This protocol should ony be used to refer patients with no suspicion of cancer.
If there is a suspicion of cancer, the patient should be referred using the guidelines and protocols in the Lanarkshire Cancer Referral Centre
Category: General Practice Referrals
General Practice referral guidelines
Falls Service (Lanarkshire)
Guideline for GP Practice Falls Screening
Framework for Action for Scotland highlights that health and social care services have a conversation to identify people who have fallen or are at risk of falling. This includes:
- Anyone over the age of 65.
- Anyone who may be at risk of falls due to a long term condition such as dementia, multiple sclerosis, arthritis etc.
Lanarkshire has developed a Falls Pathway to ensure that anyone who is identified as being at risk of falls or has had a fall has the opportunity for further assessment and intervention. The basic falls screening conversation may take place in the GP practice using the 6 screening questions contained in this referral.
What happens next?
The referral will be reviewed by the Falls Register Team for further triage and signposting
The Falls Register team will contact the patient and discuss their basic falls screening and commence a more detailed Falls Assessment. They will signpost the person to Leisure, Physiotherapy, Occupational Therapy, Social Care, Community Rehabilitation and Home Fire Safety as appropriate. All referrals to the register team are discussed with the specialist Falls Team and can be passed for more complex assessment as appropriate.
The Falls Register is a database of all patients who have had a falls screening conversation. The Register Team can review previous falls assessments and discuss any new falls with the specialist Falls Team and GP Practice/Care Manager.
If the patient has more complex falls needs and requires medical assessment, they referral will be forwarded to Falls Medical Clinic for Complex Falls Assessment at the location selected in the referral.
What can the GP Practice do to help prevent falls?
- Provide information on healthy active ageing (see useful resources)
- Lying and Standing blood pressure check
- Medication Review
- Leisure referral for strength and balance
Useful Resources
There are several resources available to support the pathway:
Up and About Booklet available from Jim Rae, Health Promotion Library Email Tel: 01698 377629.
Falls Team Contact
Falls Register, Glendoe Building, Coathill Hospital, Coatbridge, ML5 4DN
- Lanarkshire Falls Register Tel: 01236 707716
- Lanarkshire Falls Service Tel: 01236 707750
Reference:
Lead Clinician:
Review Date:
ENT Cancer Referral
Consider referral to ENT when the patient presents with any of the following signs or symptoms:
- Hoarseness persisting for more than 3 weeks
- High dysphagia persisting for more than 3 weeks
- Unresolved neck masses for more than 3 weeks
- (** Also refer to Monklands or Hairmyres Hospital for ultrasound and or FNA **)
- Persistent unilateral unexplained throat pain
- Unilateral nasal obstruction particularly when associated with purlent discharge
- Unexplained ear pain particularly with any of the above
Stridor should be referred as an emergency
Consider referral to Maxillofacial when the patient presents with any of the following signs or symptoms:
- Ulceration of oral mucosa persisting for more than 3 weeks
- Oral swellings persisting for more than 3 weeks
- All red or red and white patches of the oral mucosa
- Unexplained tooth mobility not associated with peridontal disease
Consider referral to Ophthalmology when the patient presents with any of the following signs or symptoms
- Orbital masses
Consider referral to General Medicine when the patient presents with any of the following signs or symptoms
- Cranial neuropathies
CCI Guidelines
The CCI Referral Guidelines can be found at ENT Referral Pathways.
Dietetics Service Referral
NHS Lanarkshire Dietetics Service
Adult Nutritional Support – Only patients who are at risk of malnutrition should be referred to this service. These will be patients with a MUST score of 2 and above (see below for detailed explanation).
Paediatric Dietetics – should be used for all paediatric referrals
Adult Dietetics – All other adult dietetic referrals should be completed here
Guidelines for Adult Oral Nutrition Support Referrals
The Community Dietetic Service will accept referrals which conform to our referral criteria.
