower GI symptoms, IBD, surveillance

Liver stiffness (FibroScan / transient elastography)

Second-line fibrosis test for indeterminate FIB-4 (BSG 2018). NICE NG50 recommends it to look for cirrhosis in people drinking at harmful levels (≥50 units/week men, ≥35 units/week women) — as cited in BSG 2018. Usually accessed via hepatology or a community liver pathway

📊 Managing Abnormal LFTs

A systematic approach — based on the BSG 2018 guideline (NICE has no dedicated abnormal-LFT guideline)

🧭 The five BSG principles every GP should know

Look back first. Interpret any abnormal result only after reviewing previous results, past history and current illness.
Size isn't everything. The degree of abnormality is not a reliable guide to significance — hepatitis C and NAFLD can cause serious disease with only mildly raised (or normal) enzymes.
Investigate, don't just repeat. Any analyte outside the reference range should prompt a liver aetiology screen, whatever its level or duration. In the BALLETS study, 84% of abnormal tests were still abnormal a month later. Only repeat alone if you are confident the cause is a transient, identified insult.
Normal LFTs don't exclude cirrhosis. Assess fibrosis risk (FIB-4) in anyone with NAFLD/MASLD or unexplained liver disease.
A negative screen still needs a plan. Persistently abnormal tests with a negative extended screen and no NAFLD risk factors → discuss with or refer to hepatology.

BSG Guidelines on the management of abnormal liver blood tests (Newsome et al., Gut 2018), recommendations 2, 3, 4, 7 and 10

Step 1 — Decide how urgent it is

Situation	Action
Unexplained jaundice, or suspected hepatic/biliary malignancy (e.g. dilated ducts or a mass on USS)	Immediate/urgent referral (BSG). Age ≥40 with jaundice → suspected pancreatic cancer pathway referral (NICE NG12 1.2.4).
Signs of synthetic failure or decompensation — raised INR, encephalopathy, ascites, GI bleeding	Same-day discussion with the medical/gastro on-call team (BSG: marked derangement, synthetic failure or suspicious features → consider urgent referral).
Very high transaminases (ALT >1000 U/L)	Think acute hepatitis — including hepatitis A and E and CMV (BSG), plus drugs (e.g. paracetamol) and ischaemia. Discuss urgently.
Well patient, incidental abnormality	History, examination and liver aetiology screen (Step 2), then fibrosis assessment where relevant (Step 3).

Local pathway example (not national guidance): some ICBs set urgency by ALT multiples — e.g. <3× ULN investigate in primary care; 3–5× ULN hepatology advice & guidance; >5× ULN same-day gastro discussion. Use your own ICB's pathway if it has one; BSG stresses that the magnitude of ALT alone does not determine significance.

Step 2 — History, examination and the liver aetiology screen

History & examination (BSG checklist)

Alcohol — current and past units/week; use AUDIT-C
Drugs — prescribed, over-the-counter, herbal, recreational/injecting
Metabolic syndrome features — central obesity, hypertension, diabetes, dyslipidaemia
Country of birth (the strongest predictor of viral hepatitis in BALLETS), travel, occupation
Family history (haemochromatosis, Wilson's); personal history of IBD or autoimmunity (think PSC)
Symptoms — jaundice, pruritus, weight loss, abdominal pain
Examination — BMI, hepatosplenomegaly, ascites, stigmata of chronic liver disease

🔬 BSG standard liver aetiology screen (adults)

Abdominal ultrasound
Hepatitis B surface antigen
Hepatitis C antibody (with reflex PCR if positive)
Anti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody
Serum immunoglobulins
Ferritin and transferrin saturation (taken together)

Extended screen — if no cause found

Anti-HBc, anti-HBs; haemochromatosis gene testing
Anti-LKM antibody; coeliac antibodies; ANCA if cholestatic
Alpha-1-antitrypsin level; thyroid function
Caeruloplasmin (age 3–40 years)

BSG 2018, recommendation 5 and table 2

Ferritin trap: an isolated high ferritin is common in alcohol excess and NAFLD and does not by itself mean haemochromatosis. Refer if ferritin and transferrin saturation (>45%) are raised (BSG 2018).

Step 3 — Recognise the pattern

Hepatitic (↑ALT/AST)

Common causes

NAFLD/MASLD, alcohol-related liver disease, viral hepatitis, autoimmune hepatitis, drug-induced liver injury.

Key points

ALT is more liver-specific; AST is also found in muscle and heart. An AST:ALT ratio >1 suggests advanced fibrosis/cirrhosis (BSG). If only AST is raised, think muscle — check CK.

Next step

Aetiology screen + FIB-4 if NAFLD or no clear cause.

Cholestatic (↑ALP + ↑GGT)

Common causes

Primary biliary cholangitis, primary sclerosing cholangitis, biliary obstruction (stones, strictures, cancer), hepatic congestion, drugs.

Isolated ↑ALP with normal GGT

Probably not liver — most commonly vitamin D deficiency; also Paget's disease, bone metastases, growth in children, and pregnancy (placental ALP).

Next step

USS for duct dilatation; AMA for PBC; consider PSC (MRI) in IBD — PSC affects just under 10% of people with IBD (BSG).

Isolated ↑Bilirubin

Most likely

Gilbert's syndrome (5–8% of the population) — unconjugated, with otherwise normal tests.

Check

Repeat fasting with FBC and conjugated/unconjugated split. If anaemic, exclude haemolysis (reticulocytes, LDH, haptoglobin).

Reassure

Gilbert's is not associated with liver disease — reassure fully.

BSG 2018 — clinical pattern recognition section

Step 4 — Alcohol

Harmful drinking (≥50 units/week men, ≥35 units/week women): assess for fibrosis with transient elastography (NICE NG50, as cited by BSG). Refer if features of cirrhosis/portal hypertension or FibroScan >16 kPa (BSG).
Hazardous drinking below these levels: AUDIT-C, then full AUDIT and brief intervention. If GGT >100 U/L, consider fibrosis assessment (BSG).
AUDIT score >19 (dependence): consider referral to alcohol services (BSG recommendation 8).

