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

3

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

4

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 clinician’s 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.

4

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:

• Barrett’s 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 Nissen’s 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

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 PATIENT IS

GIVEN POSITIVE DIAGNOSIS OF IBS

In due course direct referral to dietician services

can be considered as first line in primary care

• Education and Reassurance

• Lifestyle advice:

• Dietary Advice (NICE diet, FODMAP

information via Food Maestro app and

dietetics referral)

• Exercise

• Psychological support

• Pharmacological treatments

• Antispasmodics (e.g. mebeverine,

pepermint oil capsules)

• Aperients/anti-diarrhoeal agents

• Normacol (not Lactulose)

• Loperamide

• Low dose Tricyclic antidepressants or

SSRIs

(e.g. Amitriptyline, Sertraline)

- If diarrhoea predominant IBS then consider

earlier referral to secondary care for exclusion

of microscopic colitis and bile salt mal-

absorption.

FCP negative <50

HIGHER

PROBABILITY

OF ORGANIC

PATHOLOGY

Refer to Gastroenterology / Direct to Test

as appropriate

FCP 50-150

REPEAT TEST

AFTER 4 WEEKS.

• If FCP negative

(<50) manage as

per ‘Probable

IBS’.

• If still

indeterminate

or positive and

symptoms

persist then

REFER for

consultation

FCP Test Result

FCP positive >150

If non-responsive

See also:

1. Irritable bowel syndrome in adults: diagnosis and management (2008 updated 2017)

NICE guideline CG61

https://www.nice.org.uk/Guidance/CG61

2. ROME IV Criteria Lacy, B.E. et al Bowel Disorders Gastroenterology 2016;150:1393–

1407

American College of Gastroenterology Task Force on Irritable Bowel Syndrome, Brandt

LJ, Chey WD, et al. An evidence-based position statement on the management of irritable

bowel syndrome. Am J Gastroenterol 2009; 104 Suppl 1:S1.

3. Food Maestro app for FODMAP: (patient resource, in conjunction with dietetics

referral): http://foodmaestro.me/fodmap-app/

INVESTIGATE IN PRIMARY CARE

• History and clinical examination including PR

exam.

• Faecal Calprotectin (FCP) Test: see across for

result interpretation

• NB. stop any NSAIDs 4 weeks prior

to FCP testing

• Bloods:

1. FBC (for anaemia, refer if indicated)

2. ESR /CRP (for inflammation)

3. Thyroid function test

4. Bone profile tests

5. Anti tTG (for coeliac disease)

If diarrhoea-predominant symptoms, also include:

• Stool MC&S and CDT

• LFTs

• Ca

• B12

• Folate

• Fe status

• Consider FIT

test

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

Consider doing LFTs

• If sx of liver/bile system disease, eg. abdo

pain/nausea/vomiting/jaundice

• Pt drinks excessively

• Pt taking medication that affects the liver

• Pt has diabetes

• Obesity

• GGT – useful in cholestasis or monitoring

changes in alcohol consumption

Check previous tests to

confirm new finding. If

new, repeat fasting

sample: LFTs,

conjugated bilirubin and

FBC

Isolated rise in bilirubin

with other normal LFTs

No anaemia Anaemia

PROBABLE

GILBERTS

SYNDROME:

Inform patient and

provide information

HAEMOLYSIS

SCREEN:

• Haptoglobins

<200

• LDH

• Reticulocyte

count

If abnormal, refer

to haematology

Isolated rise in Alk Phos

Repeat fasting sample:

including Gamma GT,

AST and FBC

Normal

Gamma GT

Raised

Gamma GT

CONSIDER BONE

AETIOLOGY:

• Vitamin D

deficiency

• Pagets disease

LIVER SCREEN

• Ultrasound liver

• Liver test panel:

