GI and Colorectal

Upper GI

PDF version of the upper gastro-intestinal symptoms pathway and the dyspepsia non-invasive management referral guidance:

Suggested Management Pathway: Upper GI Symptoms

ENDOSCOPY – regional open access upper GI V1 (PDF Version)

ENDOSCOPY – regional open access upper GI V1 (Zipped Folder for EMIS Practices)

 

Colorectal

NCA Colorectal Symptoms Assessment Pathway for GPs V29

NCA FIT GP leaflet V5

The short film here provides FIT (symptomatic patients) information for the primary care team.

For:

  • New or persistent lower GI symptoms or abdominal pain for >3 weeks
  • Unexplained weight loss
  • Rectal bleeding
  • Base line tests FBC / U+E / ferritin / coeliac screen

2WW CRITERIA OR HIGH RISK NO CONFIRMED IDA

  • Men
  • non-menstruating women >40y
  • women >50y
NO
Rectal bleeding
NO
  • Iron deficiency Anaemia
  • Isolated low ferritin
YES
  • No clinical concern or age <50
  • Reassure / treat conservatively
  • Consider advice and guidance or routine referral for persistent or troublesome symptoms
YES
2WW REFERRAL
NO

MEDIUM RISK LOWER GI SYMPTOMS

  • clinical suspicion of colorectal cancer
  • Unexplained raised platelets >450 x2 tests 6 weeks apart
  • >60y Anaemia without IDA
YES
YES

LOW RISK IDA

  • <50y IDA explained
  • <50y change in bowel habit

MEDIUM RISK

  • Unexplained confirmed medium risk IDA
  • Unexplained low ferritin
YES
NO
NO

LOW RISK

  • <50y change in bowel habit
Possible IBD / IBS
YES
Positive FIT
Offer FIT consider CT if weight loss sx
Negative FIT
Offer faecal calprotectin test Repeat after 4 weeks if 100-250
<100
Likely IBS manage in Primary Care
100-250
Routine GI referral
>250
URGENT Not 2WW referral
SAFETY NETTING in primary care and conservative treatment as required Consider advice and guidance or routine referral for persistent or troublesome symptoms

Patients with bowel symptoms/high risk anaemia for urgent (2WW) referral

Any age with rectal mass
Consider 2WW colorectal clinic referral

Any age with abdominal mass

OR

Age 40+ with abdominal pain and weight loss

Consider 2WW colorectal referral and/ or contrast CT of abdomen and pelvis

Age 50+ with rectal bleeding

OR

Age 60+ with unexplained change of bowel habit (exclude drug causes and infections first where appropriate)

Age <50 with rectal bleeding

PLUS 1 of:

  • abdominal pain
  • change of bowel habit
  • weight loss
  • iron deficiency anaemia
FIT positive
Consider offering urgent 2WW colorectal referral for colonoscopy or clinic depending on frailty / patient preference

High risk IDA (please offer urinalysis and TTG as well)

All men with confirmed IDA with low ferritin and Hb<130

Women – age >50 with confirmed IDA and Hb<115 (irrespective of menopause exclude drug causes and infections)

Women age 40-50 who are post-menopausal or non-menstruating (e.g. Mirena) with confirmed IDA with low ferritin and Hb<115

Consider offering urgent 2WW colorectal referral for gastroscopy and colonoscopy or clinic depending on frailty / patient preference

Patients with symptoms that do not fulfil 2WW but may require routine referral for endoscopic tests- please refer by letter via electronic referral system

Age<50 with unexplained rectal bleeding alone (People with rectal bleeding plus abdominal pain or diarrhoea or anaemia qualify for 2WW referral)
Consider routine referral to colorectal team (but may not be necessary in younger people, people with single occurrence, when there is confirmed fissure or piles or when not the presenting symptom)

Please complete the form in EMIS or System One

Medium risk lower GI symptoms

Age 50+ with either of:

  • Unexplained persistent abdominal pain alone OR
  • Unexplained documented weight loss alone

Age 50-59 with unexplained change in bowel habit OR

  • Age 50+ – vague or chronic bowel symptoms of uncertain significance for >3/52
  • Age <50 suspicion of lower GI cancer
  • Persistent raised platelets >450/dl (at least 2 recorded at least 6 weeks apart)
Check CA125 in women
Consider wide range of diagnoses - consider offering FIT or routine clinic and/or CT abdomen and pelvis
Consider offering FIT to identify people needing 2WW referral
If patients does not submit FIT within two weeks of request - review in primary care
FIT negative
FIT positive
FIT negative
If FIT negative, consider other urgent / 2WW pathways as appropriate
Exclude ovarian cancer in women
If FIT positive, consider 2WW colorectal referral for clinic or straight to test depending on frailty
If FIT negative bowel cancer is unlikely
Actively monitor for any new red flags
If still concerned, refer as routine to gastroenterology

Low risk - IDA

IDA = HB < 130g/ L (MEN) , 115g/ L (Women) AND confirmed by local definition which may include:
Ferritin < 15 or Ferritin < 30 and low MCV or Ferritin <30 and low transferrin. Please refer to local lab guidance

