Gastroenterology General Referral Guidelines

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

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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

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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

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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 to correction of causative colonoscopy factors  patient or family history of bowel cancer (first degree relative < 55 years).

Referral not appropriate for: 1. Patients with more than 12 months of symptoms, with no

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Diarrhoea with sentinel 1. Diarrhoea > 2 weeks but < 6 Must be provided: Urgent GP Management: findings months duration, affecting activities of daily living, with 1. Frequency and duration of diarrhoea When to Refer: Direct to Emergency Department for: one or more of the following: 2. Onset, characteristics and duration of  bloody diarrhoea sentinel findings (e.g. erythrocyte > 6 – 8 weeks without blood  Severe diarrhoea with  nocturnal diarrhoea sedimentation rate (ESR), C-reactive dehydration or when the  weight loss (≥ 5% of body protein (CRP), faecal microscopy and >2 weeks with blood person is systemically weight in previous 6 culture and Clostridium difficile toxin) unwell. months) 3. Previous colonoscopy results  Bloody diarrhoea > 2 weeks  abdominal or rectal mass 4. Coeliac serology

 inflammatory markers in 5. Full blood examination

the blood or stool 6. Liver function tests. Additional Comments:  iron deficiency that 1. See also: statewide referral Provide if available: persists despite criteria for inflammatory bowel 1. Previous histology results correction of potential disease 2. Details of any previous gastroenterology causative factors. 2. See also: statewide referral assessments or opinions

criteria for chronic refractory 3. Iron studies

diarrhoea 4. Thyroid stimulating hormone levels Referral not appropriate for: 5. Faecal calprotectin 1. Diarrhoea < 4 weeks duration 6. Faecal occult blood test without sentinel findings. 7. Recent travel history.

Dysphagia Must be provided: Urgent GP Management: (gastroenterology) 1. History of dysphagia and other 1. Recent onset dysphagia with any of the following: symptoms over time  Almost all patients Direct to Emergency Department for: 2. Any previous gastroscopy or other need gastroscopy  symptoms for less than 12 months relevant investigations.  Progressively worsening  progressive symptoms oropharyngeal or throat Provide if available  anaemia dysphagia 1. Barium swallow, relevant imaging or  Inability to swallow with  haematemesis gastroscopy results. drooling or pooling of

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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 saliva  weight loss (≥ 5% of body  Unresolved food bolus weight in previous 6 obstruction. months)  painful swallowing  symptoms of aspiration  previously resolved bolus obstruction.

Referral not appropriate for: Additional Comments: 1. Dysphagia that has persisted 1. Referrals for oropharyngeal for more than 12 months with dysphagia should be directed to none of the following: an ENT service provided by the health service.  progressive symptoms  anaemia  weight loss  painful swallowing  aspiration  previous resolved bolus obstruction. Gastroesophageal reflux 1. Recent onset, persistent Must be provided: Urgent if patient >54 years GP Management: Direct to Emergency Department for: symptoms of 1. Onset, characteristics and duration of gastroesophageal reflux with sentinel findings e.g. changes in weight, Routine otherwise When to Refer:  Potentially life-threatening any one of: ferritin levels

symptoms suggestive of  unintended weight loss (≥ 2. Previous endoscopy results Symptoms persisting

acute severe upper 5% of body weight in 3. Current and complete medication despite lifestyle gastrointestinal tract previous 6 months) history (including non-prescription advice/acid reduction bleeding.  dysphagia medicines, herbs and supplements). therapy  vomiting  iron deficiency that New reflux in an older persists despite person correction of potential causative factors. 2. Surveillance for previously diagnosed Barrett’s oesophagus.

Referral not appropriate for: 1. Patients with gastroesophageal reflux and no additional symptoms

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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 2. Patients with controlled symptoms following lifestyle advice/acid reduction therapy 3. Patients that cease treatment and symptoms return 4. Uncomplicated hiatus hernia 5. Belching 6. Halitosis 7. Screening for Barrett’s oesophagus in patients with gastroesophageal reflux without additional symptoms.

Hepatitis B Must be provided: Routine GP Management: Direct to Emergency Department for: 1. Patients who are hepatitis B 1. Hepatitis B virus (HBV) serology results surface antigen (HbsAg) 2. Hepatitis B PCR results GPs play an important role