• Hepatitis B & C

• Autoantibodies

• Ferritin / Transferrin saturation

• Caeruloplasmin

• Immunoglobulins

• FBC

• TFTs

• Albumin

• HbA1c, Lipids, Fasting Glucose

• Alpha Fetoprotein

• Coeliac screen

Raised ALT

ALT >300 IU/L

ALT <300 IU/L

SEEK

TELEPHONE

ADVICE AND

CONSIDER

URGENT TESTS

Repeat fasting sample:

including Gamma GT,

AST and FBC

Consider HCV and HBV

If alcohol consumption

>14 units/wk, then

consider referral to

alcohol services

If abnormal

Normal liver screen Fatty liver

demonstrated

Abnormal liver

screen

MANAGE IN PRIMARY CARE:

Lifestyle advice

Repeat LFTs in 1 year

CONTINUE TO FATTY

LIVER GUIDELINE

REFER TO LIVER SPECIALIST

FOR POSSIBLE:

• Viral hepatitis

• ALD with advanced fibrosis

• PSC, PBC, autoimmune

hepatitis

• Gallstone disease

• Hepatic vascular disorders

• Hepatic metabolic disorders

3a. Abnormal Liver Function Test Pathway GP receives abnormal LFTs

• History and examination with attention to alcohol consumption, metabolic syndrome, BMI, hepatotoxic drugs and risk factors for viral hepatitis

2WW

REFERRAL IF

HEPATIC OR

BILIARY

MALIGNANCY

SUSPECTED

Raised Bilirubin AND

raised Alk Phos / ALT

No Jaundice Jaundice

IMMEDIATE

REFERRAL TO

ACUTE

MEDICAL

ASSESSMENT.

Request liver

screen but do

not await

result.

URGENT

REFERRAL TO

HEPATOLOGY /

GASTRO

CLINIC

(depending on

local

circumstance)

Request liver

screen but do

not await result.

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

3b. Fatty liver pathway

Fatty liver suggested on

ultrasound AND/OR liver

test panel negative for

other pathology

Fatty liver suggested on

ultrasound AND/OR liver

test panel negative for

other pathology

Fatty liver suggested on

ultrasound WITH

EXCESS ALCOHOL

CONSUMPTION (>14

units/week)

Calculate NAFLD Score:

http://www.nafldscore.com/

≤ -1.445

Low risk of

advanced

fibrosis

≥ -1.445

High risk of

advanced

fibrosis

PRIMARY CARE MANGEMENT OF FATTY

LIVER:

• Is part of metabolic syndrome / CVD risk

factor

• Assess cardiovascular risk and treat:

• Cholesterol – QRISK and consider

statin

Can still initiate statin if ALT raised

due to fatty liver

• Diabetes

• Alcohol

• Hypertension

• Weight loss

ANNUAL REVIEW OF LFTs and

REASSESS NAFLD SCORE IF LFTs STILL

ABNORMAL

REFER TO SECONDARY CARE:

• For assessment of liver disease

• For management of advanced fibrosis

• Screening and treatment of portal

hypertension

• HCC screening and management

Counsel to stop drinking

+ Consider referral to

alcohol services.

Manage in primary care.

Consider referral to

secondary care for

persistently abnormal

LFTs.

Re-assess risk

annually if LFT

abnormalities persist

Once alcohol issue

addressed

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

4. Hepatitis C pathway

It is estimated that around 217,000 people are infected with Hepatitis C in

the UK and around 50% do not have a diagnosis.

• People infected with HCV are often asymptomatic.

• Many people who are chronically infected will experience non-specific

symptoms including malaise, weakness and anorexia.

• Clinical features are worse if there is a high alcohol intake or other liver

disease.

