<p> SOUTH EAST LONDON CANCER NETWORK Upper GI Urgent Suspected Cancer Referral</p><p>Please tick the box of the hospital clinic you are referring to and fax this form to the relevant Urgent Referral Team within 24 hours. Guidelines are on the reverse side.</p><p>King’s College PRUH site Queen Elizabeth Guy’s & St Thomas’ [email protected] Fax: 020 8836 4035 Fax: 020 7188 0923 Tel: 01689 866701/65790/65794 Tel: 020 8836 5964/5 Tel: 020 7188 0902 Fax: 01689 863187 King’s College Lewisham Queen Mary’s Fax: 020 3299 1515 Fax: 020 8333 3451 Fax: 020 8308 9264 Tel: 020 3299 1516 Tel: 020 8333 3450 Tel: 020 8308 3258/3088</p><p>SECTION 1 – PATIENT INFORMATION. PLEASE COMPLETE IN BLOCK CAPITALS. SURNAME Patient visited this hospital before? Y / N FIRST NAME NHS Hospital Number Number Gender M / F D.O.B. Patient aware the referral is urgent? Y / N Address First language Interpreter required? Y / N Post Code Transport required? Y / N Daytime Telephone Home Telephone (if different) / Mobile No.</p><p>SECTION 2 – PRACTICE INFORMATION. USE PRACTICE STAMP IF AVAILABLE. Referring GP Date of referral</p><p>Practice Address Telephone</p><p>Fax Post Code</p><p>SECTION 3 – CLINICAL INFORMATION. PLEASE TICK THE RELEVANT BOXES. Symptoms Dysphagia Persistent vomiting Chronic GI bleeding Frequency / description Worsening dyspepsia Progressive unintentional Age > 55 years, unexplained and weight loss persistent (4-6 weeks) recent-onset How much Unexplained upper ab pain and over dyspepsia weight loss +/- back pain Clinical Examination & Results - attach relevant reports Risk Factors Epigastric / Suspicious barium Barrett’s oesophagus Known dysplasia, abdominal mass meal result atrophic gastritis or Hepatomegaly Iron deficiency Peptic ulcer surgery intestinal metaplasia Obstructive jaundice anaemia > 20 years ago Ultrasound scan? Y / N Hb = Ferritin = History Additional information Previous investigation of upper GI tract</p><p>Location</p><p>Diagnosis</p><p>Continue on separate sheet, and attach patient computer record summary if available. SOUTH EAST LONDON CANCER NETWORK Information to support Upper GI referrals</p><p>Refer urgently patients:</p><p> Dysphagia  Unexplained upper abdominal pain and weight loss, with or without back pain  Upper abdominal mass with or without dyspepsia  Obstructive jaundice (depending on clinical state)  Patients of any age with dyspepsia and any of the following o Chronic gastrointestinal bleeding o Progressive unintentional weight loss o Persistent vomiting o Iron deficiency anaemia o Epigastric mass o Suspicious barium meal result  Patients aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone.</p><p>Consider an urgent referral for patients presenting with:  Persistent vomiting and weight loss in the absence of dyspepsia  Unexplained weight loss or iron deficiency anaemia in the absence of dyspepsia  Unexplained worsening of dyspepsia and o Barrett’s oesophagus o Known dysplasia, atrophic gastritis or intestinal metaplasia o Peptic ulcer surgery over 20 years ago.</p><p> Use this proforma to refer urgently (2 Week Wait)</p><p>Investigations in Primary Care:</p><p> When referring, a full blood count may assist specialist assessment in the outpatient clinic. This should be carried out in accordance with local arrangements.  For all patients with new-onset dyspepsia, consider a full blood count to detect iron deficiency anaemia.</p><p>Patient information and support:</p><p>Consider the information and support needs of patients and the people who care for them while they are waiting for the referral appointment. Resources for GPs to use are available from the Cancer Network on 020 7188 7090, or visit our website www.selcn.nhs.uk.</p><p>Approved by the South East London Cancer Network in July 2012 For comments or additional copies contact the Network on Tel 020 7188 7090 / Fax 020 7188 7120, or visit our website: www.selcn.nhs.uk.</p>