Removed in this update: the old "AST:ALT >2:1 strongly suggests alcohol" and ">10× ULN" rules were not found in the BSG guideline and have been replaced with BSG's own statements. Statins: BSG notes they are safe in people with pre-existing abnormal liver enzymes — do not stop them reflexively.

🧪 FIT Test Performance

Symptomatic FIT at 10 μg/g — what the numbers mean, examination, and patient communication

⚠️ FIT is a triage test, not a substitute for examination

NICE NG12 reminds clinicians to be aware of false-negative faecal occult blood results (1.15.1). People with a rectal mass, unexplained anal mass or unexplained anal ulceration should be considered for referral without waiting for FIT (1.3.1, 1.3.5, 1.3.6) — and you only find these by examining. A low FIT should never override strong clinical concern (1.3.3).

Symptomatic FIT ≥10 μg Hb/g — primary care performance

Sensitivity for colorectal cancer	90.5%
Specificity	91.3%
Positive predictive value	10.1%
Negative predictive value	99.9%

In plain numbers: of 100 people with a positive FIT, about 10 have bowel cancer. Of 100 people with a negative FIT, more than 99 do not — but about 1 in 10 cancers will be FIT-negative, which is why safety-netting matters.

Nicholson et al., Aliment Pharmacol Ther 2020 — 9,896 symptomatic adults in English primary care

True/false positives & negatives

True positive: FIT positive and cancer present.
"False" positive (for cancer): most FIT-positive people do not have cancer — but many have other significant bowel disease; PPV was higher for serious colorectal disease than for cancer alone.
True negative: FIT negative and no cancer — very reassuring.
False negative: roughly 1 in 10 cancers — safety-net and act on persisting symptoms (NG12 1.3.3).

Corrected: these figures describe symptomatic FIT at 10 μg/g. The previous version labelled them as performance "at the 80 μg/g threshold", which is the screening cut-off — a different population and test purpose.

💬 How to explain FIT results to patients

🔴 Positive FIT

"A positive FIT doesn't mean you have cancer. It means we've found a tiny amount of blood in the stool. About 1 in 10 people with a positive test turn out to have bowel cancer, so we arrange an urgent hospital assessment to check properly."

✅ Concrete ratio, no catastrophising, clear next step.

🟢 Negative FIT

"A negative FIT is very reassuring — more than 99 in 100 people with a negative test don't have bowel cancer. But if your symptoms carry on or change, come back and we'll look again, and may still arrange tests."

✅ Reassures with a number, and safety-nets.

⚠️ Always say this too

"I'd also like to do a brief internal examination of the back passage. The stool test doesn't replace an examination, and it's an important part of making sure we don't miss anything."

🎯 Screening & Surveillance

National programmes for early detection

NHS Bowel Cancer Screening (England)

Who

Ages 50–74 (expansion to age 50 completed in 2025)

Test & frequency

Home FIT kit every 2 years

Threshold

Being lowered from 120 to 80 μg Hb/g — phased roll-out from February 2026, national coverage expected by March 2028, so your local service may still be on 120 for now. Scotland and Wales already use 80.

Positive result

Managed by the screening programme (specialist screening practitioner, then usually colonoscopy). Expected effect: about 35% more screening colonoscopies and around 600 more cancers detected each year in England.

NHS England announcement, January 2026; Cancer Research UK

Barrett's Oesophagus Surveillance

Who

People with confirmed Barrett's oesophagus

Method

Endoscopy with biopsies — interval set by the specialist according to segment length and dysplasia (BSG guideline)

GP role

Make sure surveillance is happening and act on new dysphagia or weight loss (NG12).

Liver Surveillance in Cirrhosis

Who

People with cirrhosis; people with chronic hepatitis B (under specialist care)

Method

6-monthly ultrasound (with or without AFP) for hepatocellular carcinoma, plus variceal screening — organised by hepatology (NICE NG50)

GP role

Check the patient is on a surveillance list and attending.

3️⃣ Upper GI Conditions

Common presentations from oesophagus to duodenum

Clinical Features

Heartburn, acid regurgitation; worse after meals, lying flat or bending
May cause nocturnal cough, hoarseness, dental erosion

Management (NICE CG184)

First check NG12 criteria — dysphagia, or age ≥55 with weight loss, needs a suspected cancer pathway referral, not a PPI trial
Lifestyle: weight loss, smoking cessation, avoid triggers, raise head of bed
Uninvestigated dyspepsia: full-dose PPI for 4 weeks or H. pylori "test and treat" (CG184 — either first)
Test with urea breath test or stool antigen (not serology); leave 2 weeks off PPIs before testing

💊 Full-dose PPIs (NICE CG184)

Drug	Full dose	Frequency	Duration
Omeprazole	20 mg	Once daily	Uninvestigated dyspepsia: 4 weeks. Endoscopically-confirmed GORD: 4 or 8 weeks. Then step down to the lowest dose that controls symptoms.
Lansoprazole	30 mg	Once daily
Pantoprazole	40 mg	Once daily
Esomeprazole	20 mg	Once daily

Offer an annual review to people on long-term acid suppression, encouraging the lowest effective dose or "as needed" use (CG184). The MHRA has warned about hypomagnesaemia with prolonged PPI use.

NICE CG184 Dyspepsia and GORD (PPI dose table); MHRA Drug Safety Update

H. pylori Eradication

💊 First-line — 7 days, all twice daily (NICE CG184)

Group	Regimen (all BD × 7 days)
No penicillin allergy	PPI (e.g. omeprazole 20 mg) + amoxicillin 1 g + either clarithromycin 500 mg or metronidazole 400 mg
Penicillin allergy	PPI + clarithromycin 250 mg + metronidazole 400 mg
Penicillin allergy + previous clarithromycin	PPI + bismuth + metronidazole 400 mg + tetracycline 500 mg

Second line: use the antibiotic not used first time; seek gastroenterology advice if second-line fails. Choose clarithromycin vs metronidazole by previous exposure and local resistance — check your local antimicrobial guide and the UKHSA quick reference guide (updated May 2025).

Re-testing: NICE does not recommend routine re-testing after eradication. Re-test (urea breath test, ≥4 weeks after treatment and ≥2 weeks off PPI) where there is a clear reason — e.g. persisting symptoms or peptic ulcer, per local guidance.

