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Gastroenterology Service Referral Guidelines

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Indications for Referral

In order to make triage and first specialist assessments as efficient as possible, we have listed referral criteria and referral expectations for each condition in the table below.

Conditions which are not generally seen

  • Recurrent abdominal pain.
  • Irritable bowel syndrome.
  • Idiopathic constipation.
  • Uncomplicated gastro-oesophageal reflux.
  • Food allergies or intolerances.

Referrals for endoscopy

  • Some children may be accepted directly for endoscopy without being seen in clinic first
  • Please include details of all medications and previous surgery, so we can assess suitability for direct access endoscopy

Referrals for procedures

We perform the following specialised investigations but generally most children requiring these would be referred by a general or specialist paediatrician:

  • 24-hour pH impedance study
  • oesophageal manometry
  • wireless capsule endoscopy.

Referrals for percutaneous endoscopic gastrostomy (PEG) should be made to the Department of Paediatric Surgery

We are happy to discuss specific cases with colleagues if there is uncertainty about the need for a referral. Please discuss the child with the on-call paediatric gastroenterologist via the Starship Hospital operator (09 307 4949). This contact may be managed as a virtual consultation.

Common elective/ outpatient referrals and criteria

Diagnosis / Symptom  Refer to Gastroenterology when: Referral to include:
Neonatal cholestasis/liver disease • Conjugated hyperbilirubinaemia.
• If pale stools - urgent referral.
• Pigmented stools still require referral but may be seen less urgently.
• Full liver function panel.
• Coagulation screen.
• Documentation of stool colour.
• Results of complete diagnostic work-up to date.
Neonatal unconjugated hyperbilirubinaemia • Persistent unconjugated hyperbilirubinaemia requiring phototherapy after 2 weeks of life.
• Exclusion of haemolytic cause.
• Please phone to discuss patient.
• Serial bilirubin results.
• Details of phototherapy requirement and response.
• Results of complete diagnostic work-up to date.
Acute liver failure • Elevated LFTs with coagulopathy and/or encephalopathy - refer urgently to on call service. • LFTs & albumin.
• Coagulation.
• Glucose.
• Paracetamol level . 
Hepatitis B or C • Positive hepatitis B or C serology.
• NB: HBsAg may be transiently positive within 1 month of infant vaccination.
• Hep B - HbsAg, HBeAg, HBeAb, Hep B viral load.
• Hep C - HCV IgM/antibody, HCV load, Hep C genotype.
• HIV serology if relevant.
• LFTs and albumin.
• U&E.
• FBC.
• Alpha-fetoprotein.
• Abdominal ultrasound.
• Family history of affected individuals.
• Interpreter requirements. 
Other chronic liver disease  • Any undifferentiated liver disease i.e. persistently abnormal LFTs.
• Any known chronic liver disease e.g. Alagille, alpha-1-antitrypsin deficiency, Wilson's, autoimmune liver disease, sclerosing cholangitis, progressive familial intrahepatic cholestasis.
• Fatty liver disease with persistently abnormal liver function tests.
• NB: Any patients with coagulopathy, low glucose, encephalopathy or hypoalbuminaemia should be referred urgently (as above).
• FBC.
• U&E.
• LFTs and albumin.
• Glucose.
• Hep A, B, C serology.
• AFP.
• Abdominal USS.
• Growth measurements.
• For non-urgent referrals, alpha-1-antitrypsin phenotype, immunoglobulins (G, A, M), ANA, SMA, copper & caeruloplasmin (if older than 3 years).
Hepatosplenomegaly  • Evidence of hypersplenism on FBC or features of portal hypertension on USS.
• No evidence of haematological or metabolic cause for hepatosplenomegaly.
• Liver tumours should be referred to paediatric oncology.
• FBC.
• Coagulation.
• LFTs.
• Abdominal USS.
Extrahepatic portal venous obstruction or other cause portal hypertension • History of gastrointestinal bleeding.
• Clinical features of portal hypertension.
• Hypersplenism on blood count.
• Imaging findings suggesting portal hypertension.
• Any patient with a clinically significant gastrointestinal bleed should be referred urgently to the on-call gastroenterologist. 
• Details of bleeding episodes.
• Relevant imaging (Ultrasound scan as minimum).
• Neonatal history (including umbilical vessel cannulation).
• Medication history (in particular steroids, aspirin, non-steroidal anti-inflammatory drugs).
• FH of bleeding or thrombophilia. 
Inflammatory bowel disease  • High index of suspicion of IBD.
• Abdo pain, diarrhoea, weight loss, blood in stools.
• Stool infections excluded.
• Orofacial granulomatosis.
• Extraintestinal manifestations.
• Raised inflammatory markers.
• Children with suspected acute severe colitis should be discussed by phone and referred urgently.
• Abdo pain without red flag symptoms will not be seen. 
• Stool culture results.
• FBC & iron studies.
• ESR.
• CRP.
• Faecal calprotectin.
• LFTs & albumin.
Rectal bleeding  • Recurrent rectal bleeding.
• Unresponsive to laxative therapy.
• Any rectal bleeding in a child with FH of known or suspected polyposis syndrome.
• Children with idiopathic constipation will not be seen. 
