Category: All Referrals

Gastrointestinal (Upper) Cancer Endoscopy

Scott McLaughlin
Oesophago-gastric, hepatobiliary and pancreatic cancers

Approximately 3,000 people are diagnosed with a primary oesophago-gastric, hepatobiliary or pancreatic cancer in Scotland every year.

Common symptoms of oesophago-gastric cancer include weight loss, dysphagia, heartburn or pain, vomiting and anaemia. Common symptoms of hepatobiliary or pancreatic cancer include jaundice, abdominal mass, epigastric pain and weight loss. The risk of developing an oesophago-gastric cancer is higher in patients of East Asian origin and a higher suspicion of risk should be used in these patients.

An abdominal examination and appropriate blood tests (for example, full blood count, ferritin, urea and electrolytes test [U&Es] and liver function tests [LFTs]) should be performed on all patients with symptoms suggestive of these cancers. These findings can facilitate triage in secondary care. Referral should not be influenced by Helicobacter pylori (H pylori) status. Proton pump inhibitors should be avoided if possible prior to investigation. H2 antagonists may be used for symptomatic relief.

All patients with high-risk features should be referred to a team specialising in the management of oesophago-gastric, hepatobiliary or pancreatic cancers, depending on local arrangements.

Urgent suspicion of cancer referral

Oesophago-gastric cancer

Dysphagia (interference of the swallowing mechanism that occurs within 5 seconds of the swallowing process) or odynophagia (pain on swallowing) at any age.

New onset upper gastrointestinal pain or discomfort in people over 55 years.

New or worsening upper gastrointestinal pain or discomfort combined with one or more of the following features:

  • unexplained weight loss
  • unexplained iron deficiency anaemia

 

Persistent vomiting more than 4 weeks.

Upper gastrointestinal pain or discomfort combined with at least one of the following risk factors:

  • family history of oesophago-gastric cancer in more than two first-degree relatives
  • family history of familial adenomatous polyposis in any first-degree relative
  • Barrett’s oesophagus
  • pernicious anaemia
  • gastric surgery over 20 years ago
  • known dysplasia, atrophic gastritis or intestinal metaplasia
Hepatobiliary and pancreatic cancer

Features of hepatobiliary or pancreatic cancer can be vague and non-specific, and may include:

  • unexplained obstructive jaundice
  • upper abdominal or epigastric mass
  • unexplained back pain (consider other cancer causes such as malignant spinal cord compression)
  • unexplained weight loss
  • any suspicious abnormality, in the hepatobiliary tract, found on imaging (such as biliary dilatation or pancreatic/liver lesion)

Primary care management

Dyspepsia under 55 years without accompanying symptoms or risk factors should be managed according to local or national guidelines.

Good Practice Points

There should be a low threshold for considering investigation (perhaps with discussion about appropriate imaging with a radiologist) or routine referral for patients presenting with:

  • late onset diabetes in a weight-losing patient
  • non responsive dyspepsia following initial test and treat
  • post prandial pain or early satiety
  • new onset irritable bowel syndrome symptoms in middle age
  • steatorrhoea or fat malabsorption

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 87 – Management of oesophageal and gastric cancer
Clinical Lead Mr Hakim BenYounes, Chief of Medical Services, NHS Lanarkshire
Review Date March 2017

Gastro Intestinal (Upper) Cancer Endoscopy dictation template

Falls Service (Lanarkshire)

Scott McLaughlin
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.

NHS Inform Falls Zone Website

Falls Assistant Website

National Falls Program

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

Scott McLaughlin

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

Scott McLaughlin

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.

MUST Calculator

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.

Dietetics Firstport page

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

Scott McLaughlin

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).

999

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

Dental Orthodontic

Scott McLaughlin

Key Messages

Referred patients are seen for assessment by a Consultant Orthodontist.
The majority of orthodontic treatment can be carried out in Specialist Orthodontic Practice and the main role of the NHS Lanarkshire based service is to treat patients with more complex problems, in particular multi-disciplinary cases.

This may include:

  • Patients with clefts of the lip and palate and other craniofacial anomalies
  • Patients requiring combined orthodontic/restorative management
  • Patients requiring combined orthodontic/orthognathic surgery
  • Patients with ectopic teeth requiring minor oral surgery as part of their overall management
  • Patients requiring combined orthodontic/ paediatric dentistry management.
  • Index Of Treatment Need (IOTN) 4 and 5 only should be referred.

