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
Tag: gastrointestinal
Gastrointestinal (Upper) Cancer, Surgeon Template
This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Presenting Complaint
Main Presenting Complaint: [Text – 98 character maximum]
Reason for Referral: [Text]
World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:
Options:
- Asymptomatic
- Symptomatic but completely ambulatory
- Symptomatic, <50% in bed during the day
- Symptomatic, >50% in bed, but not bedbound
- Bedbound
Priority: Urgent Suspicion of Cancer
Date of Onset: [Date]
Will the patient accept any site for treatment:
- Yes
- No
Symptoms and Investigations
Symptoms
Unexplained weight loss:
- Yes (If Yes, please provide brief details)
- No
Unexplained iron deficiency anemia:
- Yes (If Yes, please provide brief details)
- No
Family history of oesophago-gastric cancer in more than two first degree relatives:
- Yes (If Yes, please provide brief details)
- No
Family history of familial adenomatous polyposis in any first degree relative:
- Yes (If Yes, please provide brief details)
- No
Barrett’s oesophagus:
- Yes (If Yes, please provide brief details)
- No
Pernicious anaemia:
- Yes (If Yes, please provide brief details)
- No
Gastric surgery over 20 years ago:
- Yes (If Yes, please provide brief details)
- No
Known dysplasia, atrophic gastritis, intestinal metaplasia:
- Yes (If Yes, please provide brief details)
- No
Upper abdominal epigastric mass:
- Yes (If Yes, please provide brief details)
- No
Iron deficiency anaemias:
- Yes (If Yes, please provide brief details)
- No
Clincal Examination
Jaundice:
- Yes (If Yes, please provide brief details)
- No
Upper abdominal mass:
- Yes (If Yes, please provide brief details)
- No
Investigations
FBC and ESR sent:
- Yes
- No
LFT, U&E sent:
- Yes
- No
Previous endoscopy done:
- Yes
- No
Gastrointestinal (Upper) Cancer, Endoscopy Template
This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Presenting Complaint
Main Presenting Complaint: [Text – 98 character maximum]
Reason for Referral: [Text]
World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:
Options:
- Asymptomatic
- Symptomatic but completely ambulatory
- Symptomatic, <50% in bed during the day
- Symptomatic, >50% in bed, but not bedbound
- Bedbound
Priority: Urgent Suspicion of Cancer
Date of Onset: [Date]
Will the patient accept any site for treatment:
- Yes
- No
Symptoms and Investigations
Symptoms
Unexplained weight loss:
- Yes (If Yes, please provide brief details)
- No
Unexplained iron deficiency anemia:
- Yes (If Yes, please provide brief details)
- No
Family history of oesophago-gastric cancer in more than two first degree relatives:
- Yes (If Yes, please provide brief details)
- No
Family history of familial adenomatous polyposis in any first degree relative:
- Yes (If Yes, please provide brief details)
- No
Barrett’s oesophagus:
- Yes (If Yes, please provide brief details)
- No
Pernicious anaemia:
- Yes (If Yes, please provide brief details)
- No
Gastric surgery over 20 years ago:
- Yes (If Yes, please provide brief details)
- No
Known dysplasia, atrophic gastritis, intestinal metaplasia:
- Yes (If Yes, please provide brief details)
- No
Upper abdominal epigastric mass:
- Yes (If Yes, please provide brief details)
- No
Iron deficiency anaemias:
- Yes (If Yes, please provide brief details)
- No
Clincal Examination
Jaundice:
- Yes (If Yes, please provide brief details)
- No
Upper abdominal mass:
- Yes (If Yes, please provide brief details)
- No
Investigations
FBC and ESR sent:
- Yes
- No
LFT, U&E sent:
- Yes
- No
Previous endoscopy done:
- Yes
- No
Gastrointestinal (Upper) Cancer Surgeon
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
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
Colorectal, Suspicion of Cancer Referral
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 | |
|---|---|
| Bleeding | Repeated rectal bleeding without an obvious anal cause Any blood mixed with the stool |
| Bowel Habit | Persistent change in bowel habit especially to looser stools (more than 4 weeks) |
| Mass | Right-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 |
| Other | Past 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