 Acute liver failure positive 3. Hepatitis C virus and HIV serology in diagnosis, education 4. Liver function tests and monitoring of chronic  Sepsis in a patient with 2. Pregnant women who are 5. Full blood examination hepatitis B – shared care cirrhosis hepatitis B surface antigen 6. If pregnant, gestational age models may be  Severe hepatic (HbsAg) positive 7. Current and complete medication recommended encephalopathy 3. Patients who are history (including non-prescription  Severe ascites restricting immunosuppressed or starting immunosuppressant medicines, herbs and supplements). Chronic infection requires movement and breathing. life-long follow-up, medicines who are hepatitis B core antibody (HbcAb) positive Provide if available including 6-12 monthly 1. Upper abdominal ultrasound results hepatitis B monitoring, Additional comments: (e.g. transplant patients, starting chemotherapy). 2. Previous liver biopsy results yearly hepatitis B DNA 1. Assessment and management 3. Details of previous medical viral load, liver function of pregnant women with chronic Referral not appropriate for: management including the course of testing and antiviral hepatitis B may be undertaken treatment and outcome of treatment. therapy if indicated as part of perinatal care at an 1. Patients who are hepatitis B surface antigen (HbsAg) appropriate institution eg Mercy Certain populations with Perinatal Clinic negative, unless they are immunosuppressed or chronic hepatitis B require lifelong monitoring for starting immunosuppressant medicines and are hepatitis B hepatocellular carcinoma with ultrasound and AFP core antibody (HbcAb) positive. every 6 months

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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 Hepatitis C Must be provided: Next available Hepatitis C Direct to Emergency Department for: 1. Patients who are hepatitis C 1. Hepatitis C virus serology, genotype and clinic (link to Austin Hep C (HCV) RNA positive unable to RNA results internet page)

 Acute liver failure be managed and treated in 2. Hepatitis B virus serology results 3. HIV serology results Patients may be offered  Sepsis in a patient with community-based services. 4. Liver function tests including aspartate appointment at community- cirrhosis 2. Patients who have hepatitis C transaminase (AST) based Austin Health clinics  Severe hepatic and cirrhosis. 5. Full blood examination if appropriate encephalopathy 6. Current and complete medication  Severe ascites restricting Referral not appropriate for: history (including non-prescription movement and breathing. 1. Hepatitis C should be medicines, herbs and supplements). managed and treated through suitable community-based Provide if available services wherever possible 1. Upper abdominal ultrasound results 2. Patients who are hepatitis C 2. Previous liver biopsy results (HCV) RNA negative who are 3. Details of previous medical not at ongoing risk of management including the course of cirrhosis. treatment and outcome of treatment 4. History of alcohol intake 5. History of injectable drug use, including if the patient is still injecting. Inflammatory bowel  Must be provided: Routine disease 1. Known inflammatory bowel 1. Current and previous colonoscopy results. Direct to Emergency Department for: disease. 2. Strongly suspected 2. Current and previous imaging results. 3. Inflammatory marker result  Acute severe colitis: inflammatory disease based on: (erythrocyte sedimentation rate (ESR) patients with ≥ 6 bloody  recurrent perianal fistulas or C-reactive protein (CRP)). bowel motions per 24 or abscesses 4. Full blood examination. hours plus at least one of 5. Current and complete medication  imaging results that the following: history (including non-prescription strongly suggest Crohn’s o temperature > medicines, herbs and supplements). disease or colitis 37.8°C  endoscopy findings o pulse rate > 90 Provide if available consistent with bpm 1. Faecal calprotectin. o haemoglobin < 105 inflammatory bowel gm/L disease. o raised inflammatory markers (erythrocyte

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 | 9

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 sedimentation rate (ESR) > 30 mm/hr or C- reactive protein (CRP) > 30 mg/L)  Suspected or known Crohn’s disease with acute complications: o bowel obstruction o sepsis or intra- abdominal or pelvic abscess.

Additional Comments: 1. See also: statewide referral criteria for symptoms such as diarrhoea or abnormal imaging or colonoscopy results

Persistent iron deficiency Must be provided: Urgent Direct to Emergency Department for: 1. Persistent iron deficiency in 1. History of menorrhagia men and post-menopausal 2. Dietary history, including red meat  Shortness of breath or women with either: intake

chest pain, syncope or pre-  ferritin < 30 µg/L 3. Iron studies or serum ferritin 4. Full blood examination syncope with iron  ferritin 30-100 µg/L in the 5. Coeliac serology results deficiency anaemia presence of inflammation 6. Current and complete medication (ferritin below the lower (e.g. C-reactive protein history (including non-prescription limit of normal). (CRP) ≥ 5 mg/L) medicines, herbs and supplements). 2. Iron deficiency that persists

despite correction of potential Provide if available causative factors 1. Faecal occult blood test 3. Iron deficiency anaemia in 2. Faecal calprotectin pre-menopausal women: 3. Any family history of gastrointestinal  with positive coeliac cancer. Additional Comments: serology 1. Referrals for iron deficiency  with positive faecal occult related to persistent, heavy blood test menstrual bleeding should be

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 | 10

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 made to suitable community-  that persists despite based services wherever treatment of possible (see 1800 My Options). menorrhagia, with good Where this is not practicable, cycle control. referrals should be directed to a gynaecology service provided by Referral not appropriate for: the health service. 1. Iron deficiency in pre- menopausal women with:

 no positive coeliac serology  negative faecal occult blood test  managed menorrhagia and with good cycle control 2. Isolated low serum iron 3. Non-iron deficiency anaemia without evidence of blood loss 4. Vegetarian diet without iron supplementation. Rectal bleeding Must be provided: Urgent Direct to Emergency Department for: 1. Rectal bleeding in patients 1. Onset, characteristics and duration of with any of the following: symptoms