See also:

1. Professional link: http://patient.info/doctor/hepatitis-c-pro

2. Patient link: http://patient.info/health/hepatitis-c-leaflet

PRIMARY CARE MANAGEMENT ALGORITHM FOR INCIDENTAL OR

POST SCREENING FINIDNGS OF POSITIVE HEPATITIS C ANTIBODY

HCV antibody

positive

Has the patient

ever had HCV

RNA test

No

Request HCV

RNA

HCV RNA

Negative

HCV RNA

Positive

HCV RNA

Negative

Repeat test at

6 month

interval

Refer with

results to Liver

clinic

HCV RNA

Negative

Yes

One negative

test

Two negative

tests greater

than 6 months

apart

Repeat test at

6 month

interval

Tell patient that they have had Hepatitis

C in the past that it has been cleared

and they are negative, non-infectious

and will not have future problems. Give

the patient copy of the results so that

they are not repeated in the future. NW London Gastroenterology Referral Guidance -Version1.0 4 October 18

5. Primary Care IBD management guidance • This guideline applies to patients with an established diagnosis of IBD (Crohns

Disease (CD) or Ulcerative Colitis (UC)).

• The majority of IBD patients should be under joint primary/secondary care.

• Azothioprine/6MP, Methotrexate, Infliximab and adalimumab should only

be started by a specialist.

Clinical History

• GI symptoms: Stool frequency and consistency, rectal bleeding, abdominal pain

• Extra-intestinal manifestations: Skin, Joints, Eye

• General wellbeing: Malaise, fever, weight loss

• Drug History

• Smoking

• Recent travel history

Examination

• Basic Observations : Pulse, Blood Pressure, Temperature, Weight

• Hydration status + Pallor

• Abdominal exam (distension, tenderness, palpable masses) and perineal/DRE

examination (for fissure/fistula, PR bleeding)

Investigations

• Bloods: FBC, U&E, CRP

• Stool:

• Microscopy, culture and sensitivity

• Clostridium difficile toxin. (to exclude an infective aetiology)

1. HISTORY AND INVESTIGATIONS:

3. PRIMARY CARE MANAGEMENT OF IBD:

2. CLASSIFICATION OF IBD SEVERITY

Mild Moderate Severe

Ulcerative Colitis

• < 4 stools daily, +/- blood

• No systemic disturbance

• Normal ESR and CRP

• 4 – 6 stools a day • Minimal systemic

disturbance

• > 6 stools daily, containing blood

• Systemic disturbance

(fever, tachycardia, anaemia, hypoalbuminaemia)

Crohns Disease

• < 4 stools daily, • No / minimal abdo

pain • Systemically well

• 4 – 6 stools a day • Mild abdo pain • Minimal systemic

disturbance

• > 6 stools daily, containing blood

• Moderate/ severe abdominal pain

• Systemic disturbance

(fever, tachycardia, anaemia, hypoalbuminaemia)

MILD ULCERATIVE COLITIS:

Patient to contact IBD nurse prior to initiating treatment

1. Increase mesalazine to maximal therapeutic dose

2. Add mesalazine enema as appropriate

3. If proctitis, add 5-ASA suppositories

4. If persistent symptoms at 2 week review, consider initiating reducing dose regimen of Prednisolone:

5. If symptoms continue, refer for specialist review.

MILD CROHNS DISEASE:

Patient to contact IBD nurse prior to initiating treatment

1. Consider a course of oral Budesonide (Budenofalk or Entocort), for small bowel disease, 9mg OD for 8

weeks, tapering dose over 2 weeks (6mg then 3 mg – one week on each dose) or over 4 weeks (two

weeks on each dose) to zero.

2. Consider initiating reducing regimen of Prednisolone.

3. Review at 2 weeks, for persistent symptoms or further flare on reducing/cessation of steroids or

recurrent steroid courses required (>2 courses in 6 months), REFER for specialist review.

NOTES ON CORTICOSTEROID USE

- Ensure stool cultures are negative before prescribing

- Reducing regimen:

- Commence Prednisolone at 40mg po od

- Reduce by 5 mg per week

- Budesonide has lower potency than Prednisolone but has significantly fewer systemic side

effects. It is therefore generally better tolerated and longer courses can be prescribed.

- Warn patients of potential side effects of steroids:

- impaired diabetic control, weight gain, moon face, insomnia, labile mood and, rarely,

psychosis

- Steroids should not be used for maintenance therapy. If patient requires more than 2 courses in 6

months , REFER for specialist review.

