Gastroenterology October 2018

Version 1 (4 October 2018)

North West London

Referral Guidance

GASTROENTEROLOGY REFERRAL GUIDELINES These guidelines are intended to replace all existing guidelines for this specialty.

This guidance does not replace any guidance issued in relation to Planned Procedures With a Threshold (PPWT).

Name of Guideline: Gastroenterology referral guidelines

Date of issue: 29/08/2018

Signed off by:

Sign-off by lead Provider

and CCG Clinical Leads.

Named Consultant

Lead:

Dr Ana Wilson Named Primary Care

Lead:

Dr Shantha Sethurajan

Signed:

Ana Wilson Signed:

Shantha Sethurajan

Dated: 29/08/2018 Dated: 29/08/2018

Approved by members

of the Outpatient Board

on:

19/09/2018

Guidelines available

via:

EMIS, SYSTM1,

https://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelines

Version: 1

Date of 6 week review: 19/10/2018

Date of next routine

review:

29/08/2021

https://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelineshttps://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelineshttps://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelineshttps://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelineshttps://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelineshttps://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelineshttps://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelineshttps://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelineshttps://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelineshttps://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelineshttps://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelineshttps://www.healthiernorthwestlondon.nhs.uk/referral-guidelines/xx-emis-guide-accessing-guidelines

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NWL Gastroenterology transformation working group The gastroenterology transformation working group was attended by gastroenterology consultant leads from each NWL Trust, GP clinical leads from each NWL CCG, patient representatives and management staff from the CCGs and Trusts.

Members of the gastroenterology transformation working group are:

Name Position Organisation

Dr Ana Wilson Consultant Gastroenterologist

London NW University Hospitals

NHS Trust

Dr Shantha Sethurajan General Practitioner

Hounslow CCG

Dr Afsana Safa General Practitioner

Central London CCG

Dr Bob Grover Consultant Gastroenterologist The Hillingdon Hospitals NHS Trust

Eimear Finn

Dietetics Lead

Imperial College Healthcare NHS

Trust

Dr Jas Gill General Practitioner Hillingdon CCG

Dr Martin Benson Consultant Gastroenterologist Chelsea & Westminster Foundation

Trust

Dr Mona Vaidya General Practitioner Central London CCG

Dr Pritpal Ruprai General Practitioner Hammersmith and Fulham CCG

Dr Vijay Tailor General Practitioner Ealing CCG

Dr William Howson Consultant Gastroenterologist Imperial College Healthcare NHS

Trust

Dr Evangelos Russo

Consultant Gastroenterologist

Imperial College Healthcare NHS

Trust

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Important notice

This guidance is intended to support general practice. The guidance has been developed after careful consideration of the information and clinical opinion available to the speciality transformation working group, including consultant and GP leads for NW London Trusts and CCGs. Whilst it has been produced with significant input from clinicians, it provides general advice only and does not replace any part of a clinicians responsibility to assess each clinical case on its own merits, when exercising their clinical judgement. The CCG will not, therefore, accept liability for any loss, damage or inconvenience arising as a consequence of any use of or the inability to use any information in this guidance.

This guidance is not intended to be used as a performance management resource.

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Referral guidelines list

1. Dyspepsia

2. Change in bowel habit

3. Abnormal LFTs

4. Hepatitis C

5. Primary Care IBD Management

6. Isolated rectal bleeding

7. Family history of bowel cancer

1. Dyspepsia pathway

Dyspepsia

A group of symptoms that alert doctors to consider disease of the upper GI tract

including:

Upper abdominal pain/ discomfort

Heartburn

Gastric reflux

Nausea or Vomiting

Post-prandial fullness

Early satiation

GORD: Endoscopically determined oesophagitis or non-erosive reflux disease

1. REFERRAL FOR ENDOSCOPY: RED FLAG SYMPTOMS AND SIGNS REFER FOR URGENT ENDOSCOPY

(within 2 weeks).

1. History of non-acute

haematemesis

OR

2. Dysphagia, especially progressive

OR

3. Age >55 and unexplained weight

loss, and any of :

1. Upper abdominal pain

2. Reflux

3. Dyspepsia

If endoscopy reveals concerning

pathology, the patient will be

managed as per local two-week wait

pathway.

OTHER SYMPTOMS

REFER FOR

NON-URGENT ENDOSCOPY

(within 6 weeks):

1. Persistent dyspepsia after PPI

therapy and H.Pylori eradication

AND/OR

a history of any of:

Barretts oesophagus

Intestinal metaplasia

Dysplasia

Recent NSAID use

Previous gastric surgery

Strong family history

2. Raised platelets with nausea or

vomiting.

Lifestyle advice:

Healthy eating, smoking cessation, weight loss, avoidance of common precipitants

(e.g. smoking, alcohol, coffee, chocolate, fatty foods)

Medication review:

NSAIDS, corticosteroids, calcium antagonists, bisphosphonates, nitrates,

theophyllines and SSRIs

Test for H. Pylori:

Stool antigen testing

Empirical full-dose PPI:

for 4 weeks for people with dyspepsia

4 8 weeks for reflux

Eradicate H. Pylori:

Two weeks of triple therapy.

N.B. No routine re-testing is recommended: only re-test eradication according to

PHE guidelines (see link).

If dyspepsia recurs off PPI, identify minimum effective maintenance dose

(including prn strategies)

Long term, full dose PPI post oesophageal stricture dilatation or

severe oesophagitis

Consider H2 blocker treatment if refractory to PPI

2. MANAGEMENT IN PRIMARY CARE:

1. Persistent symptoms and failure to eradicate H. Pylori

2. When oesophageal physiologic testing is contemplated

(e.g prior to Nissens fundoplication)

3. REASONS TO REFER TO SECONDARY CARE

See also:

1. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management Published

September 2014, NICE guideline CG184.

www.nice.org.uk/guidance/cg184/

2. PHE Test and Treat Helicobacter pylori in dyspepsia:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/633673/Helicob

acter_pylori_Quick_Reference_Guide.pdf

3. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults:

https://www.cag-acg.org/images/publications/Hp_Toronto_Consensus_2016.pdf

NW London Gastroenterology Referral Guidance -Version1.0 4 October 18

http://www.nice.org.uk/guidance/cg184/https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/633673/Helicobacter_pylori_Quick_Reference_Guide.pdfhttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/633673/Helicobacter_pylori_Quick_Reference_Guide.pdfhttps://www.cag-acg.org/images/publications/Hp_Toronto_Consensus_2016.pdfhttps://www.cag-acg.org/images/publications/Hp_Toronto_Consensus_2016.pdfhttps://www.cag-acg.org/images/publications/Hp_Toronto_Consensus_2016.pdf

Any RED FLAG / HIGH risk features (listed

below)?

Any age with suspicious abdominal or

rectal mass

Any age with unexplained anal mass or

ulceration

40 years with unexplained abdominal

pain and weight loss

40 years with unexplained iron deficiency

anaemia

50 years with rectal bleeding with any of

the following unexplained symptoms:

Abdominal pain

Change in bowel habit

Weight loss

Iron deficiency anaemia

50 years with unexplained rectal bleeding

50 years with unexplained abdominal

pain or weight loss

50 years with unexplained change in

bowel habit

60 years with unexplained anaemia even

in the absence of iron deficiency

REFER via

2WW

No

Yes

2. Change in bowel habit pathway

PROBABLE IBS

If no red flags and all tests normal PAT