NICE CG184 (as reproduced in GPnotebook's H. pylori triple-therapy page); UKHSA H. pylori quick reference guide

Corrected: the penicillin-allergy regimen previously said clarithromycin 500 mg — NICE's dose is 250 mg BD. The statement that eradication should always be confirmed at 4–6 weeks has been removed. Note that some UK regions (e.g. NHS Forth Valley) now use metronidazole-based first-line regimens because of clarithromycin resistance — follow your local guide.

Barrett's Oesophagus

Metaplasia of the lower oesophageal lining associated with chronic reflux
Raises the risk of oesophageal adenocarcinoma — surveillance endoscopy per BSG guidance

Risk Factors

H. pylori infection — the main cause
NSAIDs/aspirin; smoking; alcohol; physiological stress

Presentation

Epigastric pain, nausea, bloating
Complications: bleeding (haematemesis/melaena), perforation, gastric outlet obstruction

Management (NICE CG184)

H. pylori positive: eradication therapy (above)
H. pylori negative, not on NSAIDs: full-dose PPI (or H2RA) for 8 weeks
NSAID-associated: stop the NSAID where possible, then full-dose PPI (or H2RA) for 8 weeks; test for H. pylori
Gastric ulcer: repeat endoscopy and H. pylori re-testing are usually arranged by the endoscopist — check the report

Corrected: the previous "duodenal 4 weeks / gastric 8 weeks after eradication" table was not NICE wording and has been replaced.

NICE CG184

Who to test (NICE NG20 — examples)

Persistent unexplained GI symptoms, IBS-type symptoms, unexplained weight loss, fatigue
Unexplained iron, B12 or folate deficiency
Type 1 diabetes, autoimmune thyroid disease, dermatitis herpetiformis, first-degree relatives

Diagnosis

⚠️ Must be eating gluten in more than one meal every day for at least 6 weeks before testing
tTG IgA + total IgA; if IgA-deficient, use an IgG-based test
Positive serology → refer to gastroenterology for endoscopic biopsy to confirm

Management

Lifelong gluten-free diet; dietitian input
Annual review (NG20): weight/BMI, symptoms, diet adherence; bloods and bone health as clinically indicated
Pneumococcal vaccination is advised by the BSG because of possible hyposplenism

NICE NG20 Coeliac disease; BSG coeliac guideline

4️⃣ Lower GI Conditions

From small bowel to rectum — common presentations and management

Diagnosis

Use the NICE CG61 criteria (see Brainy Bites); exclude red flags and check FBC, ESR, CRP, coeliac serology ± faecal calprotectin
Subtypes: IBS-D, IBS-C, IBS-M

Management — stepwise (NICE CG61)

Step 1: explanation, regular meals, adjust fibre, limit caffeine/alcohol/fizzy drinks
Step 2: if symptoms persist, specialist dietary advice (e.g. low FODMAP) from a healthcare professional with dietary expertise
Psychological therapies if no response to drugs after 12 months

💊 IBS Medications

Use	Drug	Dose	Notes
Pain/spasm (1st line)	Mebeverine	135 mg three times daily	Preferably 20 minutes before meals; review after a month
IBS-D	Loperamide	Titrate to response (max 16 mg/day)	NICE: first-choice antimotility agent; aim for soft, formed stool (Bristol type 4)
IBS-C	Ispaghula husk	1 sachet twice daily	May increase bloating
IBS-C	Macrogol	1 sachet once or twice daily, adjusted	NICE: discourage lactulose in IBS
IBS-C, refractory	Linaclotide	—	Only if laxatives from different classes have failed and constipation ≥12 months; review at 3 months
2nd line (pain)	Tricyclic antidepressant, e.g. amitriptyline	Start 5–10 mg once at night	Increase if needed, but not usually beyond 30 mg. Review at 4 weeks, then every 6–12 months. Other TCAs can be used at amitriptyline-equivalent doses. Off-label; explain it is used for pain, not depression.
3rd line	SSRI	—	Only if TCAs ineffective

NICE CG61 (TCA dosing, loperamide, linaclotide, lactulose advice); mebeverine, loperamide, ispaghula and macrogol doses as listed in NHS Tayside IBS guidance

Corrected: amitriptyline start dose now 5–10 mg (was "10 mg"); the "non-NICE nortriptyline" row has been removed because NICE recommends TCAs as a class at amitriptyline-equivalent doses. Peppermint oil and hyoscine butylbromide doses were not re-verified in this update, so specific doses are omitted — check the BNF.

Causes (Think: MIST)

Medications: opioids, anticholinergics, iron, calcium, aluminium antacids, calcium-channel blockers, some antidepressants and antiepileptics
Inactivity / low fibre / dehydration
Systemic: hypothyroidism, hypercalcaemia, diabetes, Parkinson's
Tumour / structural — remember the NG12 FIT criteria for change in bowel habit

Stepwise approach (NICE CKS, via NHS pathways)

Bulk-forming first → if stools stay hard, add/switch to an osmotic (macrogol; lactulose if macrogol unsuitable) → if stools soft but hard to pass, add a stimulant
Opioid-induced: do not use bulk-forming laxatives; use osmotic + stimulant
Wean laxatives gradually once passing soft, formed stool

💊 Laxatives (adult doses)

Type	Drug	Dose	Notes
Bulk-forming	Ispaghula husk 3.5 g sachet	1 sachet twice daily	With plenty of fluid; takes days to work
Osmotic	Macrogol	1–3 sachets daily in divided doses	Maintenance usually 1–2 sachets daily
Stimulant	Senna	7.5–15 mg at bedtime	Max 30 mg daily; acts in 8–12 hours
Stimulant	Bisacodyl	5–10 mg at night	Increase to 20 mg if needed
Rectal	Glycerol suppository	4 g as required	Rapid effect

BNF dosing as reproduced in NHS Scotland (East Region) formulary and St George's constipation pathway; CKS stepwise approach as summarised in NHS Humber & North Yorkshire pathway

Not re-verified: lactulose dose — check the BNF before prescribing.

