Page | 1 Gastroenterology General Referral Guidelines Department of Health clinical urgency categories for specialist clinics Urgent: A referral is urgent if the patient has a condition that has major functional impairment and/or moderate risk of permanent damage to an organ/bone/tissue/system if not seen within 30 days. Semi Urgent: Referrals should be categorised as Semi Urgent where the patient has a condition that has the potential to deteriorate within 30-90 days. Routine: Referrals should be categorised as routine if the patient’s condition is unlikely to deteriorate quickly or have significant consequences for the person’s health and quality of life if specialist assessment is delayed beyond one month. Exclusions: The following conditions should not be referred to outpatients, but rather patients should be advise to present directly to A&E: ‘Active haematemesis and/or melaena; Acute severe colitis; Jaundice with fever / abdominal pain, Food bolus obstruction, Suspected bowel obstruction Decompensated cirrhosis with encephalopathy, jaundice or sepsis; Clinically significant ascites/hepatic hydrothorax’. Patients with Hepatocellular Carcinoma should not be referred to outpatients or present to A&E, rather referred directly to the Hepatocellular Carcinoma Unit. See Referral Form and Referral Guidelines. These guidelines have been set by DHHS: src.health.vic.gov.au Condition / Symptom Criteria for Referral Information to be included Expected Triage Outcome Austin Specific Guidance Notes Abnormal liver function 1. Features suggestive of Must be provided: Urgent if aspartate tests cirrhosis: 1. History of alcohol intake transaminase (AST) or platelet count < 120 x 109 2. History of injectable drug use alanine aminotransferase Direct to Emergency Department for: per litre 3. Current and historical liver function (ALT) ≥ 5 times the upper Acute liver failure splenomegaly tests level of the normal range Severe hepatic ascites 4. Full blood examination encephalopathy hepatic encephalopathy 5. International normalised ration (INR) Routine otherwise Aspartate transaminase result (AST) > 2,000 U/L. 2. Genetic haemochromatosis 6. Urea and electrolytes (C282Y homozygotes and 7. Upper abdominal ultrasound results C282Y/H63D compound 8. Hepatitis B virus and Hepatitis C virus heterozygotes only) serology results 3. Abnormal liver function test 9. History of diabetes with aspartate transaminase 10. Iron studies (AST) or alanine 11. Current and complete medication aminotransferase (ALT) ≥ 5 history (including non-prescription times the upper level of the medicines, herbs and supplements). normal range Provide if available: 1. Height, weight and body mass index 1. Two abnormal liver function 2. Any relevant family history. test results performed at least 3 months apart with aspartate Austin Health Template Referral Guidelines | Created: 21/01/2020 By: Dr Josephine Grace. Last Reviewed: Dr Josephine Grace 24/01/2020. Review & Update By: 23/01/2022. Page | 2 These guidelines have been set by DHHS: src.health.vic.gov.au Condition / Symptom Criteria for Referral Information to be included Expected Triage Outcome Austin Specific Guidance Notes transaminase (AST) or alanine aminotransferase (ALT) 2-5 times the upper level of the normal range. Referral not appropriate for: 1. Fatty liver with normal liver function tests. Chronic refractory Must be provided: Routine constipation 1. Constipation lasting more 1. Onset, characteristics and duration of Direct to Emergency Department for: than 12 months with refractory symptoms that affect the symptoms Suspected large bowel 2. Details of previous medical obstruction person’s activities of daily living despite an adequate management including the course of Faecal impaction that has trial of treatment. treatment and outcome of treatment not responded to adequate 3. Current and complete medication medical management. history (including non-prescription Referral not appropriate for: medicines, herbs and supplements) 1. Patients with no sentinel 4. Thyroid stimulating hormone levels findings, who have not had an 5. Serum calcium. adequate trial of treatment (e.g. regular osmotic laxatives) Provide if available: Additional comments: 2. Laxative dependence. 1. Current and previous colonoscopy 1. The referral should note that the results request is for advice on, or 2. Details of any previous gastroenterology review of, the current assessments or opinions. management plan as requests 3. Current and previous imaging results. for a second opinion will usually not be accepted. 