May 2015 CLINICAL REFERENCE. gastroenterology

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1 May 2015 CLINICAL REFERENCE gastroenterology

2 Introduction As co-leads for the Alberta Referral Pathway for Gastroenterology (GI) and on behalf of our fellow working group, we are pleased to present this document. This document is intended for all physicians and other allied health professions who want to refer patients for outpatient consultations in Gastroenterology and Hepatology. The aim of this initiative is to improve and standardize the referral process for gastroenterology and hepatology in the province of Alberta by outlining key information necessary for appropriate triage and acuity assessment. This pathway reflects the collective input and recommendations of a panel of your peers, representing urban and rural GI specialists, primary care, hepatologists, cancer care and surgery, who came together given concerns about long wait times and the desire to improve the referral process. As physicians, the health and care of our patients is paramount and it is clear to us that referral processes impact both patient care and outcome. In order to optimally prioritize referrals according to clinical need, consistent and complete information is essential. It is recognized that Alberta is facing significant challenges in access to gastroenterology and hepatology. This document is not meant to address the access problem to GI in Alberta as wait times and access will vary depending on local circumstances. However, hopefully by providing the best possible information about a particular referral the request for consultation can be triaged according to acuity. We believe the use of a uniform provincial GI referral pathway will improve the referral process and contribute to better patient care. We also expect it has the potential to improve satisfaction with the system, by both physicians, support staff and patients. We recognize that there is considerable variation in the scope, location and practice pattern across the province. The pathway by no means aims to dictate practice, rather to provide a foundation to improve the referral process. We welcome any comments and suggestions you may have. Based on feedback and review of its use the document will be updated and hopefully further improved by the committee who generated this pathway. Kindly send them to: jodi.glassford@albertahealthservices.ca Kerri Novak MD FRCPC Medical Lead, Quality Assurance Inflammatory Bowel Disease Clinic Clinical Assistant Professor Division of Gastroenterology Department of Medicine University of Calgary Sander Veldhuyzen van Zanten, MD, MSc, MPH, PhD Director, Division of Gastroenterology AHS Zone Head, Edmonton GI 3

3 Contents GENERAL What is Alberta Referral Pathways? 6 How to use these guidelines 6 Emergency referral information 7 Mandatory requirements for all referrals 7 COLORECTAL CANCER SCREENING Fecal Immunochemical test (FIT) : positive finding 8 Personal history of colon cancer or adenomatous polyp 8 Family history of cancer of colon 8 Polyp on sigmoidoscopy, CT colonography, barium enema or other 8 Average risk screening for colorectal cancer 9 COMMON LUMINAL DISORDERS GI bleed 9 Rectal bleed 9 Iron deficiency anemia 10 Change in bowel habit 10 Constipation 10 Abnormal imaging of gastrointestinal tract 10 Gastroesophageal reflux disease/ dyspepsia 10 Barrett s Esophagus 10 Dysphagia 10 Weight loss (unexplained) 11 Abdominal pain 11 Diarrhea 11 Celiac disease 11 Inflammatory bowel disease 12 Irritable bowel syndrome 12 HEPATOLOGY Acute liver disease / hepatitis 13 Chronic liver disease / elevated liver enzymes 13 Cirrhosis of liver 14 Isolated liver mass 14 PANCREATOBILIARY Pancreatitis / pancreas abnormalities 15 Referral for ERCP 15 Referral for endoscopic ultrasound 15 Referral for capsule endoscopy 15 OTHER other 16 4 LAST UPDATED 06 May