For proposed referrals which do not fit these referral criteria please use the links to our First Line Advice Documentation provided.
| Medical or Dietary Condition | Referral Criteria |
|---|---|
| Adult Obesity | BMI of 35kg/m² or greater , BMI 30kg/m² or greater with co-morbidities or requiring advice to support use of anti obesity medication e.g. Orlistat Patients who do not fit these criteria can receive advice from the following websites: British Dietetic Association Weight Wise British Dietetic Association Food Fact Sheets For patients with a BMI of 25 or higher, who do not fufill the referral criteria, a self referral can also be made to the Weigh To Go weight management/lifestyle initiative run in North and South Lanarkshire leisure venues : Weigh To Go |
| Hyperlipidaemia | Total Cholesterol of 6.0mmol/l or greater and/or Serum Triglycerides > 2.0mmol/l will be accepted in the community Patients who do not fufill these criteria can receive advice using these websites: British Heart Foundation Publication Search British Dietetic Association Food Fact Sheets |
| Hyperlipidaemia Food Allergy/Intolerance | Single Adult Food Allergy/Intolerance can be seen in the community setting following a confirmed medical diagnosis from a specialist in allergy medicine. Adult Multiple Food Allergy can be seen by community dietetics following a confirmed allergy specialist diagnosis. Paediatric Single or Multiple Food Allergy/Intolerance should be referred via the SCI Gateway Paediatric Referral page. |
| Coeliac Disease | Patients will have received a confirmed diagnosis of Coeliac Disease following blood anti body tests and small bowel biopsy and/or a diagnosis of Dermatitis Hepetiformis In addition patients should be directed to: Coeliac UK website |
| Gastrointestinal Diseases Irritable Bowel Syndrome Diverticular Disease | Referrals will be accepted for patients who have been unsuccessful in improving or settling their IBS symptoms following use of first line advice provided on the British Dietetic Association Food Fact Sheets website Referrals will be accepted for patients with a confirmed diagnosis of Crohn's Disease, Ulcerative Colitis and Diverticular Disease |
| Therapeutic Diets Low Iron Levels Low Vitamin B12 Levels Low Vitamin D levels Low Calcium Levels Constipation | Please use first line advice information located on the British Dietetic Association Food Fact Sheets website Please only refer to the service if first line advice has proved unsuccessful |
| Texture Modification | Referrals should be made in conjunction with a referral to a Speech and Language Therapist for confirmation of the required texture before dietary advice can be provided. |
Additional Information
All patients will be seen in an outpatient clinic setting in a health centre within or near their home locality.
Domicilliary Visits will only be accepted by the service for patients who are permanently confined to their home and meet the referral criteria laid out above.
The department will aim to see urgent referrals from receipt of the referral within 1 month and routine referrals within 9 weeks.
Guidelines for Paediatric Dietetic Referral
Please consider whether it is appropriate to refer to dietetics in the first instance from the guidance provided below:
Medical paediatric referrals
The following conditions require initial referral to a Paediatrician who will then make onward referral to dietetics where appropriate:
Allergy – unconfirmed multiple and/ or severe including anaphylaxis
Cystic Fibrosis
Diabetes
Endocrine
Enteral feeding
Gastroenterology – suspected Crohns/ colitis/ IBS/ liver disorders
Neonatology – feeding difficulties, poor growth
Neurodisability
Renal
Child and Adolescent Mental Health Service (CAMHS) referrals
If a child or young person is suspected of having an eating disorder they should be referred directly to the local CAMHS team:
Airdrie/Cumbernauld Child and Family Clinic,
Glendoe Building,
Coathill Hospital,
Hospital St,
Coatbridge,
ML5 4DN
01236 707774
Bellshill/ Coatbridge Child and Family Clinic,
Coatbridge Health Centre,
1 Centre Park,
Coatbridge
ML5 3AP
01236 438402
Clydesdale, East Kilbride and Hamilton Child and Family Clinic,
194 Quarry Street,
Hamilton,
ML3 6QR
01698 426753
Motherwell/Wishaw Child & Family Clinic,
49/59 Airbles Rd,
Motherwell,
ML1 2TJ
01698 269651
First Line Advice
Please use first line advice for simple conditions as listed below. Public health nurses and Integrated Children’s Services may also be able to offer support. If the situation has not improved within 2 to 3 months then a referral can be made to dietetics.
