XX FAMILY HEALTH TEAM Medical Directive #PA-8 Title and Number of Directive: Order Table PA-8: Gastroenterology This table cannot be relied upon in the absence of: PA Medical Directive #8 - Gastroenterology 1. OVERALL CONDITIONS - The PA may evaluate and provide care for patients presenting with the following new or ongoing conditions: o Infectious . Acute gastroenteritis . Helicobacter pylori infection . Traveller’s diarrhea . Clostridium difficile infection o Diseases of esophagus: . Gastroesophogeal reflux disease (GERD) . Esophageal dysmotility o Diseases of stomach: . Gastritis . Duodenitis . Delayed gastric emptying . Peptic ulcer disease o Diseases of small intestine and colon: . Diarrhea . Constipation . Malabsorption . Small bowel obstruction . Crohn’s disease . Ulcerative colitis . Irritable bowel syndrome . Diverticular disease . Colonic polyps o Diseases of rectum and anus: . Anorectal abscess . Anal fissure . Hemorrhoids 1 XX FAMILY HEALTH TEAM Medical Directive #PA-8 o Diseases of appendix and pancreas: . Appendicitis . Pancreatitis o Diseases of biliary tract: . Cholecystitis . Cholelithiasis o Miscellaneous conditions: . Hernias . Lactose intolerance . Celiac disease . Neonatal jaundice o GI symptoms: . Diarrhea, constipation, abdominal pain, abdominal bloating, flatulence, belching, nausea, vomiting, dysphagia. - Directives for Periodic Health Exam apply, with adaptations as identified in this order table. - PA will discuss patient status and care with the physician on an ongoing basis as identified in the Practice Outline, and as necessary. Guidelines: - Anti-infective Guidelines for Community-acquired Infections, 2012 edition. - Canadian Association of Gastroenterology Clinical Practice Guidelines, www.cag-acg.org/guidelines - Compendium of Pharmaceuticals and Specialties, 2012. Orders Indications and Contraindications. 2. HISTORY AND PHYSICAL EXAMINATION - The PA may complete a focused history based on presenting condition. o History of present illness. o Pertinent past medical history. - Focused physical exam may include: o Vital signs. o Growth in children. 2 XX FAMILY HEALTH TEAM Medical Directive #PA-8 o ENT. o Respiratory system. o Cardiovascular system. o Abdominal exam. 3. COUNSELING - Dietary counseling where indicated. - Lifestyle modification as appropriate. - Smoking cessation if applicable. - Environmental factors if contributory. - Supportive therapy as appropriate. - Education regarding condition. 4. LABS AND INVESTIGATIONS - The PA may order any of the following labs as necessary: o CBC. o TSH. o Electrolytes. o Renal function (creatinine, BUN, A:Cr). o Liver function tests (AST, ALT, alk phos, GGTT, bilirubin). o Pancreatic enzymes (lipase, amylase). o Lactic acid. o Serum albumin. o ESR, hs-CRP. o PT, PTT, fibrinogen. o H pylori serology. o Hepatitis viral serology. o Alcohol/drug screen. 3 XX FAMILY HEALTH TEAM Medical Directive #PA-8 Stool culture Indications: - Bloody diarrhea. - Fever. - Tenesmus. - Severe or persistent symptoms. - Recent travel to a third world country. - Known exposure to a bacterial agent. - Presence of fecal leukocytes. Fecal occult blood Indications: - Detection of gastrointestinal bleeding. - Screening test for bowel cancer. Fecal leukocytes Indications: - Assist in the differential of diarrhea disease. - Fecal leukocytes may indicate the following: o Bacteria that invade the colonic mucosa. o Ulcerative colitis. o Antibiotic colitis. o Pseudomembranous colitis. Stool sample for ova & parasites Indications: - Establish the diagnosis of intestinal parasitic infestation or infection. Clostridium difficile toxins Indications: - Determine presence of toxins produced by C diff. 4 XX FAMILY HEALTH TEAM Medical Directive #PA-8 Upper gastrointestinal series Indications: - Evaluation of the gastrointestinal tract for the following: o Presence of neoplasms. o Inflammatory diseases. o Ulcers. o Diverticula. o Obstruction. o Foreign body. o Hiatal hernia. o Gastroesophageal reflux. Abdominal x-ray series Indications: - Assessment of intestinal obstruction. - Location of foreign bodies, free peritoneal or retroperitoneal air. - Displacement of the gastric air bubble. - Elevation of diaphragm. - Displacement of the lateral and pelvic fat lines. - Disturbance of normal bowel patterns and renal shadow. Abdominal ultrasound Indications: - Presence of neoplasms, cystic lesions, enlarged lymph nodes, bile ducts, abdominal abscesses, pancreatic mass or pseudocysts, gallbladder calculi, or any malignancies. Abdominal CT scan Indications: - In consultation with supervising physician. - Diagnosing abdominal disease. - Investigating acute abdomen. 