2. See also: statewide referral criteria for Constipation with Sentinel Findings Chronic refractory Routine diarrhoea 1. Chronic refractory diarrhoea Must be provided: 1. Onset, characteristics and duration of lasting more than 6 months with refractory symptoms symptoms Additional Comments: 2. Details of previous medical 1. The referral should note that the (following an adequate trial of treatment) that affect the management including the course of request is for advice on, or treatment and outcome of treatment review of, the current Austin Health Template Referral Guidelines | Created: 21/01/2020 By: Dr Josephine Grace. Last Reviewed: Dr Josephine Grace 24/01/2020. Review & Update By: 23/01/2022. Page | 3 These guidelines have been set by DHHS: src.health.vic.gov.au Condition / Symptom Criteria for Referral Information to be included Expected Triage Outcome Austin Specific Guidance Notes management plan as requests person’s activities of daily 3. Details of any previous gastroenterology for a second opinion will usually living. assessments or opinions not be accepted. 4. Previous histopathology results. 2. See also: statewide referral criteria for Diarrhoea with Provide if available: sentinel findings 1. Full blood examination 2. Iron studies Referral not appropriate for: 3. Vitamin B12 and folate test results 1. Laxative dependence. 4. 25-OH vitamin D results 5. Faecal calprotectin 6. Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) 7. Previous colonoscopy results. Cirrhosis Must be provided: Urgent if hepatic Direct to Emergency Department for: 1. Suspected cirrhosis encephalopathy, ascites or suggested by one or more of 1. History of alcohol intake jaundice Acute liver failure the following: 2. History of injectable drug use < 3 months otherwise Sepsis in a patient with evidence of cirrhosis on 3. Current and historical liver function cirrhosis imaging tests Severe hepatic platelet count < 120 x 109 4. Full blood examination encephalopathy per litre 5. International normalised ration (INR) Severe ascites restricting ascites result movement and breathing. hepatic encephalopathy 6. Urea and electrolytes AST to platelet ratio index 7. Upper abdominal ultrasound results (APRI) >2.0. 8. Hepatitis B virus and Hepatitis C virus serology results 9. History of diabetes 10. Iron studies 11. Current and complete medication history (including non-prescription medicines, herbs and supplements). Provide if available: 1. Height, weight and body mass index. Coeliac disease Must be provided: <3 months GP Management: 1. Positive coeliac serology If coeliac disease 2. Advice on, or review of, 1. Coeliac serology results or previous confirmed (positive symptomatic coeliac disease histology results serology and abnormal Austin Health Template Referral Guidelines | Created: 21/01/2020 By: Dr Josephine Grace. Last Reviewed: Dr Josephine Grace 24/01/2020. Review & Update By: 23/01/2022. Page | 4 These guidelines have been set by DHHS: src.health.vic.gov.au Condition / Symptom Criteria for Referral Information to be included Expected Triage Outcome Austin Specific Guidance Notes (previous histological 2. Full blood examination small bowel biopsy), refer diagnosis) not responding to 3. Iron studies. to a dietitian for gluten- dietary and medical free diet. management. Provide if available: 1. Gastrointestinal symptoms (e.g. If diagnostic uncertainty Referral not appropriate for: diarrhoea, weight loss) await specialist clinic 1. Positive coeliac gene test 2. Previous gastroscopy results appointment before without positive coeliac 3. Previous histology results commencing gluten free serology. 4. Previous gastroenterology assessments diet. or opinions 5. Urea and electrolytes 6. Liver function tests 7. Details of previous medical management including the course of treatment and outcome of treatment 8. Details of any other autoimmune conditions. Constipation with sentinel 1. Constipation in patients with Must be provided: Patients with positive findings a duration of more than 6 1. Onset, characteristics and duration of Urgent faecal occult blood test weeks but less than 12 constipation and sentinel findings may be triaged to Direct to Emergency Department for: months, with any of the 2. Current and previous colonoscopy colonoscopy prior to the following: results appointment at a Suspected large bowel >40 years of age 3. Full blood examination specialist clinic. obstruction rectal bleeding 4. Iron studies Faecal impaction that has positive faecal occult not responded to adequate blood test Provide if available medical management. weight loss (≥ 5% of body 1. Current and previous histology results weight in previous 6 2. Details of any previous gastroenterology months) assessments or opinions 3. Faecal occult blood test abdominal or rectal mass Additional Comments: 4. Thyroid stimulating hormone levels iron deficiency that 1. As part of the referral persists despite assessment, patients may be triaged by phone direct