REFERRAL GUIDELINES Upper Gastro-Intestinal & Hepaticobilary

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1 REFERRAL GUIDELINES Upper Gastr-Intestinal & Hepaticbilary Referral Frm: The GP Referral Template is the preferred referral tl (previusly knwn as the Victrian Statewide Referral Frm) GP Referral Template This tl is hused in mst majr clinical sftware r can be dwnladed frm Click n categry t advance t that page: Upper Gastr-Intestinal Oesphageal Cancer Peptic Ulcer Disease Gastr-Oesphageal Reflux Disease (GORD) Hiatus Hernias Achalasia Hyperplenism Hepatic-bilary Liver Cancer Jaundice Obstructed Jaundice Gallstnes Gallbladder Plyps IMPORTANT: The fllwing infrmatin is required: Demgraphic: Date f birth Cntact details (incl. mbile) Referring GP details Usual GP (if different) Interpreter requirements Clinical: Reasn fr referral Duratin f symptms Management t date and respnse t treatment Relevant pathlgy and imaging reprts (please refer t specific guidelines) Past medical histry Current medicatins and medicatin histry if relevant Functinal status Psychscial histry Dietary status Services nt prvided Liver Transplant Family histry Diagnstics as per referral guidelines PLEASE NOTE: All referrals received by Mnash Health are triaged by clinicians t determine urgency f referral. Patients assessed as having an urgent need are ffered an appintment within thirty days as assessed by the clinician. Patients assessed as having a nn-urgent need fr appintments in clinics where there is n waiting list, are ffered an appintments within fur mnths n a treat in turn basis. Patients assessed as having a nn-urgent need fr appintments in clinics that have a waiting list, referrers and patients will be ntified f the expected wait times. Where the wait time des nt meet patient needs, alternative service prviders can be fund by searching the Human Services Directry at HEAD OF UNIT Mr. Paul Cashin PROGRAM DIRECTOR Mr. Alan Saunder OUTPATIENT ENQUIRIES (Access Unit) P: F: (03) Review: Dec

2 Upper Gastr - Intestinal Oesphageal Cancer Dysphagia, dynphagia LOW Haematemisis r malaena FBE, irn studies Gastrscpy & bipsy Cmmence PPI Ensure adequate nutritin (supplements) After initial wrk -up Peptic Ulcer Disease Dyspepsia nt relieved after cmmencing PPI Alarm symptms Dysphagia LOW Palpable mass Haematememis r malaena Gastrscpy & bipsy H. Pylri breath test Cmmence PPI Eradicatin therapy fr H. Pylri if present Prven gastric/ dudenal ulcer n gastrscpy Gastr-Oesphageal Reflux Disease (GORD) Heartburn/ dyspepsia nt relieved by PPI Atypical symptms; cugh, asthma, recurrent chest infectins, halitsis, harse vice, pr dental hygiene Alarm symptms Dysphagia LOW Haematemisis r malaena Mass Evidence f cmplicatins: Oesphagitis, Barretts, Strictures, Cancer Atypical Symptms Alarm Symptms Yung <40 years Cnsider gastrscpy if: Typical symptms nt relieved with PPI Atypical symptms Alarm symptms >50years with lng histry f GORD Cmmence PPI Eradicatin therapy if H. pylri present 2

