• Refer to secondary care anyone who presents with a red flag indicator (see Differential diagnosis).
• Urgently refer:
• Anyone 40 years of age and older, reporting rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or more.
• Anyone 60 years of age and older, with rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms.
• Anyone 60 years of age and older, with a change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding.
• Anyone presenting with a right lower abdominal mass consistent with involvement of the large bowel, irrespective of age.
• Anyone presenting with a palpable rectal mass (intraluminal and not pelvic), irrespective of age. (A pelvic mass outside the bowel warrants an urgent referral to a urologist or gynaecologist.)
• Men of any age with unexplained iron deficiency anaemia and haemoglobin of 11 g/100 mL or less.
• Non-menstruating women with unexplained iron deficiency anaemia and haemoglobin of 10 g/100 mL or less.
• Refer to a registered dietitian for advice and treatment (including single food avoidance and exclusion diets) if general lifestyle and dietary advice are insufficient by themselves to improve symptoms. Such advice should only be given by a registered dietitian.
• Consider referral for psychological interventions (cognitive behavioural therapy, hypnotherapy, or psychological therapy) for people who do not respond to diet, lifestyle, and drug treatments after 12 months.
• Consider referral if there is uncertainty abut the diagnosis.
• Consider referral if the person has health-related anxieties that have not been allayed.

Basis for referral of people with red flag indicators

• Recommendations for referral of people with red flag indicators are from the National Institute of Health and Clinical Excellence (NICE) guideline Irritable bowel syndrome in adults [NICE, 2008] and the NICE Referral guidelines for suspected cancer [NICE, 2005b].

Basis for referral if there is uncertainty about the diagnosis

• The British Society of Gastroenterology guidelines for the management of irritable bowel syndrome recommend referral if there is genuine uncertainty about the diagnosis [Spiller et al, 2007].

Basis for referral to a registered dietitian

• This recommendation is from the NICE guidance Irritable bowel syndrome in adults [National Collaborating Centre for Nursing and Supportive Care, 2008; NICE, 2008].
• Although there is some evidence to support the use of exclusion diets, the Guideline Development Group (GDG) believed that such diets should only be undertaken with the specialist help of a dietitian to ensure that the diet remains well balanced.

Basis for referral if there is health-related anxiety

• The British Society of Gastroenterology guidelines for the management of irritable bowel syndrome recommend referral if the person has concerns that have not been successfully allayed by consultation with their primary healthcare professional [Spiller et al, 2007].

Basis for referral for psychological interventions

• This recommendation is from the NICE guidance Irritable bowel syndrome in adults [National Collaborating Centre for Nursing and Supportive Care, 2008; NICE, 2008].
• There is some evidence in people with long term irritable bowel syndrome (IBS) of a significant global improvement in symptoms after 12 weeks and after 15 months, for dynamic psychotherapy plus medical therapy compared with medical therapy alone. Compared with 'usual treatment', psychotherapy improved global symptoms after 12 weeks, but this improvement was not maintained in the longer term (52 weeks); there was no difference in pain score at 12 weeks, nor at 52 weeks.
• There is good evidence, mainly in people with psychiatric comorbidities and refractory IBS, of a significant global improvement in symptoms for cognitive behavioural therapy (CBT) compared with no treatment or symptom monitoring. Evidence did not suggest an improvement in individual symptoms with CBT.
• Evidence on hypnotherapy in the management of irritable bowel syndrome (IBS) is generally poor, making it difficult to draw any conclusions about the efficacy of hypnotherapy for IBS.