Constipation
Fussy eating
Healthy eating (including vegetarian)
Infant feeding
Iron deficiency anaemia
Low Vitamin D
Weaning
The first line advice is available via two routes:
Email – Public Folders/ Paediatric dietary help sheets
Firstport/ Intranet – Clinical services/ Child health/ General paediatrics/ dietetic advice for children
Dietetic Referrals:
- Referrals can be made for the following conditions:
- Allergy – single foods (including milk allergy and reflux), confirmed multiple allergies
- Autism – for dietary manipulation and or associated faltering growth
- Chronic respiratory conditions – where there are concerns about nutrition and growth
- Dietary assessment – where there are concerns over nutrient quality, adequacy and growth (after first line advice has been given)
- Gastroenterology – coeliac disease
- Growth – faltering, undernutrition, weight management
- The dietitians will triage them to seen in the acute or community settings as per ‘Dietetic Guidelines for referrers FEB 2012’
Guidelines for Adult Oral Nutrition Support Referrals
Screening
Only patients referred with a MUST score of 2 or more will be accepted into the service.
The “Malnutrition Universal Screening Tool”, (MUST), has been designed to help identify adults who are underweight and at risk of malnutrition and is supported by the British Dietetic Association, The Royal College of Nursing, the Registered Nursing Home Association and the Royal College of Physicians.
MUST has been designed to help you to identify adults in your practice who are underweight and at risk of malnutrition and who may benefit from dietetic involvement.
“Using MUST Malnutrition risk has been identified in 18% to 30% of patients attending outpatients clinics and GP surgeries”, Elia, M. Screening for malnutrition: a multidisciplinary responsibility. Development and use of the “Malnutrition Universal Screening Tool” – (MUST) for Adults. MAG, a standing committee of BAPEN, 2003
“Greater use of healthcare and costs associated with malnutrition mean: 65% more GP visits; 82% more hospital admissions; 30% longer hospital stay”, www.mindthehungergap.com
Key MUST links:
The MUST Itself
Introducing MUST
The “Malnutrition Universal Screening Tool” (MUST) has been evaluated in hospital wards, outpatient clinics, general practice, the community and in care homes. Using the MUST to categorise patients for their risk of malnutrition was found to be easy, rapid, reproducible, and internally consistent.
The Department of Nutrition and Dietetics aims to provide an efficient, equitable service to patients and to assist in this, the provision of a MUST score is highly desirable.
Patients with a MUST score of 1 or less will not be seen by the service and should be provided with first line nutritional advice which can be found on Firstport.
These include: –
- Get More In!
- Get More In! for Diabetics
- Get More in Drinks!
- Get More in Drinks! for diabetics
- Snacks to Supplement your Diet
Triage
Referrals will be prioritised and triaged based on their MUST score. (This will be vetted by the dietitians)
Patients with a MUST score of 4 and above will be prioritised as URGENT .
Additional Considerations
- Only patients that are house bound and unable to attend a clinic will be offered a domiciliary visit.
- Patients with alcohol or drug misuse who are not currently being supported by another appropriate service (such as addiction services, CPNs etc) will not be seen.
- Patients referred only due to low albumin, will not be seen as this alone is not an indicator of nutritional status.
- Patients at the end of life are likely to be an inappropriate referral. Please seek guidance from the Management of Patients in Late Palliative Care.
- Care pathway link to Long Term Conditions document – Guidance for the nutritional management of patients in late palliative care
Diabetes (Acute) Guidelines
SCI Gateway Referral Protocol for NHS Lanarkshire Acute Diabetes Service
MCN Guidelines are contained in the ‘Lanarkshire Diabetes Clinical Guidelines’ folder on the Diabetes Service Firstport page. (This link is only available within NHS Lanarkshire’s network).
