University Medical Center at Brackenridge. Gastroenterology Clinic Worksheet
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1 Gastroenterology Clinic Worksheet 1. GI Bleeding (occult or symptomatic) a. CBC b. Iron, Ferritin b. Medication history 2. Iron Deficiency Anemia and no evident source (if no iron deficiency consider hematological evaluation prior to GI referral) a. CBC b. Iron, TIBC or Ferritin c. Stool hemoccult. 3. Abnormal Liver Tests [LFTs First assess alcohol use and review medication causes a. Abnormal LFTs on 2 sets of results at least 6 weeks apart b. Abdominal liver ultrasound c. Ferritin, Iron, TIBC d. Acute Viral hepatitis panel 4. Cirrhosis a. CBC, PT/INR, CMP b. Acute Viral Hepatitis Panel, hepatitis A antibody total, Hepatitis B surface antibody total, and Hepatitis B core antibody total. c. Abdominal/liver ultrasound d. Documentation of ETOH history e. Document Hepatitis A and B vaccination according to serologies. (Do not exclude patient if this is not included but other materials are present.) f. Recommend Flu/Pneumovax. Pg.25
2 5. Hepatitis C Antibody Positive [HCV Ab +] Check the following and refer to GI if HCV is present by PCR. a. HCV RNA PCR quantitative & genotype b. CMP, CBC, HIV antibody c. Hepatitis A total antibody d. Hepatitis B surface antigen, surface antibody, core total antibody e. Abdominal/ liver Ultrasound 6. Hepatitis B Surface Antigen Positive [HBSAg +] Check the following and refer if HBV is present by PCR. a. HBV DNA PCR quantitative b. Hepatitis B surface antigen, surface antibody, e antigen and e antibody c. CMP, CBC, HIV antibody d. Hepatitis A total antibody e. Hepatitis C antibody f. Abdominal/liver Ultrasound 7. Inflammatory Bowel Disease a. Previous History b. Most recent endoscopy and colonoscopy reports c. Pathology reports. d. LFTs, CBC, CMP e. Recommend Pneumovax vaccination f. Document Hepatitis A and B vaccination according to serologies. (Do not exclude patient if this is not included but other materials are present.) g. Recommend flu shot (Must check the type of IBD therapy that the patient is getting before flu shot). Pg.26
3 8. Family History of Colon Polyps or Cancer [any age] Refer to GI Clinic if 1st degree family history- Age and what relative, 10 years of diagnosis of relative 9. Chronic Diarrhea (> 3 weeks duration) (refer to GI Clinic for any 1 or more of the following): I. Diagnostic uncertainty despite history, physical examination, and laboratory testing including: a. CBC, CMP and sedimentation rate b. Stool C&S, O&P X3 c. C. difficile toxin d. Stool WBCs e. HIV f. Thyroid studies g. Fecal occult blood X 3 If appropriate clinical history: Celiac panel, Qualitative Fecal fat. Giardia antigen, cyclospora, microspora, cryptosporidium. II. History or findings suggestive of malabsorption, or colonic or terminal ileal disease III. Previous surgery involving extensive resection of ileum, right colon, bypass procedures, or cholecystectomy 10. Abdominal Pain (refer to GI Clinic for any 1 or more of the following): I. Diagnostic or therapeutic uncertainty after evaluation, including ALL of the following: a. Laboratory testing (CBC, CMP, serum amylase, serum lipase, urinalysis, urine pregnancy test) b. Noninvasive imaging studies (plain x-rays, ultrasonography, and/or computed tomography) Pg.27
4 II. Abdominal pain in special populations, including 1 or more of the following: a. Patients > 50 years old b. HIV-positive patients c. Immunosuppressed patients 11. Dysphagia Get ESOPHAGRAM on all patients 12. Dyspepsia (refer to GI Clinic for any 1 or more of the following): a. Persistent symptoms despite negative H. pylori stool antigen or Urea Breath test testing and 4 week PPI trial b. Persistent symptoms despite positive Helicobacter pylori stool antigen or Urea Breath test testing and eradication therapy. The Urea Breath test is a good option instead of the stool antigen with the following precautions: Patient must fast at least one hour prior to testing The patient should not take: Antimicrobials within 4 weeks prior to testing. Proton pump inhibitors or bismuth preparations within 2 weeks prior to testing. H2 antaganist within 3 days prior to testing. Phenylketonuria patients should not have Urea breath test. Wait a minimum of 4 weeks following treatment prior to Urea Breath testing-because of false negative results. c. Patients with 1 or more of the following: Involuntary weight loss Gastrointestinal bleeding Dysphagia Odynophagia Pg.28
5 Unexplained iron-deficiency anemia Persistent vomiting Palpable mass or lymphadenopathy Jaundice Family history of upper gastrointestinal cancer Patients 50 years of age or older 13. Gastroesophageal Reflux Disease (GERD) (refer to GI Clinic for any 1 or more of the following): a. Symptoms of heartburn or regurgitation that have not responded to 8 week PPI trial b. Symptoms of laryngeal origin (eg, dyspnea, cough, hoarseness) that have not responded to 8 week PPI trial c. Suspected complicated GERD, as indicated by 1 or more of the following: Dysphagia Odynophagia Bleeding Weight loss Early satiety Choking Anorexia Frequent vomiting d. Symptoms of GERD that have lasted longer than 5 years 14. Chronic Constipation a. Documentation of fiber, laxatives, stool softeners tried b. Acute bowel habit change c. List of medications d. TSH Pg.29
6 e. Serum Calcium f. CBC 15. Suspected Gastroparesis FOUR HOUR Gastric Emptying Study Revised May 2015 Pg.30
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