Isolated low ferritin without anaemia (also offer tTG and urinalysis)

>50 offer FIT if any suspicion of IDA

<50 FIT not needed

Low risk IDA or isolated low ferritin (also offer tTG and urinalysis)

Menstruating women <50 without rectal bleeding and when menstruation, diet or blood donation is likely as the cause

  • Treat with iron + active monitoring
  • Monitor ferritin and Hb and if anaemia recurs 3 months after normalising, consider routine referral to IDA clinic/ Gastroenterology
  • Check FIT if this has not already been done

Medium risk - IDA

IDA = HB < 130g/ L (MEN) , 115g/ L (Women) AND confirmed by local definition which may include:
Ferritin < 15 or Ferritin < 30 and low MCV or Ferritin <30 and low transferrin. Please refer to local lab guidance

Medium risk Anaemia: also check tTG and urinalysis): Menstruating women <50 with confirmed IDA

  • Without rectal bleeding
  • Menstruation, diet or blood donation unlikely to be the cause
Offer FIT test in primary care. If patient does not submit FiT in 2/52, review in primary care
FIT positive
Offer 2WW referral for bidirectional endoscopy
FIT negative
Treat with iron + active monitoring. Monitor ferritin and Hb and if anaemia recurs 3 months after normalising, consider routine referral to IDA clinic/ Gastroenterology. Check FIT if this has not already been done

Low risk patients
Patients with symptoms that do not fulfil 2WW but may require routine referral for endoscopic tests - please refer by letter via electronic referral system

  • Age <50 with unexplained change in bowel habit
  • +/- abdo pain for >3/52 - consider check Hb and coeliac antibodies
  • Faecal Calprotectin (FC) is considered the more appropriate test in people under 50 instead of FIT
Inflammatory Bowel Disease suspected*
Check faecal calprotectin (FC) and Hb
IBS suspected - based on ABC (abdominal pain, bloating and/or change of bowel habit)
No further investigations usually needed
Monitor and manage symptomatically using IBS pathway.
If FC<50 and age<50 99% confidence of IBS https://cks.nice.org.uk/irritable-bowel-syndrome#!scenario
Age<60 with significant watery diarrhoea (Bristol stool type 6 or 7) that impacts on patient's life for >36/52
(drug and infectious causes excluded)
(people 60 and older with unexplained change of bowel habit qualify for 2WW colonoscopy)
Consider routine referral for colonoscopy to rule out microscopic colitis

* Any patient with symptoms suggestive of fulminant colitis should be admitted or seen in OPC clinic urgently

Monitor and manage symptomatically using IBS pathway. If FC<50 and age<50 99% confidence of IBS https://cks.nice.org.uk/irritable-bowel-syndrome#!scenario

Offer routine referral for colonoscopy or clinic

If weight loss is present, consider wide range of diagnosis.

Offer FIT but consider CT abdo/pelvis or serious non-specific symptoms pathway.

If patient do not submit FIT within 2 weeks of request, review in primary care.

Notes

  1. FiT is 85-90% sensitive for bowel cancer (at lower end of estimate in anaemic patients) and 80% specific at a cut off of 10µ/gm faeces
  2. Confirmed IDA may include: IDA = HB < 130g/ L ( MEN) , 115g/ L ( Women) AND Ferritin < 15 or Ferritin < 50 and low MCV or Ferritin <50 and low transferrin. There may be local differences in definition please consult local labs
  3. Pre-menopausal women have low risk of colorectal cancer or GI causes of anaemia and most need no testing at all. Risk increases between age 40 and 50. Menstruating women younger than 40 with anaemia and no rectal bleeding should rarely need GI anaemia pathway.
  4. Young people (<50), and blood donors with low ferritin alone and normal Hb are extremely unlikely to have GI cause and may need no testing or just TtG. Older ones may be offered FiT. There is no NICE recommendation on low ferritin with a normal Hb.
  5. For the low risk patients with anaemia and negative FiT, watchful waiting should be purposeful - it generally requires treatment with adequate oral iron for at least three months to ensure that Hb comes back into normal range and iron stores are filled. It is suggested that the patient has repeat ferritin and Hb at 3 and 6 months after adequate treatment. Recurrent IDA is often due to inadequate treatment. If anaemia recurs or does not resolve despite adequate treatment, then consider referral to gastroenterology to consider bidirectional endoscopy
  6. Patients >50 with rectal bleeding qualify for 2ww referral irrespective of anaemia
  7. CT colonography is an acceptable means of ruling out bowel cancer as an alternative to colonoscopy and may be offered as a an option form straight to test triage.
  8. Urgent 2ww OPA is preferable to direct access endoscopy if age >80 or major organ dysfunction/frailty or patient wishes
  9. Calprotectin should not be used for diagnosis in people >50 - use FiT instead (Calprotectin can be used in monitoring known IBD in older patients)
  10. This pathway takes into account all NICE guidance + Commissioning advice and Letter from NHC Cancer team and the York faecal calprotectin pathway