Diverticulosis & diverticular disease

Very common with age; often an incidental finding
Healthy balanced diet including wholegrains, fruit and vegetables

Acute diverticulitis

Left lower quadrant pain, fever, change in bowel habit, raised inflammatory markers
Complications: abscess, perforation, fistula, stricture, bleeding

⚠️ NICE NG147: consider NO antibiotics if systemically well

Uncomplicated diverticulitis in a systemically well person: consider a no-antibiotic strategy, paracetamol, and advice to re-present if symptoms persist or worsen. Avoid NSAIDs and opioids where possible (perforation risk). Offer antibiotics if systemically unwell, immunosuppressed or significant comorbidity.

💊 Oral antibiotics for acute diverticulitis (NICE NG147)

Drug	Dose	Duration
Co-amoxiclav (first choice)	500/125 mg three times daily	5 days
Cefalexin (caution in penicillin allergy) + metronidazole	Cefalexin 500 mg two or three times daily (up to 1–1.5 g three or four times daily if severe) + metronidazole 400 mg three times daily	5 days
Trimethoprim + metronidazole	200 mg twice daily + 400 mg three times daily	5 days
Ciprofloxacin + metronidazole	500 mg twice daily + 400 mg three times daily	5 days — only if switching from IV ciprofloxacin with specialist advice

Symptoms

Bloody diarrhoea, pain, fever; complication: liver abscess.

Management

Stool microscopy/PCR; treatment (a tissue agent followed by a luminal agent) via infectious diseases/microbiology advice. Notifiable.

Removed in this update: specific doses for Salmonella (ciprofloxacin), cholera, amoebiasis and cryptosporidium could not be verified against NICE CKS or the BNF during this review, so they have been replaced with "seek specialist advice".

When to send a stool sample

Diarrhoea >7 days, or blood/pus in stool
Immunocompromised; recent hospital or antibiotics
Recent foreign travel
Suspected outbreak; food handler or healthcare worker

Red flags — consider admission

Severe dehydration or unable to tolerate oral fluids
Altered consciousness, suspected sepsis or HUS
Frail older adults with significant comorbidity

GP pearl: most gastroenteritis is self-limiting. Avoid antimotility drugs if bloody diarrhoea or fever. Take stool samples before any antibiotic.

NICE NG199 visual summary (C. difficile); NHS Tayside and HSE antimicrobial guidance (Campylobacter, Giardia); UKHSA exclusion advice

5️⃣ Inflammatory Bowel Disease

Ulcerative colitis and Crohn's disease — recognition, flares, monitoring

Ulcerative Colitis

Continuous mucosal inflammation starting at the rectum and extending proximally
Bloody diarrhoea, urgency, tenesmus
Increased colorectal cancer risk with longstanding extensive disease — colonoscopic surveillance per NICE

Extra-intestinal manifestations

Joints (peripheral and axial arthritis), skin (erythema nodosum, pyoderma gangrenosum), eyes (episcleritis, uveitis), liver (primary sclerosing cholangitis)

🧠 Remember: maintenance therapy (e.g. an aminosalicylate) is specialist-directed. Don't stop it without specialist input.

Crohn's Disease

Patchy (skip) inflammation anywhere from mouth to anus; terminal ileum commonly affected
Transmural — strictures, fistulae, abscesses
Diarrhoea (often non-bloody), abdominal pain, weight loss
Perianal disease — fissures, fistulae, skin tags, abscesses
Smoking worsens Crohn's — support cessation

GP Role in IBD Monitoring

Shared care

Follow the shared-care protocol for immunomodulators (e.g. azathioprine blood monitoring)
Bone health — consider fracture risk in people with repeated or prolonged steroid courses
Vaccinations: annual flu; pneumococcal as indicated. Avoid live vaccines in people on immunosuppressants/biologics
Check that surveillance colonoscopy is booked when due

Recognising a flare — contact the IBD team early

More frequent stools, more blood, urgency, nocturnal symptoms, fever, weight loss
Send stool culture and C. difficile toxin, FBC, CRP; calprotectin if the team uses it
Suspected acute severe colitis (≥6 bloody stools/day plus systemic features) → same-day hospital assessment

Acute Flare Management

⚠️ Key rule: liaise with the IBD team before starting or changing treatment where possible. Exclude infection (stool culture, C. difficile) before escalating steroids.

Ulcerative colitis (NICE NG130)

Mild–moderate proctitis: topical aminosalicylate first-line; add oral aminosalicylate if no remission within 4 weeks; then consider a time-limited topical or oral corticosteroid
Acute severe UC: hospital admission

Crohn's disease (NICE NG129)

Conventional glucocorticosteroid (e.g. prednisolone) to induce remission; budesonide is an option for ileal/ileocaecal/right-sided disease in selected people — specialist decision
Severe flare: admission

💊 Oral prednisolone course for an IBD flare (specialist-agreed)

Drug	Dose	Taper / duration
Prednisolone	40 mg once daily (morning) for 1 week	Reduce by 5 mg each week until stopped — 8-week course. Do not stop abruptly.
Budesonide (Crohn's, ileum/ascending colon)	9 mg once daily in the morning	Up to 8 weeks; prescribe by brand

Recommend calcium and vitamin D while on oral steroids, and assess fracture risk. Steroids are for induction, not maintenance.

Northern Ireland Formulary 1.5.2 (Corticosteroids in IBD); NICE NG130 and NG129 for treatment sequence

Verification note: NICE NG130/NG129 do not specify steroid doses — the regimen above comes from a named NHS formulary. The previous page described budesonide as "preferred" in Crohn's; this was changed because NICE positions conventional glucocorticosteroids first. Please re-check the NG129 wording on budesonide before publishing.