• FBC.
• Coagulation screen.
• Results of imaging to date.
Refractory iron deficiency anaemia or occult GI blood loss • Evident melaena or altered blood in stool.
• Iron deficiency not explained by diet and/or not responsive to iron therapy or recurrent after effective treatment. 
• FBC.
• Haematinics.
• Coeliac serology.
• History of NSAIDs/steroids.
• Any known FH of peptic ulcer disease, H pylori, polyposis.
• Faecal occult blood testing is very sensitive and frequently positive in the absence of clinically significant blood loss. It is recommended to avoid using this test in this patient group.
Coeliac disease  See Coeliac Disease assessment and pathway  
Intestinal failure • Short bowel syndrome.
• Suspected intestinal dysmotility or pseudo-obstruction syndrome necessitating intravenous nutrition.
• Suspected congenital enteropathy or diarrhoeal syndrome.
• Any child requiring intravenous nutrition for ≥20 days (excluding preterm neonates).
• The majority of these patients will be inpatient at the time of referral, so early discussion with the on call gastroenterologist is recommended. 
• Details of all previous surgeries (in particular details of any resection, length & health of residual gut, presence of IC valve, stomas).
• Central line history (including number and sites of previous lines, details of septic episodes, results of vascular imaging, if done).
• All relevant imaging (PACS or CD-ROM).
• Results of diagnostic work-up to date.
• Current feeding regime (enteral and parenteral).
• Most recent IVN monitoring investigation results.
Suspected malabsorption • Suspected disaccharidase deficiency, congenital enteropathy or diarrhoeal syndrome, protein-losing enteropathy, exocrine pancreatic insufficiency.
• Unexplained iron deficiency, vitamin or other micronutrient deficiency.
• Results of diagnostic work-up to date. 
Severe gastro-oesophageal reflux  • Complicated gastro-oesophageal reflux (e.g. faltering growth, anaemia, haematemesis, stricture, known Barrett's oesophagus, respiratory or ENT complications).
• Proven or suspected reflux unresponsive to acid suppression.
• Suspected "silent" reflux requiring investigation.
• Diagnostic uncertainty e.g. Sandifer syndrome, respiratory manifestations, ENT manifestations.
• Referrals of children with uncomplicated reflux will not be accepted. 
• Details of investigations performed.
• Details of treatment to date (and response to treatment).
• Coeliac serology.
• Personal and family history of atopy. 
Food impaction or dysphagia  • Dysphagia.
• Recurrent food bolus obstruction.
• Suspected eosinophilic oesophagitis.
• Acute impaction or dysphagia should be directly referred to on-call paediatric surgeon. 
• History of episodes and triggers.
• PMH of reflux, ingestion of caustic agents.
• FH of atopy.
• Upper GI contrast study results. 
Severe feeding difficulties in infancy  • Feeding difficulties leading to faltering growth or requirement for supplemental NG feeds.
• No evidence of non-gastrointestinal cause e.g. anatomical abnormality, neurological diagnosis etc.
• Unresponsive to trial of acid suppression.
• Unresponsive to input from local dietetic and SLT services.   
• Details of investigation and management to date. 
Suspected polyposis syndromes   • Presentation with recognised gastrointestinal complications (bleeding, anaemia, intussusception, pain).
• FH of polyposis syndrome or early onset gastrointestinal malignancy.
• Multiple polyps on previous endoscopy.
• Extraintestinal manifestations suggesting syndrome, especially if positive FH (eg lip freckling, desmoid tumour, Gardner fibroma).
• Children born to parents with a diagnosed polyposis syndrome should be referred directly to the NZ Familial Gastrointestinal Cancer Service 
 
Chronic or recurrent acute pancreatitis  • Recurrent episode of acute pancreatitis.
• Single episode of acute pancreatitis in child with family history of pancreatitis.
• Evidence on investigation of chronic pancreatitis. 
• Detailed history of episodes.
• Relevant imaging (ultrasound scan, CT, MRCP).
• Results of diagnostic work-up to date. 
Referral for pH/impedance studies • Gastro-oesophageal reflux is primarily a clinical diagnosis.
• Detailed investigation is only required in a small minority of children.
• These might include those with diagnostic uncertainty.
• Extraintestinal manifestations (e.g. ENT, respiratory, neurological).
• Lack of response to therapeutic trials of acid suppression.
• Severe reflux prior to anti-reflux surgery.
• Previous detailed clinical assessment by a general or specialist paediatrician.
• Documentation of previous trials of anti-reflux therapy.
Referral for manometry studies
(available for children > 8 years of age only)
• Suspected oesophageal dysmotility.  • Details of investigations to date.
• Copies of relevant radiological imaging.

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Document Control

  • Date last published: 15 December 2015
  • Document type: Other
  • Services responsible: Paediatric Gastroenterology/Hepatology
  • Owner: Helen Evans
  • Editor: Greg Williams
  • Review frequency: 2 years

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