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THOSE WITH UNCONSCIOUS HYPOGLYCAEMIA, SUSPECTED KETOACIDOSIS OR NON-KETOTIC HYPEROSMOLAR COMA NEED REFERRAL TO A&E VIA SCOTTISH AMBULANCE SERVICE (SAS)
Acute Admission via ERC
- Any patient with Type 1 diabetes who presents with vomiting and/or is biochemically unstable (including new diagnosis)
- Patients with infected, necrotic or gangrenous foot ulcer/suspected Charcot foot IF unable to access specialist podiatrist
- Patients presenting with acute deterioration in renal function
Acute Diabetes Specialist Nurse (DSN) same day (by telephone)
- Newly diagnosed Type 1 Diabetes, where patients are not vomiting and who are biochemically stable
- Patients with recurrent hypoglycaemia or loss of hypo awareness, who have been referred to the Consultant for review, contact the acute DSN service for interim advice
General Notes
In general, if patients require assessment, intervention and support by a diabetes specialist allied health professional (nursing, dietetics) and have Type 1 Diabetes they should be directed to the Acute service. If they have Type 2 Diabetes they should be directed to the Community service.
Expected outcome
- Please refer to Diabetes SESP for guidance. Patients referred for ‘Continuing care of a complex patient’ may no longer be eligible for the Enhanced Service.
Consultant Diabetologist
Routine
- People with Type 1 Diabetes who previously failed to attend, but who are now receptive to Consultant review
- Recurrent hypoglycaemia or loss of hypo awareness
- Persistent hypertension and hyperlipidaemia despite intensive management as per current guidelines
- Microvascular complications associated with poor glycaemic control despite maximising treatment as per current guidelines
- Painful neuropathy not responding to treatment as per current guideline
- Erectile dysfunction associated with poor glycaemic control despite maximising treatment as per current guidelines
- Suspicion of autonomic neuropathy (e.g. gustatory sweating, gastric paresis) associated with poor glycaemic control
- Patients under 35 with a new diagnosis of Type 2 Diabetes
- Patients for whom insulin pump therapy (CSII) is to be considered
- Patients with Type 2 Diabetes to be considered for GLP-1 analogue therapy (e.g. exenatide, liraglutide) or insulin therapy
Diabetes Specialist Nurse (DSN) Service
Urgent
- Destabilised Type 1 or Type 2 Diabetes ( Intercurrent illness or new medication (e.g. corticosteroids)
- Women with Type 1 or Type 2 Diabetes contemplating or with confirmed pregnancy
Routine
Type 1
- Poor glycaemic control in Type 1 Diabetes despite intensive management
- People with Type 1 Diabetes who previously failed to attend, but who are now receptive to DSN review and support
- Those requiring one to one support to overcome barriers to self-care
- Patients for DAFNE programme (structured education for Type 1 Diabetes)
Type 2
People with Type 2 Diabetes on dual or triple oral therapy with poor glycaemic control
- HbA1c > 58 – 64 mmol/mol (7.5 – 8%) or outwith individual agreed target, despite increasing/maximising medication
- Recurrent hypoglycaemia, despite reduction in oral medication (or loss of hypoglycaemia awareness)
People with Type 2 Diabetes on insulin therapy with poor glycaemic control
- HbA1c > 58 – 64 mmol/mol (7.5 – 8%) or outwith individual agreed target
- Fasting BG levels persistently > 7 mmol
- Pre-meal BG levels persistently > 9 – 10 mmol
- Recurrent problems with hypoglycaemia or loss of hypoglycaemia awareness
- Those requiring one to one support to overcome barriers to self-care
Diabetes Specialist Dietician
Type 1
- All patients with Type 1 Diabetes aged 16 and over
- Patients with Type 1 or Type 2 Diabetes who have developed complications which have nutritional implications (e.g. gastroparesis, nephropathy)
- Patients with Type 1 or Type 2 diabetes who require enteral feeding
Type 2
- Newly diagnosed Type 2 Diabetes
- Newly identified increased risk of Diabetes (Impaired Fasting Glycaemia or Impaired Glucose Tolerance, Gestational Diabetes)
- Patients with Type 2 Diabetes who are being commenced on insulin or GLP-1 therapy
- Deteriorating glycaemic control in Type 2 Diabetes despite maximum tolerated oral and/or insulin therapy
