Gastroenterology Clinic

Gastroenterology/Hepatology Referral Guidelines for MAP Provider Handbook

Please consult the appropriate algorithm for common GI and Liver Conditions PRIOR to your referral. If the algorithm suggests an imaging study or subsequent lab test, please obtain prior to referral. There may be conditions or symptoms not listed here that require individual physician discretion.

Summary of Appropriate URGENT Outpatient referrals

Emergent conditions that may require ER evaluation include:

• Acute hematemesis
• Large volume hematochezia or melena
• Intractable nausea and vomiting
• Diarrhea with dehydration
• Severe abdominal pain especially with fever or abdominal distension
• Jaundice, especially with fever
• Profound anemia requiring transfusion (Hgb <7)
• Suspected hepatic encephalopathy
• Cirrhotic patients with ascites and new renal insufficiency
• Dysphagia with food impaction, GI foreign bodies

Referral for GI and Hepatic Symptoms and Conditions

1. Initial Evaluation of Abdominal pain: A significant majority of patients with chronic pain can be diagnosed by careful history especially if symptoms of gas, bloating and altered bowel habits are present. Irritable bowel diagnosis accounts for the cause most of the time. Special populations requiring special attention include those with dysphagia, weight loss, fever, blood in stool, HIV + or immunosuppressed
   1. Labs:
      • If pain is epigastric, obtain Urea Breath Test for H pylori and begin trial of Proton Pump Inhibitor (PPI) for 4 weeks
      • If over 50, consider whether patient has had a previous screening colonoscopy or Fecal Immunochemical Test (FIT).
   2. Diagnostics:
      • If pain is intermittent, in the right upper quadrant, and related to food, obtain abdominal ultrasound and if negative, proceed with Cholecystokinin (CCK) HIDA scan
      • If pain is in the left lower quadrant and the patient has a fever, obtain CT scan to rule out diverticulitis
2. Abdominal pain in patient previously evaluated (Many patients with Irritable bowel syndrome will experience recurrence of abdominal pain and this is usually due to reduced compliance with management recommendations, but some may require additional intervention).
   1. Obtain careful history regarding life stress, dietary compliance with low FODMAP diet, management of any constipation, increase anxiety in life, recent bout of gastroenteritis (post infectious irritable bowel syndrome (IBS)
   2. Re-acquaint patient with management strategies of diet, stress management
   3. Obtain CBC, CMP, lipase, stool studies if having diarrhea (see diarrhea evaluation).
   4. Occasionally CT of abdomen nay be required for patient reassurance or if symptoms suggest diverticulitis
   5. Obtain history of previous endoscopic evaluation and/or colon cancer screening.
3. Nausea and Vomiting (if associated with dehydration or abdominal pain, see above for urgent or emergent referral). Intermittent nausea and vomiting is usually associated with functional origin. Consider following special circumstances
   1. Inquire about use of THC or marijuana. Cannaboid nausea and vomiting is suspected if symptoms relieved by hot showers or baths and admitted history of heavy use.
   2. Inquire about medication use, especially opioids
   3. If diabetic, assess Hgb A1C for adequacy of control and optimize control. Consider Gastric Emptying study
4. GERD (Gastroesophageal Reflux Disease)
   1. Typical symptoms of epigastric to retrosternal burning should be treated with trial of PPI for 4 weeks.
   2. Atypical symptoms include hoarseness, cough, asthma not otherwise explained should also be empirically treated with trial of PPI for 4 weeks.
   3. Those refractory to 4 weeks of PPI should be referred
   4. Those requiring long term PPI, especially white males, obese patients, or patients over 50, should be referred for EGD to screen for Barrett’s esophagus.
5. Dysphagia
   1. Careful history to sort out esophageal from oropharyngeal dysphagia
   2. Obtain barium swallow to help identify any strictures, masses or dysmotility
   3. EGD with dilation may be required for esophageal dysphagia
   4. Consider modified barium swallow to assess for pharyngeal pooling and aspiration
   5. ALL dysphagia patients should be seen by GI
6. Diarrhea (Chronic > 3 weeks duration)
