Anaemia Pathway. Anaemia. Type of Anaemia Check Haematinics (Iron stores,b12,folate) Fit for endoscopies. endoscopies yes no. Non Iron Deficient

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1 Cognitive if unable to consent, must attend clinic with next of kin to act as advocate. Rockwood Frailty Score 6 consider appropriate referral to elderly care. See attachment Anaemia Pathway Anaemia Type of Anaemia Check Haematinics (Iron stores,b12,folate) Fit for endoscopies Independent No Cognitive impairment Rockwood frailty score of <6 endoscopies yes no Iron deficient Post Menopausal women + any men Gastro referral B12 Deficiency Non Iron Deficient Folate Deficiency Check Coeliac Serology + IgA levels If frail and cannot come to clinic then refer to IHT Elderly services for consideration of a community assessment Or Referral to IHT Outpatient elderly care services. Premenstrual women Check Coeliac Serology Nutrition review (i.e. Vegan) Menstrual History No risk factors for iron deficiency Gastro Referral +ve Treat with B12 Check Antigastric parietal + Intrinsic factor Antibodies -ve +ve GI Symptoms +ve Gastro referral No GI Symptoms Treat with B12 and watch -ve Nutritional assessment Replace with folic acid and see Other Consider Chronic Illness Check Renal function Myeloma Screen TFTS However any patient with cognitive impairment and unable to consent must attend any clinic with a next of kin Positive risk factors then treat and see Gastro referral Treat cause + refer appropriately

2 Cognitive Function Has the patient got mental capacity? The Mental Capacity Act says that someone who lacks mental capacity cannot do one or more of the following four things: understand information given to them retain that information long enough to be able to make a decision weigh up the information available and understand the consequences of the decision communicate their decision - this could be by any possible means, such as talking, using sign language or even simple muscle movements like blinking an eye or squeezing a hand. If not. need to attend clinic with Next of Kin to act as Advocate Montreal Cognitive Assessment (MOCA score) Deprivation of Liberty Safeguards (DOLs)

3 Rockwood Frailty Score

4 Dyspepsia Pathway Dyspepsia Cognitive if unable to consent, must attend clinic with next of kin to act as advocate. Alarm symptoms: Dysphagia Abnormal weight loss Iron deficiency Anaemia < 55 years old 55 years old No Alarm symptoms Primary Lifestyle Advice Trial of Antacids Organise HP faecal antigen Stool Test Direct to OGD routine Has alarm symptoms Rockwood Frailty Score 6 consider appropriate referral to elderly care. See attachment HP faecal antigen +ve HP eradication therapy Still symptomatic HP faecal antigen -ve GP Dysphagia Weight loss and one of the below Upper Abdominal Pain Reflux Dyspepsia 4 Week trial of PPI Re-iterate Lifestyle 2WW referral Review Improved then reassure and discharge Improved Step down to Antacids Re-iterate Lifestyle No Improvement Refer Gastro referral Direct Non-urgent OGD

5 Diagnosis of Irritable Bowel Syndrome (IBS) in Primary Care Rome 3 Criteria Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months, associated with 2 or more of the following: 1. Improvement with defaecation 2. Onset associated with change in stool frequency 3. Onset associated with change in stool form or consistency Yes Assessment of adult patient (aged 16 45) in primary care setting Consider Rome 3 Criteria Blood Tests (See below) Stool Culture (if diarrhoea) Alarm symptoms or signs? Blood in stool Unintentional weight loss Nocturnal symptoms Anaemia OR significant family history of bowel cancer Cognitive if unable to consent, must attend clinic with next of kin to act as advocate. Rockwood Frailty Score 6 consider appropriate referral to elderly care. See attachment No Likely Functional Persistent Symptoms Lifestyle advice by GP Faecal Calprotectin Referral to Gastroenterology Yes Faecal Calprotectin Positive? No Manage in primary care according to NICE IBS guidelines Community Dietician Blood Tests: FBC U+E LFT TFT CRP Coeliac Screen (Anti-TTG) IgA

6 Cognitive if unable to consent, must attend clinic with next of kin to act as advocate. Rockwood Frailty Score 6 consider appropriate referral to elderly care. See attachment ALT Pathway Raised ALT ALT normalises GP Monitor 6/12 Mild ALT<100 (Review and repeat LFTs in 1-3 months) History Risk factors Family Hx Drug Hx Moderate, ALT (Review and repeat in 4 weeks) Examination Stigmata CLD BMI Check PT/INR Stigmata CLD PT/Abnormal INR Albumin Urea Severe ALT >400 Initial PT/INR normal Modify lifestyle & review medication + Repeat ALT, PT and INR as per above in-bracket time schedule Fibroscan See next slide Negative Liver screen USS-fatty liver ALT Persistently raised x2.5 ULN for >3 months Negative Liver screen USS-Non fatty liver Liver Screen + Ultrasound Liver & Spleen Refer to Gastroenterology Acute Virology CMV, EBV, HepA, HepB, HepE Ultrasound Liver Screen