- People with Type 2 Diabetes requesting a one to one appointment for education instead of X-pert structured patient education
Diabetes Specialist Podiatrist
- High risk feet (by telephone) – followed by SCIGW referral marked as urgent
General Podiatry
(use existing referral routes and not diabetes eReferral protocol)
- Newly diagnosed Type 1 or Type 2 Diabetes for initial foot screening and foot care education
- Moderate risk feet
Multidisciplinary Foot Clinic
- Tertiary referral via specialist diabetes podiatrist
Retinal Screening
- Automatically via SCI DC Network when diagnostic code for diabetes added to the GP Clinical IT system **only add the code when the patient has been informed of the diagnosis**
- Via direct referral letter (if patient declines SCI DC Network inclusion)
Self Management Structured Education Programmes throughout NHS Lanarkshire
Xpert (Type 2 Diabetes)
- Self referral by telephone
DAFNE (Type 1 Diabetes)
- Via tertiary referral following assessment by Diabetes Specialist Team
Dermatology Referral
This protocol should only be used to refer patients with no suspicion of cancer.
If there is a suspicion of cancer, the patient should be referred using the guidelines and protocols on the Lanarkshire Cancer Referral Centre
Cysts, Direct Access
This referral will not be vetted or prioritised by a consultant
Patients referred using this protocol will be seen at a nurse led routine cyst clinic (chalazion or meibomian cysts).
If your patient is less than 14 years of age, or there is any uncertainty about the nature of the lesion the patient should be referred using the general ophthalmology protocol
Before referring the patient have you considered warm compresses and or topical antibiotic therapy (see Blepharitis Treatment Tab)
Community Claudication
General Guidelines
Priority will be given to patients with critical limb ischaemia (severe rest pain, arterial ulcers, necrosis), symptomatic carotid stenosis and aortic aneurysm – who are likely to require surgical or radiological intervention.
Leg Ischaemia
Most patients with recent onset intermittent claudication will improve spontaneously – especially if they are encouraged to correct known risk factors (e.g. smoking, cholesterol, hypertension, obesity, low activity level). Furthermore timely attention to secondary prevention will reduce mortality and morbidity due to cardiac and cerebro-vascular disease in this high-risk group.
Patients with mild to moderate intermittent claudication do not require invasive vascular interventions.
Patients with suspected mild to moderate intermittent claudication may be referred to the local Community Claudication Clinic (via SCI Gateway) for confirmation of the diagnosis, cardiovascular risk factor assessment and appropriate counselling.
The Community Claudication Clinic
Our service has been set up in eight clinics across Lanarkshire for patients with suspected intermittent claudication (i.e. early peripheral arterial disease). We offer initial assessment and management by a Vascular Nurse and onward referral to the Vascular Physiotherapist and local services as appropriate.
NB We are unable to provide patient transport to the Community Claudication Clinic.
Fasting blood sugar, fasting lipids and full blood count, prior to referral, would facilitate patient management.
Patients with severe intermittent claudication, not improved by a regime of smoking cessation, walking exercise, antiplatelet treatment, statin, weight reduction etc. may be referred for Hospital Vascular OP Clinic assessment.
Patients with suspected critical limb ischaemia (rest pain, arterial ulcers, necrosis) should initially be discussed by contact with one of the Vascular Secretaries at Wishaw general Hospital or Hairmyres Hospital in hours on WGH 01698 366549 and HM 01355 584743. Appropriate arrangements will be confirmed by return call.
In the case of suspected ACUTE limb ischaemia with possible immediate limb threat (e.g. failed perfusion and sudden diminished sensation and movement): please refer as an emergency via ERC to the receiving surgical team.
Aortic Aneurysm
Patients with aortic aneurysm > 5cm, even without related symptoms, should be referred as an urgent case to the Hospital Vascular OP Clinic. Smaller aortic aneurysms may be referred as routine cases.