MODERATE ULCERATIVE COLITIS:

Contact IBD nurse prior and expedite clinic review

1. Increase mesalazine to maximal therapeutic dose

2. Consider interim course of oral corticosteroid:

MODERATE CROHNS DISEASE:

Contact IBD nurse prior and expedite clinic review

1. Consider interim course of oral corticosteroid:

SEVERE ULCERATIVE COLITIS OR SEVERE CROHNS DISEASE:

CONTACT IBD TEAM TO CONSIDER URGENT ADMISSION

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

6. Isolated rectal bleeding pathway The vast majority of patients with isolated rectal bleeding will have benign

disease (e.g. haemorrhoidal bleeding).

Common causes of rectal bleeding:

• haemorrhoids

• anal fissure

• fistula in ano

• diverticular disease

• inflammatory bowel disease

Most patients with colorectal cancer will not have rectal bleeding.

Clinical History

• The quantity and nature of bleeding

• Quantity is very difficult to assess from the history but it is

important to get a description from the patient (e.g. egg-cup,

mug-full, bowl-full)

• Fresh bright red blood noticed on the toilet paper is usually from

a perianal source (e.g. haemorrhoids, fissures)

• Blood mixed in with the stool has usually originated higher in the

GI tract.

• Change in bowel habit (both frequency of defecation and consistency

of stool) must be noted.

• Tenesmus

• Anal symptoms (eg. soreness, itching or prolapse, occur often with

piles)

• Progressive unintentional weight loss

• Drug History (including warfarin , aspirin, clopidogrel and DOACs)

• Family history of bowel cancer or polyposis

Examination

• Abdominal exam

• DRE (check for haemorrhoids, tags, fissures, rectal mass)

Investigations

• Bloods:

• FBC

• Ferritin

(Carcinoembryonic antigen (CEA) is not sufficiently sensitive or specific

test for general population bowel cancer screening and should not be used)

1. HISTORY AND INVESTIGATIONS:

Suspected haemorrhoids

Symptoms are pain and/ or bleeding.

• Painful symptoms – Should be treated with an over the counter haemorrhoid cream and

suppositories.

• Bleeding – treat constipation, requires dietary and lifestyle modification e.g. fibre and fluids advice

see external resources (below).

If symptoms persist for 4 weeks despite treatment, refer for flexible sigmoidoscopy via direct

access or local protocol.

Suspected Anal Fissure

1. Examine to confirm diagnosis

2. Stool bulking agents and softener

3. Glyceryl trinitrate 0.4% rectal ointment applied to the anus BD for 6 weeks on a daily basis. Approx.

70% heal in this time; The glyceryl trinitrate headache usually settles after two to three days.

4. If cannot tolerate glyceryl trinitrate (can’t stand the headaches, BP issues or pregnant) then 2%

Diltiazem ointment – same treatment regimen as above.

If symptoms persist for >6 weeks despite treatment above, refer to colorectal surgery for further

management.

Prolapse

• Nothing works other than surgery

• Give the normal advice regarding time spent on toilet and straining (see external resources)

2. PRIMARY CARE MANAGEMENT OF ISOLATED RECTAL BLEEDING:

See also:

• Rectal Bleeding PIL (patient advice): http://patient.info/doctor/rectal-bleeding-in-

adults

• Anal fissure (patient advice): http://patient.info/health/anal-fissure

• Haemorrhoids (patient advice): http://patient.info/health/piles-haemorrhoids

• Rectal prolapse (professional advice): http://patient.info/doctor/rectal-prolapse

• Bowel Habit, Fibre and Fluids: http://www.westmidcolorectal.org.uk/docs/faf.php

• Haemorrhoids: http://www.westmidcolorectal.org.uk/docs/pph.php

SUSPECTED CANCER SECONDARY CARE REFERRAL (TWO WEEK WAIT) 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

EMERGENCY ADMISSION:

• Profuse, continuous rectal bleeding

• Severe abdominal pain associated with rectal bleeding

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

7. Family history of bowel cancer pathway Of an average population:

• up to 9% will have at least one first degree relative (FDR e.g. sibling, parent or child)

• over 20% will have at least one second degree relative (SDR e.g. Grandparent, uncles, aunts,

half siblings) with bowel cancer.

