Pediatric Gastroenterology Referral Guidelines

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Suggested Pre-Referral Workup This is a general suggestion of possible testing to confirm a suspected diagnosis. Although referrals will be accepted without the suggested work up being complete, to ensure referrals are processed timely we do require that items listed in the Referral Documentation section be submitted with the initial referral. In addition to the suggested Pre Referral Workup in the tables below, it is recommended that the following information is also provided: Referring physician name, office address, and phone number Patient demographics and parent contact information Reason for referral with notes Requested department or physician name for the referral Insurance information for patient Authorization (when required) If the referral is a second opinion evaluation, please include prior endoscopic reports, pathology reports, relevant clinical documentation, and names of prior specialty physicians. Diagnoses Listed Urgent Diagnoses Melena/hematochezia/hematemesis Hyperbilirubinemia or jaundice Rule-out biliary atresia, complaints of white or gray colored stool Elevated liver enzymes Ingestion of a foreign body Hepatitis Other Diagnoses Abdominal pain Constipation Esophageal reflux Failure to thrive Diarrhea Vomiting alone Celiac disease Inflammatory bowel disease (IBD) Crohn s disease/ulcerative colitis Eosinophilic esophagitis (EoE)

Abdominal Pain ICD-10: R10.* Abdominal pain persistent or Urine analysis recurrent with routine care measures Stool O&P and Giardia antigen Pain associated with weight loss or Stool H. pylori specific antigen poor growth Pain waking patient at night Pain associated with: fevers, vomiting, diarrhea, GI bleeding Comprehensive metabolic panel Patient < 5 years of age Serum IgA History of previous abdominal Celiac panel surgery or midline congenital Abdominal ultrasound (optional) abnormalities Abnormal radiologic studies Constipation ICD-10: K59.00 Failure to stool in the first 24 hours of life Thyroid function tests Constipation associated with: Serum IgA Recurrent rectal bleeding Tissue transglutaminase IgA Growth failure or poor weight gain Persistent abdominal pain Sacral dimple, umbilical hernia, hypotonia, developmental delay Encopresis

Esophageal Reflux ICD-10: K21.9 Unexplained nausea, vomiting, or Infants < 1 year of age: no additional abdominal pain unresponsive to work-up suggested therapy Persistent nausea, vomiting, or Children > 1 year of age: abdominal pain associated with Urine analysis weight loss or growth failure Stool guaiac (occult blood) Unexplained apnea, choking, Stool H. pylori antigen swallowing, or feeding problems Complete blood count Unexplained chronic cough, (CBC) wheezing, halitosis, hoarseness of Sedimentation rate (ESR) voice, dental enamel erosion, and C- recurrent otitis media or sinusitis Unexplained dysphagia Comprehensive metabolic History of previous abdominal panel (CMP) surgery or midline congenital abnormalities Failure to Thrive ICD-10: R62.50, R62.59 Growth failure unexplained by Urine analysis endocrine abnormalities or constitutional growth Qualitative fecal fat Poor weight gain unresponsive to Stool reducing substances Parental heights adequate nutritional intake Fecal elastase or stool trypsin Inability to sustain adequate Stool alpha-1 antitrypsin Please indicate if: nutritional intake Stool O&P and Giardia antigen Patient has a feeding tube in place Inadequate growth or weight gain associated with vomiting, diarrhea, Comprehensive metabolic panel (e.g., gastrostomy tube, nasogastric tube) abdominal pain, fevers, arthralgia, (CMP) Registered dietician consult is also or perianal lesions TSH and T4 requested Serum IgA and tissue transglutaminase IgA Sweat chloride test

Diarrhea ICD-10: R19.7 Diarrhea unresponsive to dietary Stool cultures, including O&P, manipulations that might include Giardia antigen, C. difficile toxin lactose restriction and addition of dietary fiber Diarrhea associated with rectal Comprehensive metabolic panel bleeding, weight loss or growth failure, joint pains, rashes, or fever Diarrhea that awakens patient from a sound sleep at night Liver disease ICD-10: K76.9 Jaundice Pale or gray colored stools Elevated liver enzymes Comprehensive metabolic panel Elevated bilirubin levels GGT Easy bleeding, easy bruising Direct bilirubin History of prior abdominal surgery Coagulation studies (PT/INR) Abdominal ultrasound Vomiting alone ICD-10: R11.10 Persistent nausea and vomiting Urine analysis Persistent nausea, vomiting, or abdominal pain associated with Stool H. pylori antigen weight loss, growth failure, or other symptoms Comprehensive metabolic panel Vomiting associated with headaches Dysphagia Lipase Chest pain with swallowing Upper GI study Recurrent evidence of H. pylori infection History of foreign body ingestion or caustic ingestion

History of dry swallowing pills History of previous abdominal surgery Pediatric Gastroenterology Referral Guidelines Celiac disease, abnormal celiac panel ICD-10: K90.0, R89.4 Abnormal celiac markers or normal Celiac panel, including serum IgA serum markers with low total IgA Stool O&P and Giardia antigen Unexplained growth failure or weight loss Celiac panel, including serum IgA Chronic diarrhea Comprehensive metabolic panel Abdominal pain Family history of celiac disease Do not limit gluten intake prior to GI evaluation Hematochezia ICD-10: K92.1 Painless rectal bleeding Bleeding associated with Comprehensive metabolic panel constipation Bleeding associated with growth failure or weight loss Family history of inflammatory Stool culture including Yersinia and bowel disease Campylobacter Family history of colon polyps or Stool C. difficile toxin assay colon cancer

Inflammatory bowel disease, Crohn s disease, ulcerative colitis ICD-10: K50.9* Anemia, low albumin, elevated ESR Stool C. difficile toxin assay or CRP Stool calprotectin, if available Unexplained: growth failure or Stool O&P and Giardia antigen weight loss, diarrhea/rectal Endoscopy and pathology reports, bleeding, vomiting, abdominal pain if available Family history of Crohn s disease or Comprehensive metabolic panel ulcerative colitis Second opinion evaluation of IBD/Crohn s disease/ulcerative colitis Known diagnosis of IBD/Crohn s disease/ulcerative colitis, establishing care Suspected eosinophilic esophagitis (EoE) ICD-10: K20.0 Feeding problems Dysphagia Comprehensive metabolic panel History of food impaction Persistent vomiting Persistent reflux symptoms despite Upper GI study medical therapy Poor appetite Failure to thrive

Feeding difficulties, oral aversion ICD-10: R63.3 Gastrostomy status ICD-10: Z93.1 Feeding problems Abnormal feeding behaviors Poor appetite Failure to thrive Need for nutritional support, formula selection Gastrostomy tube status Consideration for placement of a feeding tube (nasogastric tube, PEG tube) Comprehensive metabolic panel Upper GI study Additional Diagnoses Hirschsprung s disease Megacolon Non-alcoholic fatty liver disease Chronic pancreatitis Urgent Diagnoses Melena/hematochezia/hematemesis Hyperbilirubinemia or jaundice Rule-out biliary atresia, complaints of white or gray stool Hepatitis Elevated liver enzymes Ingestion of a foreign body

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