Patients with suspected symptomatic abdominal aortic aneurysm (i.e. recent onset or increasing back pain, acute tenderness of the aneurysm, distal embolism) should be referred as an emergency via ERC to the receiving surgical team.
Carotid Artery Disease
Patients with suspected carotid artery disease should be referred urgently to the Stroke Service via SCI Gateway if they present with symptoms of stroke, TIA, or amaurosis fugax.
Colorectal General Referral
This protocol should only be used where there is no suspicion of malignancy
If there is a degree of suspicion please see the guidelines below and refer through the Lanarkshire Cancer Referral Centre
Colorectal Cancer Referral Guideline
Risk-Based guidelines for Investigating Patients with Colorectal Symptoms
Patients with any of the following symptoms and associated symptoms should be referred urgently through the Lanarkshire SCI Gateway Cancer Referral Services. This will ensure that a patient pathway co-ordinator tracks the referral from the day it is sent..
Patients over 75 will be seen at the clinic first and will not be appointed straight to test.
| Main Symptom | Associated Symptom | Age | Patient will be booked for |
|---|---|---|---|
| Rectal bleeding for > 6 week | Frequent and/or loose stools for 6 weeks Constipation Constipation in isolation in isolation | >75 <75 >50-74 <50 >50-74 <50 | Outpatient clinic Colonoscopy Flexible Sigmoidoscopy and Barium Enema Please refer using Routine Colorectal Guideline (below) Flexible Sigmoidoscopy and Barium Enema Please refer using Routine Colorectal Guideline (below) |
| Diarrhoea 3 or more loose or liquid stools/day for > 4 weeks | >75 >50-74 <50 | Outpatient clinic Colonoscopy Please refer using Routine Colorectal Guideline (below) |
|
| Palpable mass, right sided Abdominal mass or Rectal mass | Any | Outpatient clinic appointment | |
| Iron deficiency Anaemia. Unexplained | Upper GI symptoms in isolation male or postmenopausal female in isolation male or postmenopausal female Pre-menopausal female | <75 >75 | Please refer using the Upper GI Suspected Cancer Guidelines Colonoscopy and gastroscopy Outpatient clinic Please refer using Routine Colorectal Guideline (below) or to Gastroenterology |
Routine Colorectal Referral Guideline
Patients with any of the following symptoms and associated symptoms should be referred routinely through the Lanarkshire SCI Gateway to the colorectal specialty in the appropriate hospital.
Patients over 75 will be seen at the clinic first and will not be appointed straight to test
| Main Symptoms | Associated symptom | Age | Patient will be booked for: |
|---|---|---|---|
| Rectal bleeding for > 6 weeks | Constipation in isolation | <50 <50 | Flexible Sigmoidoscopy Flexible Sigmoidoscopy |
| Diarrhoea 3 or more loose or liquid stools/day for > 4 weeks | <50 | Outpatient clinic | |
| Constipation recent change of bowel habit | >75 >50-74 <50 | Outpatient clinic Flexible Sigmoidoscopy and Barium Enema Outpatient clinic |
|
| Iron deficiency Anaemia. Unexplained | In isolation | Premenopausal female | Gastroenterology or Colorectal Outpatient Clinic |
All patients who require direct referral to test should be:
- Physically fit for bowel preparation
- No Anal symptoms (pain, discomfort, itching, lump and prolapse)
- No Large bowel investigations carried out in the last 2 years
Investigations
No examinations or investigations (other than abdominal and rectal examination ,Uamp;E (for patient safety with bowel prep) and FBC are recommended).
Chronic diarrhoea – recommended investigations are Uamp;E, FBC, CRP, TFT and faeces culture
FOB or CEA is not indicated and should not influence decision making in symptomatic patients.
Key Points:
Patients with the following symptoms are at very low risk of cancer and could be managed initially within Primary Care or referred non-urgently for assessment:
- Rectal bleeding with anal symptoms
- Change in bowel habit to decreased frequency of defaecation and harder stools.
- Abdominal pain without clear evidence of intestinal obstruction.
