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Gastroenterology

Referral Acceptance

Gastroenterology referrals are prioritised by Senior Medical Officers based on the information contained within. Additional information should be attached where available. The priorisation tool used to triage referrals can be found below under Access Criteria.

All accepted referrals will be seen within a maximum waiting time of 4 months, unless there is a clinical reason for delay.

Referral acceptance is a follows:

First Specialist Assessments:

Waiting priority 1

Accepted

Waiting priority 2

Accepted

Waiting priority 2A

Declined

Waiting priority 2B

Declined

Waiting priority 3

Declined


At First Specialist Assessment (FSA), patients are assessed by a specialist and if surgery is required, patients are then prioritised using the National Gastroenterology CPAC tool.  A 0-100 score is allocated to each patient.

Prior to acceptance for surgery, patients are assessed in Anaesthetic preassessment clinic to ensure they are fit for surgery.

All patients accepted for surgery will be treated within a maximum waiting time of 4 months, unless there is a clinical reason for delay.

Endoscopy List (Surgical/Medical) includes Colonoscopy, Gastroscopy and Sigmoidoscopy

Surgery acceptance is as follows:

Tauranga/Whakatane Endoscopy List:

Waiting priority 1

Accepted

Waiting priority 2

Accepted

Waiting priority 2A

Accepted

Waiting priority 2B

Declined

Waiting priority 3

Declined

 

Access Criteria

Lower Endoscopy

Category Criteria Examples (not an exhaustive list) Recommendations

Immediate Assessment

(Requires admission to an acute facility as soon as possible)

  • Acute lower gastrointestinal haemorrhage
  • Acute change in bowel habit with pain indicative of obstruction

Colonoscopy

  • Continuous haemorrhage / unstable /> 4 units of blood or stable / requiring blood transfusion
  • Pseudo obstruction/ obstruction

Refer to Hospital

for admission

1 –

Urgent – Two week category

  • Known of suspected CRC (on imaging, palpable or visible on rectal exam), for preoperative procedure to rule out synchronous pathology.

  • Unexplained rectal bleeding (benign anal causes treated or excluded) with iron deficiency anaemia (haemoglobin below the local reference range).

  • Altered bowel habit (Looser and/ or more frequent) for > 6weeks duration plus unexplained rectal bleeding (benign anal causes treated or excluded) aged 50years or older.

Colonoscopy

Is the appropriate investigation where:

  1. Diarrhoea or rectal bleeding is the predominant indication,

  2. A patient has a category 2 or 3 family history of bowel cancer

     

CT Colonography

Is the appropriate investigation where the above are not predominant indications or the patient being referred is over 80 years old and/or has significant comorbidities. 

Refer for Assessment Using CRC Pathway

2 A –

Semi Urgent

Six week category

  • Altered Bowel habit (looser and/or more frequent) > six weeks duration, aged 50 years or older.

  • Altered Bowel habit (looser and/or more frequent) > six weeks duration plus unexplained rectal bleeding (benign anal causes treated or excluded), aged 40 -50 years,

  • Unexplained rectal bleeding (benign anal causes treated or exclude) aged 50 years or older.

  • Unexplained iron deficiency anaemia (haemoglobin below local reference range).

  • New Zealand Guidelines Group (NZGG) category 2 family history plus one or more of Altered Bowel habit (looser and/or more frequent) > six weeks duration plus unexplained rectal bleeding (benign and anal causes treated or excluded), aged 40 years or older.

  • NZGG category 3 family history plus one or more of Altered Bowel habit (looser and/or more frequent) > six weeks duration plus unexplained rectal bleeding (benign and anal causes treated or excluded), aged 25 years or older.

  • Suspected/ assessment inflammatory bowel disease (consider FSA).
  • Imaging reveals polyp >5mm

 “Benign anal causes’ is defined as haemorrhoids, anal fissure, anal fistula, inflammatory bowel disease, radiation proctitis and mucosal or full thickness rectal prolapse. If no benign anal cause is identified or bleeding continues after the treatment of these, benign causes can be excluded. 

 Via CRC Pathway

Grade 2B -

Not accepted

 

  • Acute diarrhoea < six weeks duration – likely infectious aetiology and self-limited.
  • Rectal bleeding aged less than 50 years (normal haemoglobin) – consider FSA or flexible sigmoidoscopy if no anal cause.

  • Irritable bowel syndrome (may require specialist assessment).

  • Constipation as a single symptom.

  • Uncomplicated CT-proven diverticulitis without suspicious radiological features.

  • Abdominal pain alone without any ‘six week category’ features

  • Decreased ferritin aged <50years with normal haemoglobin.

  • Abdominal mass – refer for appropriate imaging

Metastatic adenocarcinoma unknown primary (6% is due to CRC and in the absence of clinical, radiological., or tumour marker evidence of CRC, colonoscopy is not indicated)

 

 

 

 Surveillance

Family history of colorectal cancer – category 2 and 3 as recommended in the NZ 2012 Guidelines;

Category 3 as recommended by the NZ Familial Gastrointestinal Cancer Service or a bowel cancer specialist.

History of low risk adenomas.

Refer to New Zealand Guideline: Guidance on surveillance.  Refer for Assessment


Upper Endoscopy


Category Criteria Examples (not an exhaustive list) Recommendation

Immediate Assessment

(Requires admission to an acute facility as soon as possible)

  • Upper gastrointestinal haemorrhage
  • Foreign Body

 

 

Gastroscopy

  • Upper GI haemorrhage - continuous or early re-bleeding/unstable, or >65 yrs and on NSAID, or chronic liver disease, or stable. haemoglobin <100g/L or stable. minor episode
  • Foreign Body
  • Dysphagia, food bolus obstruction

Refer to Hospital for admission

1 - Urgent

  • Upper gastrointestinal haemorrhage
  • Dysphagia

Gastroscopy

  • Upper gastrointestinal haemorrhage, >65 yrs and on NSAID
  • Dysphagia: < 3 months, progressive

Refer for Assessment

 

2 - Semi Urgent

New referrals to the department with established diagnosis, requiring gastroenterology review to prevent clinical deterioration and/or admission

 

2 A - Semi Urgent

 

  • Dysphagia
  • Dyspepsia
  • Diarrhoea / suspected IBD

Gastroscopy

  • Diarrhoea / suspected IBD
  • Change in bowel habit, recent onset / with 'alarm' symptoms
  • Positive Coeliac serology
  • 1-2 cm polyps
    • Dysphagia - < 3 months, stable, > 3 months stable, longstanding, intermittent
    • Dyspepsia > 50 yrs with 'alarm' symptoms

Refer for Assessment

2B - Semi Urgent

 

  • Change of bowel habit
  • Dyspepsia / heartburn

 

 

Gastroscopy

  • Dyspepsia, with no 'alarm' symptoms

 

CRC Pathway

Refer for Assessment

However suggest Barium studies if patients can not be seen. 

For diarrhoea, recommend faecal calprotectin,CRP, Stoll MC&S

3 - Routine

 

  • Chronic rectal bleeding
  • Surveillance

Gastroscopy

  • Surveillance - Barrett's (as directed by Gastroenterologist)
  • Functional GI disorders

 

Refer for Assessment