SCHHS Referral Guidelines. Gastroenterology. February 2015

Transcription

1 SCHHS Referral Guidelines Gastroenterology February 2015

2 Referral Guidelines Gastroenterology Published by SCHHS, February 2015 An electronic version of this document is available at:

3 CONTENTS Acknowledgement and purpose Bowel Cancer Screening Chronic constipation Chronic diarrhoea Coeliac disease Dyspepsia / heartburn / reflux Established Inflammatory Bowel Disease Iron Deficiency including Anaemia Irritable Bowel Syndrome(IBS) suspected Polyp Surveillance Rectal Bleeding

4 Acknowledgement This document has been derived from Queensland Health referral guidelines

5 Bowel cancer screening Colonoscopy is indicated in those with a family history of colorectal cancer in: a first-degree relative 55 years OR, two, first- or second-degree relatives on the same side of the family diagnosed at any age OR, FOBT Positive results from National Bowel Cancer Screening Programme (NBCSP) Please provide this specific information (re: the above indications) within referral. The age of the first degree relative with Hx of colorectal cancer is important. Also, if patient HAS had previous endoscopic procedures: Previous colonoscopy procedures (report and histology) MUST be attached to referral **Please document clearly if you do not wish for your patients to proceed directly to open access endoscopic procedures**. Recommended pre-referral treatment Medical management: For those who do not fulfil the above criteria, perform faecal occult blood testing annually from age 50. Consider colonoscopy every five years from age 50 following consultation with a specialist. Useful Links GESA (2011) Cancer Council Australia

6 Chronic Constipation FBC ELFTs TSH Calcium Iron Studies Previous colonoscopy reports and other relevant imaging (CT, Barium) if performed in past Recommended pre-referral treatment Lifestyle changes: Increase dietary fibre if lacking and increase fluid intake. Address inappropriate toileting habits. Undertake regular exercise. Review diet with a qualified dietician. Medical management: Cease any aggravating medications if possible eg. opioids, anticholinergics. bulk-forming laxatives e.g. Metamucil (while maintaining adequate fluid intake) osmotic laxatives e.g. Movicol, Lactulose stimulant laxatives e.g. Coloxyl with senna or Bisacodyl NOT suitable for long-term use Consider pelvic floor dysfunction and physiotherapy management. When to refer Presence of any red flags (as below) requires immediate referral. Patients without red flags can be referred and will be triaged appropriately. Red flags unexplained weight loss of 5% of body weight in previous six months new onset > age 50 years old unexplained iron deficiency anaemia abdominal mass Useful Links Patient resources ation_final%20web.pdf

7 Chronic Diarrhoea (Daily symptoms for > 6 weeks) History frequency, duration, overseas travel medication history - NSAIDS FBC ELFTs TSH CRP coeliac serology (if positive see Coeliac disease guidelines) Iron Studies, B12, Folate Previous colonoscopy procedures (reports and histology) stool m/c/s + PCR clostridium difficile toxin (if recent antibiotics) **Please document clearly if you do not wish your patient to proceed directly to open access endoscopic procedure**. Additional information (if relevant) family history of inflammatory bowel disease or colorectal cancer faecal calprotectin (will require funding by the patient) if culture negative only and suspect IBD; if culture positive, please see IBD guidelines plain abdominal x-ray or CT imaging Faecal eleastase (will require funding by the patient) if suspect pancreatic insufficiency Recommended pre-referral treatment Lifestyle changes: Review diet. Minimise alcohol intake. Medical management: Consider constipation and overflow. Consider faecal incontinence. Consider trial of Loperamide monitor, as it may be contraindicated if idiopathic IBD.