In addition, special needs patients where treatment is not practicable within primary care will be accepted. Also, a limited number of “routine” orthodontic cases are required to support training of orthodontic specialists and may be accepted for treatment depending on requirement at any given time.
Patients with a low/borderline need for orthodontic treatment will not be offered treatment within the Orthodontic department.

Oral Hygiene

Patients should be made aware that if their oral hygiene is inadequate they will not be accepted for treatment.

Patients referred with inadequate oral hygiene will be returned to the referring practitioner for appropriate hygiene phase therapy

Adult referrals

Adult referrals (aged 19 or over) will be accepted for assessment but are unlikely to be accepted for treatment unless they have a particularly complex problem or a need for multi-disciplinary management.
Please make this clear to any adults you refer.

Clinical Information

Our referral form provides space for you to give any additional information regarding your reason for requesting orthodontic assessment.

Radiographs

Any relevant radiographs, if available, should be sent as attachments if possible or as hard copy by post with a note to say that the patient has been referred via the SCI Gateway.

Did Not Attend Policy

As per our did ‘Not Attend Policy’ patients will not routinely be offered another appointment if they fail to attend without notifying the service before hand.
If the referrer wishes to re-refer, they may do so but please stress the importance of attending the appointment to the patient.

Please ensure:

In order for your patient to be seen as promptly as possible please ensure:

Patient demographic information is up to date
The referral is completed as fully as possible
The patient is aware of where and why they are being referred
The patient is ready for treatment and their oral hygiene is excellent

Lead Clincian: Ross Jones, Consultant Orthodontist
Review Date: 1st December 2015

Cysts, Direct Access

Scott McLaughlin

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

Scott McLaughlin

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, Suspicion of Cancer Referral

Scott McLaughlin
Lower Gastrointestinal Cancer

Lower gastrointestinal symptoms are common presentations in primary care. Rectal bleeding for instance is estimated to affect 14,000 individuals per 100,000 population each year. There are large differences in the predictive value of rectal bleeding for cancer according to its association with other symptoms and signs and the age of the patient. For example, the positive predictive value of rectal bleeding alone is 2.4%, which rises to 8.5% in combination with an abnormal rectal examination.

Different management strategies should be adopted according to cancer risk so that those patients with transient lowrisk symptoms caused by benign disease avoid unnecessary investigation. The following guideline is recommended for managing patients with features associated with a possible diagnosis of colorectal cancer. Guidance for referral to regional genetics centres for those with a family history of colorectal cancer is available available at Scottish Government Health and Social Care website. In patients with ulcerative colitis, a plan for follow up should be agreed.

An abdominal and rectal examination and a full blood count should be performed on all patients with symptoms suggestive of colorectal cancer. These findings can facilitate appropriate triage in secondary care. A negative rectal examination, or a recent negative faecal occult blood result, should not rule out the need to refer. The carcinogenic embryonic antigen (CEA) test should not be used as a screening tool. 
High-risk features
Urgent suspicion of cancer referral
BleedingRepeated rectal bleeding without an obvious anal cause
Any blood mixed with the stool
Bowel HabitPersistent change in bowel habit especially to looser stools (more than 4 weeks)
MassRight-sided abdominal mass
Palpable rectal mass
Iron deficiency anaemia
In men of any age with unexplained iron deficiency anaemia and a haemoglobin of 11g/100ml or below.
In non-menstruating women with unexplained iron deficiency anaemia and a haemoglobin of 10g/100ml or below.		Unexplained iron deficiency anaemia
OtherPast history of lower gastrointestinal cancer with any of the symptoms above

 

Primary care management

Low-risk features

  • Transient symptoms (less than 4 weeks)
  • Patients under 40 years in absence of high-risk features

Watch and wait (4 weeks)

  • Assessment and review
  • Consider bowel diary
  • Appropriate information, counselling and agreed plan for review with GP

Refer if symptoms persist or recur

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 126 – Diagnosis and Management of Colorectal Cancer
Lead Clinician Mr A Brown, NHS Lanarkshire
Review Date March 2017