4 general information WHAT IS ALBERTA REFERRAL PATHWAYS? EMERGENCY REFERRAL A patient s journey often seems like a confusing maze of uncertain choices and endless waiting. Patients and helath care providers want seamless and efficient transitions between primary and specialty care. The AHS Provincial Access Team is collaborating with the Strategic Clinical Networks, primary care, Primary Care Networks, the Alberta Medical Association and Alberta Health to lead referral transformation. Alberta Referral Pathways is a provincial program that builds connections between primary and specialty care to support clinicians and administrators to define standards and introduce processes to improve Alberta s referral experience. Each referral pathway is led by medical co-champions and representative of both primary and specialty care. The working group is populated by representatives from every point in a patient s care pathway. Determined and reviewed over a sixmonth process, the resulting provincial referral guidelines include clinical content, business processes and access standards. They are then widely distributed for physician review, feedback and adoption. HOW TO USE THESE GUIDELINES These guidelines are organized by reason for referral under sub-specialty headings. Use the table of contents to find the reason for referral, and click the reason to take you directly to the referral information The mandatory information is patient specific and required for the referral to be appropriately triaged. This information is required in addition to the comorbidities and demographics previously outlined. & SUGGESTED TIMEFRAMES The recommended assessments and essential investigations are required to be completed within the suggested time frame. 1 FECAL IMMUNOCHEMICAL TEST (FIT) : POSITIVE FINDING 2 3 Age Must be asymptomatic This is not a test to investigate anemia or GI bleeding 1-2 YEARS FIT testing (FOBT is no longer available) For all emergencies, refer directly to the Emergency Department or Contact the RAAPID Line North: or South: or REQUIREMENTS FOR ALL REFERRALS PATIENT DEMOGRAPHICS Patient last name, first name, given names PHN/ULI Gender Address, including city, postal code, province Home phone, other phone Emergency contact and/or guardian name & phone, and relation to patient OTHER Relevant medical history Indicate if interpreter is required and language REFERRING PROVIDER Name Address, including city, postal code, & province Phone & fax FAMILY PHYSICIAN Name Indicate if same as referrer or if patient has no primary care provider Phone Physical limitations Economic and social / psychological factors CO-MORBIDITIES - PLEASE IDENTIFY IN THE REFERRAL IF THE PATIENT HAS ANY OF THE FOLLOWING: History of stroke Cardiovascular disease (e.g. prior MI) Respiratory disease Peripheral vascular disease GI disease (e.g.crohn s) Renal disease Liver disease (hepatitis B or C) Diabetes Rheumatologic disease (e.g. SLE, scleroderma etc) Active infections (e.g. MRSA, shingles, TB, VRE) HIV Cognitive issues Any other concurrent medical problem Sleep apnea with CPAP Medication history including antithrombotics (type and reason) and insulin / oral hypoglycemic agent 7

5 Referral Requirements FECAL IMMUNOCHEMICAL TEST (FIT) : POSITIVE FINDING PERSONAL HISTORY OF COLON CANCER OR ADENOMATOUS POLYP FAMILY HISTORY OF CANCER OF COLON POLYP ON SIGMOIDOSCOPY, CT COLONOGRAPHY, BARIUM ENEMA OR OTHER COLORECTAL CANCER SCREENING Age Must be asymptomatic This is not a test to investigate anemia or GI bleeding Copy of previous colonoscopy and pathology reports Family history: One 1st degree relative with CRC or advanced adenomatous polyps diagnosed 60 years Two or more 1st degree relatives with CRC or advanced adenomatous polyps diagnosed at any age Screening begins at age 40 or 10 years earlier than the youngest diagnosis in the family, whichever comes first Copy of sigmoidoscopy report or imaging results 1-2 YEARS Positive FIT finding (FOBT is no longer available) 1-2 YEARS 1-2 YEARS 1-2 YEARS AVERAGE RISK SCREENING FOR COLORECTAL CANCER GI BLEED Hematemesis Melena (define) Low hemoglobin Hematochezia Age 74 years Must be asymptomatic. No GI signs and symptoms requiring specialist consult (i.e. rectal bleeding, change in bowel habits, anemia) Expected to benefit from cancer screening (i.e. no major co-morbidity that would reduce life expectancy to below five years) Medication history (antithrombotics, insulin or oral hypoglycemics) Body mass index (BMI) and whether patient requires CPAP Recent or pending surgeries; referral should be deferred 3-6 months post surgery. Copy of previous colonoscopy and pathology report (if applicable) COMMON LUMINAL DISORDERS Duration Frequency 1 YEAR / hemoglobin level Creatinine RECTAL BLEED Age<50 Age>50 Recent change in bowel habit Duration Frequency Previous colonoscopy / flexible sigmoidoscopy or imaging Reports if available Family history / hemoglobin level CRP (optional if ulcerative colitis is suspected) 8 LAST UPDATED 06 May 2015 LAST UPDATED 06 May