Maintenance (all specialist-directed)

UC: aminosalicylates; thiopurines; advanced therapies (biologics, JAK inhibitors) per NICE technology appraisals
Crohn's: thiopurines (TPMT checked before starting), methotrexate, biologics

IBD Complications

Intestinal

Toxic megacolon (UC): emergency admission
Perforation: surgical emergency
Strictures and fistulae (Crohn's): obstruction; perianal, enterocutaneous or enterovesical fistulae
Colorectal cancer: surveillance colonoscopy

Extra-intestinal

Uveitis: painful red eye with visual symptoms — same-day ophthalmology
Primary sclerosing cholangitis: affects just under 10% of people with IBD (BSG 2018) — low threshold to investigate cholestatic LFTs
VTE: increased risk, especially during flares

Nutritional

Iron deficiency (blood loss); B12 deficiency (terminal ileal disease or resection); bone loss (steroids, malabsorption)

UC vs Crohn's — Side-by-Side

Feature	Ulcerative colitis	Crohn's disease
Location	Colon only; starts at rectum, continuous	Anywhere mouth to anus; skip lesions
Depth	Mucosal	Transmural
Key symptom	Bloody diarrhoea, urgency, tenesmus	Pain, diarrhoea, weight loss
Perianal disease	Uncommon	Common
Fistulae/strictures	Rare	Common
Smoking	Appears protective (ex-smokers may flare)	Worsens disease
Surgery	Colectomy removes the diseased organ	Recurrence after resection is common

🧠 Memory trick: UC = Continuous, Colon-only. Crohn's = skip lesions, Complicated (fistulae, strictures). Smoking: UC tolerates it, Crohn's hates it — but always advise stopping.

NICE NG130 (UC), NICE NG129 (Crohn's); BSG 2018 (PSC prevalence)

🎗️ GI Cancers & Suspected Cancer Referral

Based on NICE NG12 (last updated January 2026; upper GI amended May 2025)

📌 Terminology update

NICE now uses "suspected cancer pathway referral" (formerly "2-week wait"): the person should receive a diagnosis or have cancer ruled out within 28 days of referral (NHS England Faster Diagnosis Standard). "Urgent" direct-access tests are those done within 2 weeks.

⚠️ Two FIT thresholds — don't confuse them

🚨 Symptomatic (GP-requested)

≥10 μg Hb/g → suspected colorectal cancer pathway referral (NICE NG12 1.3.2).

🔬 Screening programme (England)

120 → 80 μg Hb/g, phased from February 2026, fully in place by March 2028. Asymptomatic people aged 50–74.

Cancer	NICE NG12 trigger	Action
Oesophageal / stomach	Dysphagia (any age); or age ≥55 with weight loss + upper abdominal pain, reflux or dyspepsia	Suspected cancer pathway referral (amended 2025)
Oesophageal / stomach	Age ≥55 with treatment-resistant dyspepsia; upper abdominal pain + low Hb; raised platelets or nausea/vomiting + specified symptoms	Consider non-urgent direct-access OGD
Oesophageal / stomach	Haematemesis	Consider non-urgent direct-access OGD (assess for acute bleed first)
Stomach	Upper abdominal mass consistent with stomach cancer	Consider suspected cancer pathway referral
Colorectal	FIT ≥10 μg Hb/g	Suspected cancer pathway referral
Colorectal / anal	Rectal mass; unexplained anal mass or ulceration	Consider suspected cancer pathway referral (no FIT needed)
Pancreatic	Age ≥40 with jaundice	Suspected cancer pathway referral
Pancreatic	Age ≥60 with weight loss + any of: diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, new-onset diabetes	Consider urgent direct-access CT (within 2 weeks), or urgent USS if CT unavailable
Liver / gallbladder	Upper abdominal mass consistent with enlarged liver or gallbladder	Consider urgent direct-access USS (within 2 weeks)

NICE NG12 recommendations 1.2.1–1.2.11 and 1.3.1–1.3.6 (NICE via NCBI Bookshelf, updated 12 January 2026)

Key symptoms

Progressive dysphagia (food sticking)
Weight loss, early satiety, persistent vomiting
Persistent reflux/dyspepsia, especially new in older adults
Iron deficiency anaemia

What changed in May 2025

Dysphagia, or age ≥55 with weight loss + upper abdominal pain/reflux/dyspepsia, now triggers a suspected cancer pathway referral rather than an urgent direct-access endoscopy — the specialist team decides on the test.

🎓 AKT Pearl

Dysphagia has no minimum age threshold in NG12. Vague dyspepsia in someone aged 55+ that doesn't respond to treatment warrants endoscopy — not another PPI prescription. H. pylori is a modifiable risk factor for gastric cancer.

Risk factors

Increasing age; family history; longstanding IBD; Lynch syndrome and familial adenomatous polyposis
Obesity, smoking, alcohol, red/processed meat, low fibre

When to offer FIT (NG12 1.3.1)

Any adult with: abdominal mass, change in bowel habit, or iron-deficiency anaemia
Age ≥40 with unexplained weight loss and abdominal pain
Age <50 with rectal bleeding and unexplained abdominal pain or weight loss
Age ≥50 with unexplained rectal bleeding, abdominal pain or weight loss
Age ≥60 with anaemia even without iron deficiency

🚨 Referral

FIT ≥10 μg Hb/g → suspected cancer pathway referral
Rectal mass → consider referral without FIT
Unexplained anal mass or ulceration → consider referral for anal cancer
FIT <10 or not returned → safety-net; don't delay referral if strong clinical concern persists

🎓 AKT Pearl

Symptomatic FIT = 10 μg/g. Screening FIT = 80 μg/g (being introduced in England). A previous negative screening FIT does not replace a symptomatic FIT. Lynch syndrome and FAP need genetics referral and surveillance.

📈 Prognosis: survival is far better when bowel cancer is found early — which is why screening and prompt FIT matter. For current stage-specific UK figures, see Cancer Research UK statistics.

Symptoms — often late and subtle

Painless jaundice (head of pancreas)
Unexplained weight loss; epigastric pain radiating to the back
New-onset diabetes in an older adult; steatorrhoea; nausea, vomiting

🚨 NICE NG12

Age ≥40 with jaundice → suspected cancer pathway referral
Age ≥60 with weight loss + diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation or new-onset diabetes → consider urgent direct-access CT within 2 weeks (or urgent USS if CT unavailable)

🧠 New-onset diabetes — don't just treat the sugar

"Older patient + weight loss + new diabetes = think pancreas."

Ask why this person has developed diabetes now — especially if they are losing weight rather than gaining it.

📈 Prognosis: most people present late, when surgery is no longer possible — early recognition is the main lever GPs have. See Cancer Research UK statistics.