8 Chronic Diarrhoea - Continued When to refer Presence of any red flags (as below) requires immediate referral. Patients without red flags can be referred and will be triaged appropriately. Red flags bloody or nocturnal diarrhoea (please see IBD referral guidelines) significant weight loss of 5% of body weight in previous six months radiological evidence colitis on CT scan and stool culture negative (please see IBD referral guidelines)

9 Coeliac disease coeliac disease serology including IgA, if serology negative FBC ELFTs iron studies TSH Red cell folate and vitamin B12 25-OH vitamin D family history of coeliac disease If patients are on a gluten-free diet, advise them to add gluten to their diet for four weeks before the above tests and diagnosis. If not viable to return gluten to the diet, arrange a HLA DQ2/DQ 8 gene test. Please be aware the gold standard is biopsy proven disease. **Please document clearly if you do not want patient to proceed directly to open access endoscopic procedure** When to refer if positive coeliac disease serology if coeliac disease is strongly suspected, despite negative serology result check IgA level Post-diagnosis management Following diagnosis, a strict lifelong gluten-free diet must be maintained. Review diet with a qualified dietitian. Monitor for diet compliance with coeliac disease serology every six to 12 months. Screen family members with serology. Establish baseline bone mineral densitometry. Monitor for other autoimmune disorders Consider referral if symptoms persist despite following a gluten free diet for three months. Useful Links GESA Patient resources Coeliac Queensland Information line ph.: (07) or

10 Dyspepsia / Heartburn / Reflux FBC ELFTs iron studies Coeliac serology Previous endoscopic procedures (report and histology) **Please document clearly if you do not want patient to proceed directly to open access endoscopic procedure** Additional information (if relevant) Helicobacter pylori breath test or faecal antigen test (either test will require funding by patient) must be off proton pump inhibitor (PPI) for two weeks Upper abdominal ultrasound Recommended pre-referral treatment Lifestyle changes: cease smoking avoid alcohol intake avoid triggers e.g. caffeine, chocolate, spicy and fatty foods reduce weight if overweight. Medical management: If H pylori is present, treat and check for eradication. Cease any aggravating medications if possible e.g. NSAIDS, aspirin. Trial proton pump inhibitor at full dose for at least four weeks. Continued over page

11 Dyspepsia / Heartburn / Reflux - Continued When to refer Presence of any red flags (as below) requires immediate referral Patients without red flags can be referred if symptoms are refractory to treatment Red flags gastrointestinal bleeding unexplained weight loss of 5% of body weight in previous six months difficulty swallowing persistent vomiting unexplained iron deficiency anaemia (see Iron Deficiency anaemia guidelines) any patient >55 years with unexplained or persistent recent onset dyspepsia Useful Links GESA - Reflux Patient resources

12 (Established) Inflammatory Bowel Disease where and when diagnosed specific diagnosis previous imaging reports previous gastroscopy procedures (report and histology) FBC ELFTs CRP iron studies, vitamin B12, 25-OH vitamin D stool m/c/s including Clostridium difficile toxin (if symptomatic diarrhoea) faecal calprotectin (will require funding by patient) only if established diagnosis Additional Information family history of IBD past surgery for IBD medication history Recommended pre-referral treatment Lifestyle changes: smoking cessation for Crohn s disease When to refer Presence of any red flags (as below) requires immediate referral and/or phone call to IBD Hotline. HOTLINE (07) There is a 24 hour answering machine service and the call will be returned by the next working business day (usually same day). Patients without red flags should be referred and will be triaged appropriately. See over page for the Red Flags.

13 Established Inflammatory Bowel Disease - Continued Red flags rectal bleeding symptoms of bowel obstruction (consider Emergency Department assessment) fever and abdominal / perineal mass (consider Emergency Department assessment) significant diarrhoea 6x/day significant weight loss of 5% of body weight in previous six months significant abnormalities in investigations i.e. Hb <100 g/l, CRP >45 or faecal calprotectin >200 mcg/g Useful Links GESA LINK FOR GP s PATIENT RESOURCES:

14 Iron Deficiency (incl Anaemia) history of bleeding e.g. menorrhagia family history of colorectal cancer / coeliac disease medication history (especially NSAIDS, aspirin and corticosteroids) FBC ELFTs iron studies (including past results if available and response to iron) coeliac disease serology **Please document clearly if you do not want patient to proceed directly to open access endoscopic procedure** Recommended pre-referral treatment Lifestyle changes: If there is a dietary cause, modify diet and/or refer to dietitian. Medical management: Establish and treat the cause (e.g. menorrhagia, diet). If appropriate, treat with iron supplements Cease any aggravating medications if possible (e.g. NSAIDS) When to refer Presence of any red flags (as below) requires immediate referral. Patients without red flags can be referred and will be triaged appropriately. Red flags significant weight loss of 5% of body weight in previous six months iron deficiency anaemia with no obvious cause iron deficiency associated with any of the following : o gastrointestinal bleeding o abdominal pain o new change in bowel habit. Useful Links GESA PATIENT RESOURCES:

15 Irritable Bowel Syndrome (IBS) - suspected FBC ELFTs CRP TSH coeliac disease serology consider Ca 125 and pelvic ultrasound if bloating iron studies Previous colonoscopy or gastroscopy (reports and histology) stool m/c/s + PCR (if diarrhoea) **Please document clearly if you do not want patient to proceed directly to open access endoscopic procedure** Recommended pre-referral treatment Lifestyle changes: include regular exercise address triggers (stress, food, medications e.g. NSAIDS, antibiotics) review diet with a qualified dietitian (e.g. fermentable, oligo -, di-, mono-saccharides and polyols (FODMAP) diet). Medical management: cease any aggravating medications if possible bulk-forming or osmotic laxatives for constipation Loperamide for diarrhoea peppermint oil or Mebeverine for crampy abdominal pain consider tricyclic antidepressant (TCA) or selective serotonin reuptake inhibitors (SSRIs) if no contraindications treat anxiety and/or depression if present consider probiotics or Simethicone for bloating Continued over page

16 When to refer Presence of any red flags (as below) requires immediate referral. Patients without red flags can be referred and will be triaged appropriately. Red flags change in bowel habits of >6 weeks in patients >40 years significant weight loss of 5% of body weight in previous six months unexplained iron deficiency anaemia (see Iron Deficiency guidelines) abdominal mass. Useful Links GESA PATIENT RESOURCES: me%20-%203rd%20ed.pdf DIETARY ADVICE: FODMAP_Diet_2ndED-2013_Web.pdf

17 Polyp Surveillance personal history of colorectal cancer familial cancer syndrome eg. Lynch, FAP. previous endoscopic procedures (report and histology) previous colonic polyps (excluding recto-sigmoid hyperplastic polyps) **Please document clearly if you do not want patient to proceed directly to open access endoscopic procedure** When to refer Presence of any red flags (as below) requires immediate referral. Red flags significant weight loss of 5% of body weight in previous six months unexplained iron deficiency anaemia In the absence of any red flags, the following time frames are recommended for polyp surveillance and are based on the most recent colonoscopy performed: five-yearly: if <3 polyps (excluding diminutive rectosigmoid hyperplastic polyps) provided that all polyps are simple, as defined by dimensions (<10mm) and histopathology (no high-grade dysplasia or villous change) three-yearly: if three or four polyps (excluding diminutive rectosigmoid hyperplastic polyps) or if one or more polyps are advanced as characterised by dimensions ( 10mm) and/or histopathology (presence of high-grade dysplasia or villous change) annually: if five to nine polyps (excluding diminutive rectosigmoid hyperplastic polyps) <12 months: if required, a baseline colonoscopy may need to be repeated in cases of poor bowel preparation (immediate rescheduling), possible incomplete excision of a large polyp (often at three months) or the presence of multiple adenomas ( 10) to ensure complete clearance. Useful Links Cancer Council Australia Patient resources

18 Rectal Bleeding Describe bleeding distinguish between dark blood coating or mixed with stool; or bright red blood passed after the motion or on the paper Previous endoscopic procedures (report and histology) family or personal history of colorectal cancer or inflammatory bowel disease FBC ELFTs iron studies Recommended pre-referral treatment Medical management: treat constipation perform PR examination, +/- proctoscopy. When to refer Presence of any red flags (as below) requires immediate referral. Patients without red flags can be referred and will be triaged appropriately. Red flags rectal bleeding in patients > 40 years old urgent colonoscopy rectal bleeding in patients < 40 years old flexible sigmoidoscopy change in bowel habits > 6 weeks in patients >40 years significant weight loss of 5% of body weight in previous six months unexplained iron deficiency anaemia (see Iron Deficiency guidelines) abdominal or rectal mass.

19 References Cancer Council Australia Surveillance Colonoscopy Guidelines Working Party. Clinical practice guidelines for Surveillance Colonoscopy. Sydney: Cancer Council Australia. [Version URL: cited 2014 May 26]. Available from: eilla nce