6 Referral Requirements IRON DEFICIENCY ANEMIA CHANGE IN BOWEL HABIT CONSTIPATION ABNORMAL IMAGING OF GASTROINTESTINAL TRACT Any GI symptoms Family history of GI malignancy (colorectal cancer, gastric cancer, celiac disease, IBD) Define what the problem is including duration of symptoms Define the problem including the frequency of bowel movements and duration of symptoms Why did you request the imaging include a description of the symptoms Ferritin TTG IgA level 1 YEAR, ferritin, TSH, TTG, IgA, glucose, calcium/albumin Recent CBC WEIGHT LOSS (UNEXPLAINED) ABDOMINAL PAIN Acute abdominal pain Chronic abdominal pain Amount & duration of weight loss including BMI Any associated symptoms? Medications Associated medical conditions which might contribute to weight loss, cancer, COPD etc. Frequency Severity Duration, ferritin Electrolytes, creatinine Liver enzymes (ALT, AST, alkaline phosphatase, bilirubin) Thyroid function test Celiac serology/screen, TTG, IgA Albumin, electrolytes, BUN, creatinine LFTs ALT, ALK Phos, GGT and AST (where available), bilirubin Celiac serology/screen, TTG, IgA OPTIONAL GASTROESOPHAGEAL REFLUX DISEASE/ DYSPEPSIA Non-cardiac chest pain BARRETT S ESOPHAGUS Duration of symptoms Frequency of symptoms Severity of symptoms Whether patient is responding to medication Duration and diagnosis if present 1 YEAR DIARRHEA Frequency Duration Stool form BMI CRP, lipase If relevant acute, stool cultures for: C&S, O&P, and C. difficile TSH CRP Duration of symptoms Celiac serology/screen, TTG, IgA DYSPHAGIA Use of PPI Duration Severity Solids or liquids? Progressive or intermittent, unchanged? Weight loss 8 WEEKS (only for ages 50+) CELIAC DISEASE Celiac disease Non celiac gluten sensitivity Is patient following a glutenfree diet? Copy of small biopsy imaging and report In general it is preferred that small bowel biopsies are done to prove that the patient has celiac disease before a gluten-free diet is started., ferritin, TSH Celiac serology/screen, TTG, IgA OPTIONAL folate, INR, Ca/albumin, B12 10 LAST UPDATED 06 May 2015 LAST UPDATED 06 May

7 Referral Requirements INFLAMMATORY BOWEL DISEASE (ULCERATIVE COLITIS, CROHN S DISEASE) Active or suspected IBD Inactive IBD Symptoms diarrhea (bloody/non-bloody) abdominal pain weight loss (Kgs/months) fever duration of symptoms bowel movements per day extraintestinal (please list) relevant endoscopy diagnostic imaging surgical/pathology reports ACTIVE OR SUSPECTED stools for C&S, O&P and C difficile toxin, CRP, iron, ferritin, ALT, AST, Alk phos, GGT, bilirubin, albumin, (celiac serology if not previously done) B12 INACTIVE all above except stool tests ACUTE LIVER DISEASE / HEPATITIS ALT &/ AST > 1000 ALT &/ AST > 250 HEPATOLOGY Medication history including herbs / remedies/ all OTC drug use/illicit drugs Symptoms (e.g. jaundice, abdominal pain etc) DM Alcohol intake BMI Systemic symptoms (i.e. sore throat, rash) Liver enzymes: ALT, AST, Alk phos, GGT, LDH Liver function: INR, total / direct bilirubin, albumin Etiological: Hep A IgM, Hep B surface Ag, Hep B core IgM, Hep C Ab, IgG; IgA, IgM, ANA (anti-nuclear antibodies), SMA (antismooth muscle antibody), ceruloplasmin, ferritin, transferrin saturation, alpha 1 antitrypsin level, CK Toxin screen (acetaminophen, cocaine) if applicable IRRITABLE BOWEL SYNDROME Frequency & duration of symptoms Severity of symptoms Impact on daily activities, celiac serology/screen, TTG, IgA, TSH, and if diarrhea: stool for O & P CRP CHRONIC LIVER DISEASE / ELEVATED LIVER ENZYMES Medication History including herbs / remedies / all OTC drug use Symptoms (e.g. jaundice, abdominal pain, confusion, pruritus, pedal edema, ascites, GI bleeding) Comorbidities (e.g. DM, cholesterol, CAD etc), thyroid disease Alcohol intake BMI ultrasound Previous liver enzymes if available Liver enzymes: ALT, AST, Alk phos, GGT, LDH Liver function: INR, total / direct bilirubin, albumin, CK Etiological: Hep B, C serology, IgG,IgA, IgM, ANA (anti-nuclear antibodies), SMA (anti-smooth muscle antibody), AMA (antimitochondrial antibodies), ceruloplasmin, copper, ferritin, transferrin saturation, alpha 1 antisrypsin level, ATTG (antitransglutaminase antibodies) Fasting lipids and A1c if applicable Old liver enzymes Abdominal ultrasound (with hepatic / portal vein doppler where available 12 LAST UPDATED 06 May 2015 LAST UPDATED 06 May