Clues

Painless progressive jaundice, pruritus, pale stools, dark urine
Cholestatic LFTs (↑ALP, ↑GGT, ↑bilirubin) without gallstones
Known PSC (especially with IBD) with worsening jaundice, weight loss or new symptoms

🚨 Referral

NG12 has no cholangiocarcinoma-specific recommendation. Use: age ≥40 with jaundice → suspected cancer pathway referral (NG12 1.2.4); and BSG 2018 — unexplained jaundice or suspected hepatobiliary malignancy → immediate referral
Dilated ducts on USS → urgent referral per local hepatobiliary pathway
PSC patient deteriorating → contact hepatology urgently

Removed: stage-specific survival percentages for oesophageal, gastric, colorectal, pancreatic and bile duct cancer could not be matched to a current primary source and have been replaced with links to Cancer Research UK statistics.

🫀 Fatty Liver on a Scan — NAFLD / MASLD

What a GP should do when an ultrasound report says "fatty liver" — NICE NG49 first, BSG pathway alongside

📢 Name change — and a NICE update in progress

NAFLD → MASLD (metabolic dysfunction-associated steatotic liver disease). NASH → MASH.

The umbrella term is steatotic liver disease (SLD). The new names describe the metabolic cause rather than what the disease isn't.

NICE status (September 2026): NG49 (2016) still uses "NAFLD" and remains current guidance. NICE began updating it in 2025 and has said the update will use the terms MASLD and MASH. NICE is also appraising semaglutide and resmetirom for MASH with fibrosis (in development).

Safe exam answer: "NAFLD is now called MASLD internationally; current NICE guidance (NG49) still uses NAFLD, and an update adopting MASLD is in development."

NICE NG49; NICE final scope for guideline update (gid-ng10434), 2025; NICE gid-ta11477

🔑 The one message for this section

"We don't worry about the fat — we worry about the fibrosis." An ultrasound shows fat, not scarring. LFTs can be normal even in cirrhosis. So every person with fatty liver on a scan needs a fibrosis risk assessment — not just a repeat LFT or a repeat scan.

NICE NG49 (do not use routine liver blood tests to rule out NAFLD or advanced fibrosis); BSG 2018

🔍 Incidental fatty liver on ultrasound — the GP pathway

Read the whole scan report

Look beyond "fatty liver". Features of cirrhosis, splenomegaly, a focal lesion or dilated bile ducts change the pathway — dilated ducts or a suspected malignancy need urgent referral (BSG); an upper abdominal mass consistent with an enlarged liver → consider urgent direct-access USS (NG12 1.2.11).
Take a focused history and examine
- Alcohol in units/week (current and past) — AUDIT-C
- Medicines (including OTC/herbal) that can cause steatosis — e.g. corticosteroids, amiodarone, methotrexate, tamoxifen, valproate
- Country of birth and other viral hepatitis risks; family history of liver disease
- BMI, waist circumference, BP; signs of chronic liver disease
Check bloods and metabolic risk
- Liver panel including AST and ALT, plus platelets (both needed for FIB-4)
- HbA1c, lipids (triglycerides, HDL)
- If any liver test is abnormal → BSG standard liver aetiology screen (see Abnormal LFTs). If all normal, the screen is still reasonable when the cause is unclear
Name the type of steatotic liver disease (see table below)

MASLD needs steatosis plus ≥1 cardiometabolic criterion and alcohol below the MetALD range. Fatty liver with no metabolic risk factor = look for another cause.
Assess fibrosis risk — the key step

NICE NG49: test for advanced fibrosis using the ELF test. ELF ≥10.51 = advanced fibrosis → refer to a hepatology specialist.

BSG 2018 two-step pathway (used by many ICBs — FIB-4 first, then a second-line test only if needed): see the FIB-4 table below.

Where NICE and BSG differ: BSG suggests considering referral at ELF >9.5 (or FibroScan >7.8 kPa); NICE's ELF threshold is 10.51. On this page NICE takes precedence for the ELF threshold — but many ICB pathways use FIB-4 first and their own ELF cut-off, so follow your local pathway where one is commissioned.
Act on the result
- Advanced fibrosis (ELF ≥10.51, or FIB-4 >3.25, or high FibroScan per local pathway) → refer to hepatology
- Low risk → manage in primary care: lifestyle, cardiovascular and metabolic risk management, alcohol within 14 units/week
- Do not stop statins because of NAFLD (NICE NG49)
Re-assess — don't just repeat LFTs every year

NICE NG49: if advanced fibrosis is not found, repeat the fibrosis test every 3 years in adults (every 2 years in children and young people). Review metabolic risk factors as part of routine care (diabetes, hypertension, lipids).

NICE NG49 (ELF testing, 10.51 threshold, 3-yearly retesting, statins); BSG 2018 (FIB-4 pathway, ELF >9.5, FibroScan >7.8 kPa, abnormal USS → urgent referral)

Verification note: NICE's NG49 page could not be opened directly during this update (access blocked). The ELF threshold, 3-yearly retesting and statin advice were confirmed via BJGP 2022, NICE DG50 and a clinician summary of NG49 dated May 2026. Please re-check the NG49 wording before publishing.

🌳 Steatotic liver disease — the new classification

Subtype	Definition
MASLD	Steatosis + ≥1 cardiometabolic criterion; alcohol below the MetALD range
MASH	MASLD with inflammation and liver cell injury (a histological diagnosis)
MetALD	MASLD criteria plus alcohol 140–350 g/week (women) or 210–420 g/week (men) — roughly 17–44 and 26–52 UK units/week
ALD	Alcohol above those ranges is the main driver
Other SLD	Drug-induced, monogenic (e.g. Wilson's), and miscellaneous causes (e.g. hepatitis C, malnutrition, coeliac disease); or cryptogenic

1 UK unit = 8 g alcohol.

Multisociety Delphi consensus (Rinella et al., Hepatology 2023), as summarised in the AASLD 2023 MASLD decision tree

✅ MASLD — cardiometabolic criteria (need ≥1)

Criterion	Adult threshold
Weight / waist	BMI ≥25 kg/m² (≥23 in Asian ethnicity) or waist >94 cm (men) / >80 cm (women), or ethnicity-adjusted (e.g. ≥90 cm in South Asian men)
Glucose	Fasting glucose ≥5.6 mmol/L, or HbA1c ≥39 mmol/mol, or type 2 diabetes / its treatment
Blood pressure	≥130/85 mmHg or on antihypertensive treatment
Triglycerides	≥1.70 mmol/L or on lipid-lowering treatment
HDL cholesterol	≤1.0 mmol/L (men), ≤1.3 mmol/L (women), or on lipid-lowering treatment

Rinella et al. 2023 / AASLD decision tree; EASL–EASD–EASO 2024 table

Corrected: the BMI criterion was missing from the previous version, and HDL thresholds are "≤", not "<".