7 Fatty liver (NAFLD/NASH) Fibro-scan < 7 > 7 Criteria Low risk High risk Age <45 >45 Diabetes/IFG Absent Present BMI <30 >30 AST/ALT <1 >1 Platelet count >150 <150 Albumin >34 <34 Life style intervention Repeat fibro-scan in 1-2 years GP to monitor If > 3 criteria Referral to Gastro

8 ALT Pathway Notes This guideline is to assist GPs in deciding who and when to investigate with suggested follow up intervals for monitoring and referral to secondary care for further specialist management. The guideline is not an unequivocal recommendation and indeed given the potentiality dynamic nature of Liver disease it is important for the GP to carefully monitor and interpret results on an individual basis for the patient. NASH Risk Factors In patients with minimal to mild elevations of ALT, the natural history is that 1-2% of patients over 5 17yrs with pure fatty liver will progress to cirrhosis. These patients can be identified by identifying the following risk factors: ALT > X2 upper limit normal ALT < X2 upper limit with age > 45 BMI >27 GGT X2 upper limit of normal Diabetes Mellitus Hypertension Hyperlidaemia AST > ALT Allopurinol Amiodarone Augmentin Carbamazepine Chlorpromazine Erythromycin Fluconazole Hydralazine Drugs Consider stopping any potentially hepatotoxic medication Including prescribed, OTC, herbal etc. Itraconazole Ketoconazole Labetalol Lisinopril Losartan Methotrexate Nitrofurantoin NSAIDs Omeprazole Paracetamol Penicillin Phenytoin Pioglitazone Pyrazinamide Rifampicin Risperidone SSRIs Statins Sulfonylureas Sulphonamides TCAs Tetracycline Trazodone Valproic Acid Liver Screen FBC/UE/Ca/LFTs/INR/GGT Glucose Fasting Lipids TFTS CRP Immunoglobulins Liver autoantibodies Iron profile Alpha-1 antitrypsin Caeruloplasmin Hep B/C Alpha fetoprotein ANA ANCA Coeliac serology Stigmata of Chronic Liver disease Spider naevi Palmar erythema Ascites Gynaecomastia Asterix Scleral icterus Jaundice Portal Venous pressure Lifestyle modification Reduce alcohol intake Reduce weight if overweight / obese Control diabetes Liver Ultrasound For evidence of: Cirrhosis Portal hypertension Splenomegaly Ascites Non-hepatic causes raised ALT / AST Haemolysis Myopathy Thyroid disease Strenuous exercise (check CK, often high AST) Viral Toxins Causes of ALT > 4000 Ischaemic Autoimmune Early phase of acute obstruction

9 ALT Pathway Notes Causes of elevated ALT are summarised in the below table along with clues to help establish a diagnosis. Patients with suspected chronic liver disease should be considered for referral for specialist management Clinical Clue Diagnosis Initial test Additional tests AST > ALT, MCV Alcoholic liver disease Drug / OTC / Herbal remedy Drug induced liver disease IV Drug use, blood transfusion Chronic hepatitis B HBsAg HBeAg/eAb, HBV DNA Chronic hepatitis C HCV antibody HCVRNA Raised ALP Primary biliary cirrhosis IgM, AMA, anti-pdh Inflammatory bowel disease Primary sclerosing cholangitis P-ANCA Other autoimmune disease Autoimmune hepatitis SMA, ANA, LKM, IgG Diabetes / Joint pain Haemochromatosis Transferrin Sat, ferritin HEFE gene test Neurological signs Wilsons disease Caeruloplasmin 24hr urinary copper Lung disease Alpha-1 antitrypsin deficiency a1 antitrypsin level a1 antitrypsin phenotype Metabolic syndrome (BMI, hypertension, raised blood glucose) Non-alcoholic liver disease Glucose, Liquid profile, TSH, Blood pressure Malabsorption Coeliac Anti-TTG AB and IGA level or Endomysial antibody NB: AMA = antimitochondrial antibody; ANA = Antinuclear antibody; SMA = Smooth muscle antibody; LKM = Liver kidney microsomal antibody If asymptomatic, ALT <200 and liver screen is negative, complete abstinence from alcohol, control of diabetes and hyperlipidemia, weight loss in overweight patients, stopping potentially hepatoxic medications and supplements can correct ALT in may patients. If normalisation of ALT fails to occur, such patients should be considered for specialist management, including consideration of liver biopsy. Any confirmed liver disease should be considered for referral for specialist management