8 Referral Requirements CIRRHOSIS OF LIVER Decompensated jaundice, encephalopathy, ascites or varices Compensated Etiology- when / if established. How was diagnosis established? Symptoms of decompensation (i.e. jaundice, encephalopathy) Alcohol use Liver enzymes: ALT, AST, Alk phos, GGT Liver function: INR, total / direct bilirubin, albumin, AFP Fibroscan results (if available) Abdominal ultrasound (with hepatic / portal vein doppler where available) CT / MRI or US if available 1 YEAR PANCREATITIS / PANCREAS ABNORMALITIES Acute pancreatitis Disorder of pancreas Disorder of biliary tract Primary sclerosing cholangitis PANCREATOBILIARY Hospitalization details discharge summary and relevant information Alcohol and gallstones are common causes of pancreatitis - history of both to be included in medical history To include all relevant imaging (copy of report and findings for all) 2 MONTHS ALT, AST, alkaline phosphatase, ygt, bilirubin, lipase, liver enzymes Creatinine BUN Electrolytes If not previously done Etiological: Hep B, C serology, IgG, IgA, IgM, ANA (anti-nuclear antibodies), SMA (anti-smooth muscle antibody), ANA (anti-smooth muscle antibody, AMA (antimitochondrial antibodies), ceruloplasmin, copper, ferritin, transferrin saturation, alpha 1 antitrypsin level, ATTG (anti transglutaminase antibodies) IF AVAILABLE REFERRAL FOR ERCP Medical history Current medication To include all relevant imaging (copy of report and findings for all), INR, PTT Surgical history - cystectomy, gall bladder removal ALT, ALP, GGT, bilirubin, lipase, creatinine IF APPLICABLE pregnancy test ISOLATED LIVER MASS Weight and BMI Hx of liver disease / cirrhosis Metastatic cancer to liver excluded (i.e. no colon cancer, breast cancer, etc.) Fibroscan results Liver biopsy / endoscopy results, electrolytes, BUN, ferritin, creatinine Liver enzymes: ALT, AST, Alk Phos, GGT, LDH Liver Function: INR, bilirubin total/direct, albumin IF NOT PREVIOUSLY DONE Etiological: Hep B, C serology, AMA, IgG,IgA, IgM, ANA, Anti-smooth muscle antibody, ceruloplasmin, copper, ferritin, transferrin saturation, alpha 1 antitrypsin level CT / MRI or US if available Alpha fetoprotein REFERRAL FOR ENDOSCOPIC ULTRASOUND (EXAMINATION OF PANCREAS BILE DUCT COLON ESOPHAGUS), OTHER REFERRAL FOR CAPSULE ENDOSCOPY Not usually a family physician direct referral (either directly referred or recommended by a gastroenterologist / internal medicine or a surgeon that has seen and scoped the patient) Gastrointestinal hemorrhage Medical history Current medication To include all relevant imaging (copy of report and findings) Indication / question to be answered Relevant medications e.g. NSAIDs, iron ALT, ALP, GGT, bilirubin, lipase, PTT/INR Surgical history 8 WEEKS Creatinine Ferritin Iron studies BUN (if patient actively bleeding) CT scan or small bowel follow if available 14 LAST UPDATED 06 May 2015 LAST UPDATED 06 May

9 Referral Requirements OTHER OTHER please specify and attach relevant investigations n/a Copyright (2015) Alberta Health Services. This material is protected by Canadian and other international copyright laws. All rights reserved. This material is intended for general information only and is provided on an "as is", "where is" basis. Although reasonable efforts were made to confirm the accuracy of the information, Alberta Health Services does not make any representation or warranty, express, implied or statutory, as to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information. This material is not a substitute for the advice of a qualified health professional. Alberta Health Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use. 16 LAST UPDATED 06 May 2015 LAST UPDATED 06 May

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