🔬 FIB-4 — first-line fibrosis score (BSG 2018)

Formula: (age × AST) ÷ (platelets × √ALT) — use the MDCalc calculator.

FIB-4	Meaning	Action
<1.30 (<2.0 if aged over 65)	Low risk of advanced fibrosis	Manage in primary care; lifestyle; repeat assessment in about 3 years (in line with NICE's retesting interval)
1.30–3.25	Indeterminate	Second-line test: ELF or FibroScan (per local availability)
>3.25	High risk	Consider referral to hepatology, irrespective of second-line tests

BSG 2018 (Newsome et al.), figure 2 and text; BJGP 2022 primary-care review

Corrected: the previous version used a referral cut-off of FIB-4 >2.67 and had no age adjustment. The UK BSG guideline uses >3.25 for referral and a higher lower cut-off (2.0) for people over 65, because FIB-4 rises with age and over-calls risk in older adults.

💬 What to tell patients

"Your scan shows fat in the liver. It's very common and linked to weight, blood sugar and blood pressure. On its own the fat isn't the main worry — what matters is whether it has caused any scarring, so I'd like to do a blood test that estimates that. The good news is that it often improves with changes to diet, activity and alcohol."

🌟 Management in primary care

Diet and physical activity advice; support weight loss where appropriate
Manage diabetes, hypertension and lipids — continue statins
Alcohol within 14 units/week (and less is better)
No drug is currently recommended by NICE specifically for MASLD in primary care; NICE is appraising semaglutide and resmetirom for MASH with fibrosis
Patient resources: mylivingwell.co.uk (local weight-management resource)

🎓 AKT/SCA Exam Tips

NICE NG49 still says NAFLD; an update adopting MASLD is in development
NICE ELF threshold for advanced fibrosis: 10.51. BSG FIB-4 referral threshold: >3.25 (low-risk cut-off 1.3, or 2.0 if over 65)
Normal LFTs do NOT exclude advanced fibrosis — NICE says don't use them to rule it out
Waist or BMI alone can meet the MASLD definition — a "normal" BMI doesn't exclude it
Indeterminate FIB-4 → ELF or FibroScan, not just a repeat FIB-4
Fatty liver + no metabolic risk factor → think alcohol, drugs, Wilson's, viral hepatitis, coeliac disease
Retest fibrosis every 3 years in adults if advanced fibrosis not found (NICE)

Patient & clinician resources

🌱 MyLivingWell 📄 Patient.info — Fatty liver 🫀 British Liver Trust 🧮 FIB-4 Calculator 📘 NICE NG49

💬 Fatty Liver SMS Patient Messages

Ready to send via AccuRx, SystmOne, EMIS or similar — edit to match your local pathway

PatchesAccuRxSystmOneEMIS Patient Messaging

📩 SMS 1 — Abnormal liver test, before further tests

Your liver blood test was abnormal. We need to do some further blood tests to find out why — please contact reception to book them. We have also requested an ultrasound scan of your liver (you will receive a letter). Keeping to a healthy weight and drinking no more than 14 units of alcohol a week helps your liver. For support see https://mylivingwell.co.uk/ Results usually take about 2 weeks. Please book a routine GP appointment in 3–4 weeks so we can discuss them.

📩 SMS 2 — Scan shows fatty liver

Your ultrasound scan shows fat in the liver (fatty liver disease, also called MASLD). This is common. You can read more here: https://patient.info/healthy-living/alcohol-and-liver-disease/non-alcoholic-fatty-liver-disease The important question is whether the liver has any scarring. We will do a blood test to check this — please book it with reception. We will usually repeat this check every few years. A healthy weight, being active and keeping alcohol to 14 units a week or less all help. To discuss this, book an appointment with a practice nurse.

Updated: SMS 2 previously promised annual liver tests. It now reflects NICE's fibrosis-testing approach (repeat testing every 3 years if low risk). Adjust wording to your practice's recall system.

🏥 Other Liver Disease

Alcohol-related liver disease, cirrhosis and acute liver failure in primary care

Spectrum

Steatosis (reversible with abstinence) → alcoholic hepatitis → cirrhosis

Assessment

AUDIT-C, then full AUDIT; GGT is the liver test most predictive of liver mortality (BSG)
Harmful drinking (≥50 units/week men, ≥35 women): transient elastography to look for cirrhosis (NICE NG50 via BSG)
AUDIT >19 → consider referral to alcohol services (BSG)

💊 Thiamine (vitamin B1) — NICE CG100

Who	Drug	Dose	Duration
Harmful or dependent drinkers who are malnourished (or at risk), have decompensated liver disease, are in acute withdrawal, or are about to undergo planned withdrawal	Oral thiamine	NICE: use doses toward the upper end of the BNF range — BNF severe deficiency: 200–300 mg daily in divided doses	While malnutrition or drinking continues; review and stop once abstinent and eating well
High risk of Wernicke's encephalopathy / attending hospital	Parenteral thiamine (e.g. Pabrinex)	Hospital/specialist	As directed

Suspected Wernicke's (confusion, ataxia, eye signs) = emergency.

NICE CG100 (indications, "upper end of BNF range"); BNF thiamine dosing as quoted in BSMHFT audit and NHS Right Decisions; SPS guidance

Corrected: previously "100 mg TDS, minimum 3 months". NICE does not set a fixed 3-month minimum; local formularies vary (some use 50 mg QDS). Follow your local formulary within the BNF range.