 Potentially life-threatening  40 years or older 2. Full blood examination 3. Urea and electrolytes symptoms suggestive of  unintended weight loss (≥ 4. Iron studies acute severe lower 5% of body weight in 5. Previous and current gastrointestinal gastrointestinal tract previous 6 months) investigations and results bleeding.  abdominal or rectal mass 6. Patient age  recent change in bowel 7. Details of relevant family history of habits gastrointestinal or colorectal cancers.  iron deficiency that persists despite Provide if available correction of potential 2. Current and previous colonoscopy causative factors results. Additional Comments:  patient or family history 2. Referrals for colonoscopy of bowel cancer (first requested for a positive faecal degree relative < 55 years). occult blood test should be made using Victoria's colonoscopy referral information Referral not appropriate for: form. 1. Persistent but unchanged

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 | 11

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 3. Referrals for severe symptoms previously haemorrhoids should be investigated directed to colorectal service 2. If the patient has had a full provided by the health service. colonoscopy in the last 2 years for the same symptoms 3. Untreated anal fissures 4. Bleeding is known to be coming from haemorrhoids.

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Condition / Symptom Criteria for Referral Information to be Expected Triage Austin Specific Guidance included Outcome Notes Dyspepsia Must be provided: Urgent: Persistent dyspepsia despite PPI 1. Onset, characteristics - Age > 54 Epigastric pain therapy and/or dietary advice and and duration of any one of: sentinel findings e.g. Routine: changes in weight, - Age < 55 ferritin levels 1. Unintended weight loss (≥ 5% 2. Previous endoscopy of body weight in previous 6 and histopathology months) results 2. Iron deficiency 3. Current and complete 3. Previously diagnosed atrophic medication history gastritis (including non- 4. Previously diagnosed prescription intestinal metaplasia/gastric medicines, herbs and dysplasia supplements). 5. Family history of upper GI cancer in first degree relative

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Condition / Symptom Criteria for Referral Information to be Expected Triage Austin Specific Guidance included Outcome Notes Surveillance of colorectal Complete M53 Routine polyps colonoscopy referral form 1. History of adenomatous or sessile serrated polyps Select patients may be 1. Referrals should be made using Austin triaged by phone directly to colonoscopy referral form M53. colonoscopy 2. Information on surveillance intervals of colorectal polyps can be found on Cancer Council Australia website

Irritable Bowel Syndrome Must be provided: Urgent if any clinical GP resources can be found at: 1. Exclude clinical alarms: 1. Onset, characteristics alarms present www.ibs4gps.com a. Symptoms < 6m and duration of b. Rectal bleeding symptoms Otherwise routine c. Weight loss 2. Details of previous d. Abdominal mass medical management e. Abnormal including the course of investigations treatment and 2. Ensure cancer screening up outcome of treatment to date 3. Details of any previous 3. Failure of initial management gastroenterology eg fibre supplementation, assessments or dietary modification, opinions psychological therapies Provide if available: 1. Full blood count 2. Coeliac serology 3. Faecal calprotectin 4. Cancer screening results eg FOBT

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Condition / Symptom Criteria for Referral Information to be Expected Triage Austin Specific Guidance included Outcome Notes Family history of bowel cancer Complete M53 Routine 1. Referrals should be made using Austin Referral for colonoscopy colonoscopy referral form colonoscopy referral form M53 (link) appropriate for any of: Select patients may be 2. Information on risk categorisation of triaged by phone directly people with a family history of colorectal to colonoscopy 1. A first-degree relative with cancer can be found on Cancer Council colorectal cancer diagnosed Australia website under 55 years 2. At least two first-degree relatives with colorectal cancer diagnosed at any age 3. One first-degree relative and at least two second-degree relative with colorectal cancer diagnosed at any age

Referral not appropriate for the following risk category 1 people who should be screened with FOBT every 2 years:

4. No first or second degree relative with bowel cancer 5. One first-degree relative with colorectal cancer diagnosed at 55 years or older 6. One first-degree and one second-degree with colorectal cancer diagnosed at 55 years or older

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Condition / Symptom Criteria for Referral Information to be Expected Triage Austin Specific Guidance included Outcome Notes Unexplained weight loss Must be provided: Urgent Referral appropriate for 1. Onset, characteristics unexplained weight loss (≥ 5% of and duration of body weight in previous 6 sentinel findings e.g. months) and any of: changes in weight, ferritin levels 2. FOBT results 1. Gastrointestinal symptoms 3. Relevant imaging (rectal bleeding, altered findings bowel habit, unexplained 4. Current and complete abdominal pain) medication history 2. Positive FOBT (including non- 3. Anaemia prescription 4. Abnormal imaging medicines, herbs and suggestive of pathology of supplements). the gastrointestinal tract

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.