5 XX FAMILY HEALTH TEAM Medical Directive #PA-8 5. IMMUNIZATIONS - In accordance with PA Medical Directive #1 – Guidelines: Periodic Health Exam. - Canadian Immunization Guide – Seventh Edition 2006. 6. THERAPEUTICS Antibiotics Indications: - The PA may prescribe the following antibiotics: - Infectious gastroenteritis.* o Amoxicillin. - Helicobacter pylori infection.* o Azithromycin. - Traveller’s diarrhea.* o Ciprofloxacin. - Clostridium difficile.* o Clarithromycin. o Levofloxacin. * Not all antibiotics apply to all conditions, appropriate guidelines shall be utilized. o Metronidazole. o Norfloxacin. Contraindications: o Ofloxacin. - As per individual medication guidelines in CPS. Histamine H2 antagonist Indications: - The PA may prescribe the following histamine H2 - Short-term treatment of active ulcers. antagonists: - Duodenal ulcer prophylaxis o Cimetadine. - Gastric hypersecretory conditions o Famotidine. - GERD o Ranitidine. - Peptide ulcer disease. Contraindications: - As per individual medication guidelines in CPS. 6 XX FAMILY HEALTH TEAM Medical Directive #PA-8 Proton pump inhibitors Indications: - The PA may prescribe the following proton pump - Erosive esophagitis. inhibitors: - Nonerosive reflux disease. o Esomeprazole. - Symptomatic GERD. o Lansoprazole. - Helicobacter pylori eradication. o Omeprazole. - Prevention/treatment of NSAID-induced ulcers. o Pantoprazole. - Duodenal ulcers. o Rabeprazole. - Gastric ulcers. - Hypersecretory conditions. Contraindications: - As per individual medication guidelines in CPS. Topical corticosteroids Indications: - The PA may prescribe the following topical - Hemorrhoids. corticosteroids: - Anal itching. o Hydrocortisone cream. Contraindications: - As per individual medication guidelines in CPS. Antidiarrheal agents Indications: - The PA may prescribe the following antidiarrheal - Acute diarrhea. agents: - Chronic diarrhea. o Bismuth - Traveler’s diarrhea. o Loperamide. - Helicobacter pylori eradication (bismuth only). Contraindications: - Avoid loperamide as primary therapy in patients with the following: o Acute dysentery. o Acute ulcerative colitis. 7 XX FAMILY HEALTH TEAM Medical Directive #PA-8 o Bacterial enterocolitis. o Pseudomembranous colitis associated with broad-spectrum antibiotic use. Contraindications: - As per individual medication guidelines in CPS. Laxatives Indications: - The PA may prescribe the following laxatives: - Constipation. o Bowel evacuant: - Bowel preparation before colonoscopy (polyethylene glycol and sodium phosphates . Polyethylene glycol-electrolyte only). solution and bisacodyl. Sodium phosphates. Contraindications: o Bulk-producing laxatives (fiber - As per individual medication guidelines in CPS. supplements): . Methylcellulose. Polycarbophil. Psyllium. Wheat dextrin. o Lubricant laxatives: . Mineral oil. o Osmotic laxatives: . Glycerin. Lactulose. Polyethylene glycole 3350. Sorbitol. o Saline laxatives: . Magnesium citrate. o Stimulant laxatives: . Bisacodyl. Docusate and senna. Senna. o Miscellaneous: 8 XX FAMILY HEALTH TEAM Medical Directive #PA-8 . Castor oil. Magnesium hydroxide. Stool softeners Indications: - The PA may prescribe the following stool - Stool softener. softeners: o Docusate. Contraindications: o Docusate and senna. - As per individual medication guidelines in CPS. Antispasmodic: Indications: - The PA may prescribe the following - Gastrointestinal spasm. antistpasmodics: o Scopolamine butylbromide. Contraindications: - As per individual medication guidelines in CPS. 7. REFERRALS - The PA may make a referral to the Family Health Team as appropriate. - The PA may make a referral for endoscopy in consultation with supervising physician. - The PA may make referrals to gastroenterology specialists in consultation with supervising physician. 9 XX FAMILY HEALTH TEAM Medical Directive #PA-8 9. ABSENTEE NOTES The PA may write absentee notes as appropriate. 10 .