Signs (Think: SPLASH)

Spider naevi, Palmar erythema, Leuconychia
Ascites, peripheral oedema
Splenomegaly
Hormonal: gynaecomastia, testicular atrophy; jaundice

Decompensation — urgent referral/admission

Ascites, variceal bleeding, hepatic encephalopathy, suspected spontaneous bacterial peritonitis
Encephalopathy treatment (lactulose, rifaximin) is specialist-directed — titrate to 2–3 soft stools a day as advised

Monitoring

Make sure the patient is on hepatology surveillance for liver cancer and varices (NICE NG50)
Regular bloods including INR, albumin, bilirubin and platelets as agreed with hepatology

Causes

Paracetamol overdose; viral hepatitis (A, B, E); drug-induced injury; autoimmune hepatitis; Wilson's disease

Features

Jaundice + coagulopathy + encephalopathy; hypoglycaemia; renal failure

Management

⚠️ Emergency admission. Paracetamol overdose is managed in hospital with acetylcysteine

Anti-HEV IgM = acute; HEV RNA if immunosuppressed. Consider hep A/E and CMV if ALT >1000 (BSG).

Management & prevention

Supportive; specialist care if chronic. Cook pork thoroughly. Notifiable.

Removed: specific percentages (HBV chronicity, HCV chronicity, DAA cure rate, HEV mortality in pregnancy) could not be traced to a primary source during this update and have been replaced with qualitative statements.

🎉 You've Got This!

Red flags first. FIT at 10 for symptoms, 80 for screening. Fatty liver? Think fibrosis, not fat. Abnormal LFTs? Investigate, don't just repeat. And when in doubt — examine, safety-net, and ask.

↑ Back to Top ⬇ Download Resources

"The gut is the seat of all feeling." — Suzy Kassem

📚 Sources & Verification (September 2026)

Hierarchy used: NICE guidelines → NICE CKS → named specialist guideline (BSG, UKHSA) → named NHS formulary. Where sources conflict, NICE takes precedence. Local-pathway material is labelled as such.

NICE NG12 Suspected cancer: recognition and referral (updated 12 Jan 2026; upper GI amended May 2025)
NICE NG49 NAFLD: assessment and management (2016) — update to MASLD in development (scope 2025)
NICE CG184 Dyspepsia and GORD
NICE CG61 Irritable bowel syndrome in adults
NICE NG147 Diverticular disease — antimicrobial prescribing visual summary
NICE NG199 C. difficile infection — antimicrobial prescribing visual summary
NICE NG130 Ulcerative colitis; NG129 Crohn's disease; NG20 Coeliac disease; NG50 Cirrhosis; CG100 Alcohol-use disorders
NICE DG11 (faecal calprotectin); DG56 (symptomatic FIT)
BSG — Guidelines on the management of abnormal liver blood tests (Newsome et al., Gut 2018)
BSG — Iron deficiency anaemia guideline (2021), as cited in local pathways
Rinella et al., multisociety MASLD nomenclature (Hepatology 2023); AASLD 2023 decision tree; EASL–EASD–EASO 2024
Nicholson et al., FIT in symptomatic primary care patients (Aliment Pharmacol Ther 2020)
NHS England, bowel screening threshold announcement (Jan 2026); Cancer Research UK
UKHSA H. pylori quick reference guide (updated May 2025); MHRA Drug Safety Update (fluoroquinolones, Jan 2024)
Named NHS formularies used for dose cross-checks: NHS Somerset, NHS Dorset, NHS Scotland (East), Northern Ireland Formulary, NHS Tayside, NHS Right Decisions

Please re-check before publishing: NICE and NICE CKS web pages blocked automated access during this review, so several NICE statements were confirmed via NICE PDFs, NCBI Bookshelf copies or secondary sources that quote NICE. Items most worth a manual check: NG49 wording (ELF, retesting, statins), CKS iron dosing, NG129 budesonide positioning, NG50 surveillance wording, lactulose dose, and the Campylobacter clarithromycin dose.

Gastroenterology for GPs: Your Essential Guide

Executive Summary

Quick Links

Key Facts

Fatty liver

Bowel cancer

Symptomatic FIT

Advanced fibrosis

Downloads & Resources

📁 Downloads

🌐 Web Resources

Quick Navigation

🧠 Brainy Bites

ALARMS — Upper GI Red Flags

Diagnosing IBS — NICE first, Rome IV second

1️⃣ Role of the GP in Gastroenterology

Diagnosis

Management

Emergencies

Coordination

Prevention

2️⃣ Red Flag Symptoms & Emergencies

Upper GI (NICE NG12)

Lower GI (NICE NG12 — offer FIT)

Acute Abdomen / Emergencies

🩸 Iron Deficiency Anaemia — The Golden Rule

🔑 The One Rule You Must Remember

Why this matters — even if the patient says:

⚡ What NICE says — FIT-guided referral (NICE NG12, 2023)

Typical GP work-up for IDA

What to say to patients:

For menstruating women (if cause unclear):

💊 Oral Iron Replacement — start while investigating

🎓 AKT Pearl

🔬 Investigations & Screening

Blood Tests

FBC

Liver blood tests

Inflammatory markers

Coeliac serology

Stool Tests

🔴 FIT (Faecal Immunochemical Test)

🟡 Faecal Calprotectin

🟢 Normal result — what to say

🟡 Raised result — what to say

Stool Culture (MC&S)

Imaging

Abdominal ultrasound

CT

Endoscopy

Liver stiffness (FibroScan / transient elastography)

📊 Managing Abnormal LFTs

🧭 The five BSG principles every GP should know

Step 1 — Decide how urgent it is

Step 2 — History, examination and the liver aetiology screen

History & examination (BSG checklist)

🔬 BSG standard liver aetiology screen (adults)

Extended screen — if no cause found

Step 3 — Recognise the pattern

Hepatitic (↑ALT/AST)

Cholestatic (↑ALP + ↑GGT)

Isolated ↑Bilirubin

Step 4 — Alcohol

🧪 FIT Test Performance

⚠️ FIT is a triage test, not a substitute for examination

Symptomatic FIT ≥10 μg Hb/g — primary care performance

True/false positives & negatives

💬 How to explain FIT results to patients

🔴 Positive FIT

🟢 Negative FIT

⚠️ Always say this too

🎯 Screening & Surveillance

NHS Bowel Cancer Screening (England)

Barrett's Oesophagus Surveillance

Liver Surveillance in Cirrhosis

3️⃣ Upper GI Conditions

Clinical Features

Management (NICE CG184)

💊 Full-dose PPIs (NICE CG184)

H. pylori Eradication