3 Hiatus Hernia PPI Atypical symptms; cugh, asthma, recurrent chest infectins, halitsis, harse vice, pr dental hygiene,sur taste in muth Barium swallw Gastrscpy Cmmence PPI Cnsider specialist referral if symptms persist despite PPI therapy r investigatins suggest a symptmatic r a large hiatus hernia Vlume reflux symptms: Regurgitatin (Slids and liquids) Difficulty in swallwing (liquids and slids) Mre cmmn in patients with para esphageal hiatus hernia Night time symptms f reflux/regurgitatin/chking Cmplicatins: Oesphagitis Stricture Barretts/Cancer Strangulatin /Gastric vlvulus (mre cmmn with para esphageal hiatus hernias) presenting with vmiting and chest pain Haematemesis Severe symptms fr investigatin (as abve) Failure f medical therapy (PPI) in an individual with knwn hiatus hernia in cnsideratin fr surgery. Cnsideratin fr surgical repair f Large/Giant hiatus hernia, even if asymptmatic Achalasia Atypical dysphagia. Wrse with liquids Temperature related Regurgitatin pst-prandial and ncturnal. Weight lss Barium swallw Gastrscpy Cnsider the diagnsis in yur patients with atypical GORD like symptms. When barium swallw r gastrscpy suggests achalasia. 3

4 Hypersplenism Pancytpaenia in a patient with an enlarged spleen Infectin Bleeding Refer all patients t Haematlgy Clinic primarily FBE, Smear, White cell differential LFTs, Cag US (fr size, prtal hypertensin, discreet splenic lesins) Identify and treat cause Cmmn causes Liver disease Haematlgical malignancy Autimmune Infective (HIV, EBV, endcarditis) Strage (Gaucher) Splenectmy cnsidered in Secnd line treatment in immune thrmbcytpenia including ITP Splenmegaly in primary myelfibrsis Hereditary sphercytsis Painful splenmegaly T allw adjuvant treatment when multiple cytpenias due t hypersplenism are present Fr diagnsis in the case f splenmegaly f unknwn cause 4

5 Hepatic-Bilary Liver Cancer May have histry r signs f cirrhsis r chrnic liver disease (HCC) May has histry f previus cancer eg clrectal cancer, gastric cancer May present as an incidental mass n CT r US Tumur markers (AFP CEA Ca19-9) Hepatitis serlgy Rutine blds LFTs, U&Es, FBE, INR CT scan r US Refer t liver surgery clinic r Hepatlgy clinic Refer all patients Jaundice See Obstructed Jaundice belw Obstructed Jaundice Clinical jaundice Dark urine +/- pale stls Pruritus Send t the Emergency department if: FBE U&E LFTs US Refer all patients t either HPB surgical utpatients r the Emergency Department. Features f chlangitis, fevers, chills, sweats, rigrs, vmiting, tachycardia, hyptensive Pain nt cntrlled by simple analgesia. Bilirubin >100 Acute renal impairment Significant pruritus Gallstnes n US Otherwise refer fr urgent utpatient appintment if clinically well. Other cnditins that shuld be referred t the HPB surgical clinic: Biliary dilatatin Chledchal cyst Liver lesin/mass (except cirrhtic patients with a liver mass wh shuld be referred t the Gastrmedicine clinic) Pancreatic cyst r mass 5

6 Gallstnes Right upper quadrant Epigastric upper abdminal pain Nausea Blating Pstprandial symptms Incidental finding n imaging. Refer fr surgical pinin if: LFTs FBE U&E US Clinical bservatin if asymptmatic and nne f the fllwing. Biliary pain Weight lss Jaundice Abnrmal LFTs Imaging shws thick walled GB, wall calcificatin/prcelain GB, calculi, GB mass r plyp, biliary ductal dilatin Send t Emergency department if features f: Acute chlecystitis Acute severe pain nt settling Fevers Vmiting Tachycardia Febrile marked tenderness ver the gallbladder Guarding Psitive Murphy s test Elevated white cell cunt >14 Gallbladder Plyp Usually asymptmatic LTFs US Clinical and US surveillance if asymptmatic and nne f the belw indicatins fr referral if surveillance US in 6 mnths then yearly if n change. Refer fr surgical pinin if: Upper abdminal pain, weight lss, pst prandial symptms Jaundice Family histry f biliary malignancy Abnrmal LFTs Imaging shws - irregular plyp, plyp and calculi, GB wall calcificatin, invasin r ther features suspicius fr malignancy, biliary ductal dilatatin. - Size >7mm, increasing in size n surveillance. 6