Colorectal Cancer and Family History
Individuals who have a family history of colorectal cancer but who are asymptomatic may warrant investigations if their history meets the criteria outlined in the following table. If any of the criteria are fulfilled patients should be referred for risk assessment to:
Regional Genetics Service
Management of High Risk Groups
| Risk | Criteria for Screening | Screening | Age of Screening |
|---|---|---|---|
| High | At least three family members affected by CRC and one with endometrial cancer in at least two generations; one affected relative must be age ?50 years at diagnosis; one of the relatives must be a first degree relative of the other two Gene carriers (HNPCC genes) Untested primary relatives of gene carriers | Colonoscopy every 2 years Discuss gynaecological screening for endometrial and ovarian cancer Offer 2 yearly upper GI endoscopy for gastric cancer Consideration needs to be given to other screening for other cancers which may occur in specific families and are part of the HNPCC spectrum | From 30 to 70 years (or 5 years younger than the youngest affected relative) For stomach cancer from 50 to 70 years or 5 years younger than the youngest stomach cancer |
| Medium | One first degree relative affected by colorectal cancer when aged < 45 years; or Two affected first degree relatives (one less than 55 years); or Two (one CRC less than 55 years) or three affected individuals with colorectal or endometrial cancer who are first degree relatives of each other and one a first degree relative of consultand. | Single colonoscopy if normal findings Single repeat colonoscopy | At 30-35 years and again at 55 years |
| Low | Anyone not fulfilling medium or high risk criteria | Reassure and encourage healthy lifestyle GP to monitor | N/A |
Hereditary Nonpolyposis Colorectal Cancer (HNPCC)
Sign revised edition – in press
HNPCC is an autosomal dominant condition caused by a mismatch repair gene mutation. Individuals carrying a mismatch repair gene mutation or fulfilling high risk criteria for HNPCC should be offered endoscopic screening starting in the twenties if possible and repeated every 2-3 years taking into account the patient’s general condition and uptake. Diagnosis requires:
At least three relatives with a HNPCC-associated cancer (colorectal, endometrial, small bowel, ureter or renal pelvis) (one of whom should be a first degree relative of the other two)
At least two consecutive generations should be affected
At least one should be diagnosed before age fifty years
Referral should be made to the Regional Genetics Service for consideration of Mismatch Repair Gene mutation analysis
Familial adenomatous polyposis (FAP)
Sign Revised edition – in press
FAP is an autosomal dominant condition caused by an APC gene mutation and characterised by the development of multiple adenomatous colorectal polyps and the subsequent development of one or more colorectal cancers. In patients with FAP, referral should be made to the Regional Genetics Service for consideration of APC Gene mutation analysis. For those at risk of FAP, determined either by a positive family history or on the basis of mutation analysis should be offered:
At least three relatives with a HNPCC-associated cancer (colorectal, endometrial, small bowel, ureter or renal pelvis) (one of whom should be a first degree relative of the other two)
Colonoscopy every 2-3 years and yearly sigmoidoscopy
Patients should be offered proctocolectomy with or without ileoanal reconstruction or total colectomy with ileorectal anaastomsis once adenomas have developed. Subsequent management should include lifelong survey
Other High Risk Groups
A number of chronic conditions require structured surveillance. These include:
Chronic Inflammatory Bowel Disease
Acromegaly
Peutz-Jeghers Syndromme
Juvenile Polyposis Coli
Reference: Scottish Referral Guidelines for Suspected Cancer. Scottish Executive 2007
SIGN Guideline 67 -Management of Colorectal Cancer
Lead Clinician Mr Alistair Brown, NHS Lanarkshire
Review Date Dec 2010
Chronic Leg Ulcer
This protocol should only be used where the following conditions apply:
- Ulcers of unknown cause
- Venous ulcers and / or dermatitis unresponsive to first line treatment (SIGN guideline No 26)
- Please include details of contact allergies and recent topical treatment
Ulcers which are clearly arterial should be referred to a vascular surgeon or interventional radiologist
Diabetic foot ulcers should be referred to podiatry