Tag: dysphagia

Head and Neck, Suspicion of Cancer Referral

Scott McLaughlin

Head and Neck Cancers

The incidence of head and neck cancer is increasing and around 1,200 people are diagnosed with a head and neck cancer each year in Scotland, of which around 240 are thyroid cancers. The incidence of oropharyngeal cancer is increasing in the younger population, and appears to be associated with human papilloma virus (HPV) infection.

Risk factors for head and neck cancers (excluding thyroid) include: smoking, HPV, alcohol, poor diet, social deprivation, tobacco chewing habits (including Betel, Gutkha and Pan) and older age. The risk of developing nasopharyngeal cancer is higher in patients of Chinese origin and a higher index of suspicion should be used in these patients.

All patients with features suspicious of malignancy should be referred to a team specialising in the management of head, neck or thyroid cancers, depending on local arrangements

With the changing pattern of disease, age, non-smoking or non-drinking status should not be a barrier to referral.

Emergency Referral

Stridor

Urgent suspicion of cancer referral

Head and Neck Cancer
  • Persistent unexplained head and neck lumps for >3 weeks.
  • Ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks.
  • All red or mixed red and white patches of the oral mucosa persisting for >3 weeks.
  • Persistent hoarseness lasting for >3 weeks (request a chest x-ray at the same time).
  • Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks.
  • Persistent pain in the throat lasting for >3 weeks.
Thyroid Cancer
  • Solitary nodule increasing in size.
  • Thyroid swelling in a pre-pubertal patient.
  • Thyroid swelling with one or more of the following risk factors:
    • neck irradiation
    • family history of endocrine tumour
    • unexplained hoarseness
    • cervical lymphadenopathy.

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 90 – Diagnosis and Management of Head and Neck Cancer
Clinical Lead Mr Andrew Carton, Head and Neck Surgeon, Monklands DGH
Review Date March 2017

Gastrointestinal (Upper) Cancer Surgeon

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

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

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.