1. Gastro Pathways – Rationalising care in 2015
Dr Miles Parkes
Consultant Gastroenterologist

2. Themes GI presentations to 1ry care – v common
NB – most referrals are excellent!  - but some do not require secondary care
Reality of limited resources
Need for reasonable uniformity of care
Within 1ry care
At 1ry / 2ry interface
Within 2ry care
Myriad NICE guidelines (dyspepsia, IBS, IBD etc.)
Frequently shifting; CCG consistency eg re dyspepsia.
Relentless political ‘trumping’ re cancer diagnostics

3. Within CUH
GI Medicine + Surgery (upper GI + colorectal) now within single Digestive Disease directorate
Aim: single point of triage
GP’s refer patients to Digestive Disease
Pass through CCG referral management?
Triage by consultant to most appropriate clinic(s)
=> Patient chooses which one they can make / want
Falls within C&B rules

4. New GI proformas / guidelines
Aim
to cover most common presentations
to avoid unnecessary hospital referrals
hence incl some guidance eg re calprotectin
On Referral Proformas
Some information that is required (sorry)
Some boxes to tick
PLEASE do incl (invaluable) para of text re context / need for referral – esp for eg IBS, dyspepsia etc.

5. Frontsheet
Demogs ……..
For the desired action please tick the appropriate box below
O.P. Appointment □ Advice only □ Endoscopy only □
Please complete the appropriate proforma for the following conditions:
For all other conditions, including suspected IBD, please supply this frontsheet with a letter + lab results. We will triage all referrals to the appropriate clinic: please supply enough information to enable appropriate allocation.
Rectal Bleeding
Iron Deficiency Anaemia
Suspected
Coeliac Disease
Dyspepsia
Mainly primary care management
Irritable Bowel Syndrome
Mainly primary care management
Hernia
Bowel management service
Rectal Bleeding
Iron Deficiency Anaemia
Suspected
Coeliac Disease
Dyspepsia
Mainly primary care management
Irritable Bowel Syndrome
Mainly primary care management
Hernia
Bowel management service

7. IBS and Bowel Symptoms in Young Patients
If it’s IBS a positive diagnosis always helps management: most should be managed in primary care
Main Symptoms
IBS Abdo pain Bloating Change in bowel habit
IBS diagnosis
Abdo pain + abnormal bowel pattern – diarrhoea, constipation or (typically) rapidly alternating
Abdo pain eased by defecation
Plus 2 or more of
Bloating
Symptoms made worse by eating +/- specific foods
Passage of mucus
Tiredness
Plus
normal baseline tests (FBC, CRP, coeliac serology)
Red Flags for IBD or neoplasia
Refer for assessment
If severe IBD please phone on-call gastro SpR
Unexplained weight loss
Rectal bleeding without haemorrhoidal features
FH bowel or ovarian cancer
Age >60 + change in bowel pattern >6 weeks
Unexplained anaemia
Abdominal mass or Rectal mass
Raised ESR / CRP - mild  ESR/CRP can be 2ry to e.g. obesity - check fecal calprotectin (see below)
Investigations
Baseline tests (results required for any hospital referral)
Hb, MCV, CRP or ESR, Coeliac screen (TTG)
If normal but IBD still suspected check fecal calprotectin (see box below)
The following are NOT necessary in patients with typical IBS symptoms + normal baseline tests
Abdo ultrasound or CT
Sigmoidoscopy/Colonoscopy
Fecal Calprotectin (Fecalp)
A test for bowel inflammation
>200 means gut inflammation = refer; or if > other features of IBD = refer
<50 = normal;
= equivocal – repeat after 3 months
NB this is a sensitive test prone to false positives – e.g. caused by NSAIDs, liver cirrhosis, gastroenteritis or infectious colitis (Salmonella, C diff etc.)
Addenbrooke’s/CATCH IBS guidelines October 2014

8. Management of IBS/Bowel Symptoms in young patients
If it’s IBS a positive diagnosis always helps subsequent management: mostly managed in primary care
Patients that may warrant referral (NB this is the exception!)
Severe symptoms as assessed by-
Multiple days off work/study
On strong opiates
Recurrent A+E attendances
Lifestyle/self help/exercise
Diet, lifestyle, stress management, regular exercise (yoga, pilates+ graded exercise) all help; also self help via IBS network; and assess psychological symptoms.
Fibre
Review fibre intake and adjust (usually reduce dietary fibre)
Discourage intake insoluble fibre (eg bran); if fibre needed, increase to soluble eg oats or use cracked linseed daily (1 teaspoon increasing to 1 tablespoon bd).
BDA leaflet
Follow up
Agree follow up based on symptom responses to interventions.
Assess each time for red flag symptoms
Consider Dietician referral
If diet considered to be major factor in symptoms and dietary/lifestyle advice being followed then refer community dietician for consideration exclusion diet/group work
First line pharmacological treatment
Single or combination
All can be safely used long-term if necessary
Adjust according to response
Pain – trial antispasmodics eg mebeverine, buscopan
Diarrhoea – trial anti-motility = Regular loperamide – titrate to response.
Can use liquid (fine dose adjustments) or ‘imodium instants’ for rapid effect
Constipation –Non fermentable fibre – cracked linseed (1 tsp bd to 1 tbsp bd), or celevac (3 bd) or normacol (1 sachet bd) or
Stool softener laxatives eg Magnesium hydroxide 20ml od/bd or movicol
NB care with lactulose  gas; senna pain; consider trial of prucalopride for 4 weeks.
Aim is soft well-formed stool passed easily and with control
Alternating diarrhoea / constipation: use non-fermentable fibre supplements as above.
Take daily (do not stop on ‘diarrhoea’ days) to regulate the bowel.
Second line pharmacological treatment
Tricyclics the most effective pain management in IBS.
Take 3-4 months to work (be patient!). Start at low dose 10mg nocte amitriptyline - increase to 25mg after 2 weeks. Daytime sleepiness wears off – persevere!
F/U at 3-4 months. Continue medium-long term if effective. If truly intolerant try SSRIs (generally less effective).
Psychological intervention
Consider CBT, hypnotherapy, and/or psychological therapy if do not respond to above pharmacological treatments (refractory IBS)
Consider secondary care advice/guidance
Addenbrooke’s/CATCH IBS guidelines October 2014
Links to NICE, BSG guidelines, BDA etc

9. Example referrals to ? reconsider

10. Dyspepsia – non-fast-track

11. Dyspepsia Flow Chart

13. Issues Rarity of PUD if HP-ve and no NSAIDs
Extreme rarity of UGI cancer <55yrs
And doesn’t present with simple dyspepsia
Mx of IBS / constipn in pts with epigastric pain
Scoping to manage pt (and doctor) anxiety
What about Barrett’s?

14. Summary New referral process for GI We’re happy to advise
incl some words as well as boxes ticked!
We’re happy to advise
Feedback welcome