For the majority of these, there is no proven benefit for increased surveillance above that of the

rest of the population (National Bowel Cancer Screening Programme, NBCSP).

However a significant proportion may benefit from outpatient assessment for screening

interventions and/or genetic testing.

Information about the NBCSP for GPs, including referral guidelines, is contained in the link below.

They may be offered lifestyle modification advice in addition to reassurance. Lifestyle

interventions proven to reduce risk of bowel cancer include:

• Weight loss (if obese) to achieve a normal BMI

• Regular physical activity

• Diet: High fibre, low red meat, 5 pieces of fruit & veg per day

• Smoking cessation

• Moderate or low alcohol consumption (any alcoholic beverage)

2. MANAGEMENT IN PRIMARY CARE:

1. Moderate risk groups should be referred for assessment for screening from the age of

50 years onwards and not before in the absence of other indications.

• 1 FDR under age 50 years at diagnosis.

• ≥ 2 FDRs any age.

• 1 FDR and 1 SDR same side of the family any age.

2. High risk groups should be referred at any age.

They account for approximately 5% of all bowel cancer.

• 3 FDR with bowel cancer - one diagnosed under age 50 (e.g. Lynch syndrome or

Hereditary non-polyposis colorectal cancer (HNPCC)).

• A family history with multiple affected members in more than one generation

• A previously characterised high risk patient or relative (i.e. with a known cancer

syndrome such as Familial Adenomatous Polyposis Coli (FAP)) not currently

undergoing surveillance.

• The presence of a germline pathogenic mutation in a colorectal cancer susceptibility

gene if previously tested.

3. REASONS TO REFER TO SECONDARY CARE (GASTROENTEROLOGY)

See also:

1. BSG and ACPGBI Guidelines:

https://www.bsg.org.uk/resource/bsg-acpgbi-guidelines-for-colorectal-cancer-screening-

and-surveillance-in-moderate-and-high-risk-groups--update-from-2002--.html

2. Bowel Cancer Screening Programme (BCSP) information pack for GPs:

https://www.gov.uk/government/collections/bowel-cancer-screening-commission-provide-

inform

3. NICE Colorectal guidelines:

https://www.nice.org.uk/guidance/csg5

4. Patient information:

https://be.macmillan.org.uk/be/p-686-are-you-worried-about-bowel-cancer.aspx

https://www.cancerresearchuk.org/about-cancer/bowel-cancer/risks-causes#famhist

Clinical history

• Full family history

• details of relationships to the patient of all family members diagnosed with bowel cancer

and their age at diagnosis

• details of any other (extracolonic) cancer(s) of all family members (including relationship to

patient, site of cancer and age of diagnosis)

• Specific details of previous genetic testing (with written documentation if possible)

• Patients other risk factors

• Age

• Gender

• BMI

• Physical activity

• Diet

• Smoking and alcohol consumption

• Symptoms: often these patients are asymptomatic, but consider any alarm symptoms and

refer irrespective of family history, according to NICE referral guidelines

• Abdominal mas

• PR bleeding

• Change in bowel habit

• Progressive unintentional weight loss

Examination

• Abdominal examination + DRE (for any palpable mass)

• Superficial lesions: including naevus, buccal pigmentation etc.

Investigations

• Bloods (?Iron Deficiency Anaemia)

• FBC

• Ferritin

Low risk groups (many of these patients may seek reassurance, but do not require screening

above and beyond the rest of the population), according to national guidelines.

• 1 FDR over age 50 years at diagnosis.

• 2 SDRs

• Family history of any relative with < 10 polyps found on colonoscopy.

1. HISTORY AND INVESTIGATIONS:

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