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Chronic diarrhoea: the indications for lower GI endoscopy when functional bowel disease is suspected
  1. John Ong1,2,
  2. Carla Swift2,
  3. Ian Allwood3,
  4. Roger Norman4,
  5. Yasseen Al-Naeeb2,
  6. Arun Shankar5
  1. 1 Department of Engineering (Materials Engineering & Materials-Tissue Interactions Group), University of Cambridge, Cambridge, UK
  2. 2 Department of Gastroenterology, Bedford Hospital NHS Trust, Bedford, UK
  3. 3 Bridge House Medical Centre, Stratford-upon-Avon, Warwickshire, UK
  4. 4 Asplands Medical Centre, Woburn Sands, Milton Keynes, UK
  5. 5 Department of Gastroenterology, Norfolk and Norwich University Hospital NHS Trust, Norwich, Bedfordshire, UK
  1. Correspondence to Dr John Ong, Department of Engineering, University of Cambridge, Cambridge CB2 1PZ, UK; jo401{at}

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We read with interest the ‘Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, third Edition’ by Arasaradnam et al.1 Compared with the second edition, the new guidance provides more detailed and specific content which will undoubtedly aid the investigation of chronic diarrhoea both in primary and secondary care. However, we would like to clarify the authors’ position on the following.

On page 9 under ‘Recommendations’, the authors state ‘In patients with typical symptoms of functional bowel disease, normal physical examination and normal screening blood and faecal tests (calprotectin), a positive diagnosis of IBS can be made (Grade of evidence level 2, Strength of recommendation strong).’

However, on the same page, they also state ‘In younger patients (under 40 years) with a normal faecal calprotectin and in whom functional bowel disease is suspected, we recommend a flexible sigmoidoscopy with biopsy (Grade of evidence level 3, Strength of recommendation strong).’

It is not clear to us if the authors are recommending flexible sigmoidoscopy for all younger patients (under 40 years), with or suspected with, diarrhoea predominant irritable bowel syndrome (IBS-D) who have negative screening investigations or have important qualifiers been omitted in the latter recommendation, for example, patients with persistent and severe IBS-D symptoms that are referred to secondary care? This ambiguity could affect management in both primary and secondary care, and have further implications on cost to the National Health Service and service requirements of endoscopy units.


JO is supported by the W D Armstrong Doctoral Fellowship from Cambridge University.



  • Contributors JO conceptualised and drafted the letter after reading the newly published guidelines. The remaining authors read the new guidelines then reviewed and edited the letter before submission.

  • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS or the Department of Health.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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