   1. Careful history for associated symptoms of cramping and bloating or alteration with constipation may reveal diagnosis of irritable bowel syndrome in majority of patients. Other pertinent history includes colon or small bowel resections, cholecystectomy, bariatric bypass.
   2. Consider trial of low FODMAP diet, probiotics initially if IBS suspected
   3. If trial fails, obtain CBC, CMP, stool for C&S, O & P and giardia antigen, or fecal leukocytes, C Difficile toxin assay celiac panel, FIT.
   4. If any above positive or if symptoms persist, refer
   5. If any blood in stool, weight loss, refer sooner
7. Constipation (Chronic > 3 weeks duration)
   1. Careful history of duration of symptoms, constipating medications, especially opioids, associated rectal bleeding, age >50 with no previous colon screening, associated abdominal pain or distension, weight loss and response to laxatives.
   2. If no associated alarm symptoms, and not in need of colon screening obtain abdominal films or Abdominal CT to rule out obstruction or begin with trial of PEG 3350 (Miralax/Glycolax), Colace or Fiber supplementation. If no response, refer.
8. Hepatitis C (Evaluation and treatment of Hepatitis C has become more straightforward in the age of Direct Antiviral agents. This is a rapidly changing landscape, so this guidance will not go into treatment). If population-based HCV screen is + or +HCV found by liver enzyme elevation:
   1. Obtain HCV RNA by PCR quantitative and HCV genotype
   2. CMP, CBC, HIV antibody
   3. HAV total Antibody
   4. HBsAg, HBsAb, HBcAb (Vaccinate if neg for immunity or infection)
   5. Abdominal US (possible Fibroscan as available to evaluate fibrosis
   6. Refer for treatment suitability and choice of Direct Antiviral
9. Hepatitis B
   1. HBsAg, HBsAB, HBeAg, HBeAb, HBV DNA quantitative
   2. HAV total Antibody
   3. Hepatitis C Antibody (HCV RNA by PCR quant if +)
   4. Abdominal US to assess for cirrhosis
   5. Refer for treatment suitability and choice of Direct Antiviral
10. Anemia suspected from GI blood loss. Anemias from chronic GI blood loss are typically iron deficiency anemia. These are typically hypochromic microcytic anemias, but not always. It is the implication of potential cause of the anemia that leads to the urgency for endoscopic evaluation
    1. Obtain Fe/TIBC and ferritin and FIT of stool. Refer for evaluation of iron deficiency anemia.
    2. Begin trial of iron replacement (oral for mild iron deficiency and consider iron infusion for Hgb <8).
    3. Provide reports of any previous endoscopic evaluations.
11. Inflammatory Bowel Disease. These patients are best followed conjointly with GI specialty support. The severity and frequency of symptoms dictate the urgency
    1. Patients with IBD who have recurrent flares requiring corticosteroid therapy should be referred for consideration of remission maintenance protocols with biologics and/or immunosuppressive agents
    2. Patients managed on remission maintenance medications should be conjointly followed, but their medical home should be in the GI clinic
12. Cirrhosis with decompensation symptoms. Hepatic decompensation can present as ascites and edema, portosystemic encephalopathy, or gastrointestinal bleeding. Clinical discretion is required to determine suitability for outpatient management. Decompensated cirrhotic patients should be followed conjointly by GI/Hepatology Clinic
    1. Careful history of alcohol use, IV drug use, transfusions in remote past or family history to determine origin
    2. All cases of decompensation not requiring hospitalization should be referred urgently
    3. Obtain CBC, PT/INR, CMP, HAV, HBsAg, HBcAb, HBsAb, HCV (with reflex testing for HCV RNA quant if +), iron and TIBC and ferritin
    4. Obtain abdominal ultrasound to evaluated for presence of ascites and to rule out HCC (Hepatocellular carcinoma). Occasionally CT or MRI are required if ultrasound is inconclusive.
13. Elevated liver enzymes (Moderate-Severe 5x->15x nl) or Jaundice (bili >5)
    1. History and exam for acute alcohol intake and recent meds including herbals, supplements. Evaluate for signs of hepatic failure
    2. AST/ALT ratio of >3:1 suggestive of alcoholic hepatitis
    3. CBC w/platelets, CMP, PT/INR, HBsAg, HBcAb, HBsAb, HCV (HCV RNA by PCR if +, HAV IgM (eval for acute Hep A), HBcAb IgM (eval for acute Hep B), HSV, EBV, CMV, ceruloplasmin, ANA, ASMA, anti LKM, IgG, serum drug panel and urine toxicology panel.
    4. Abdominal ultrasound
14. Screening for Colon Cancer
    1. See attached table for average risk, high risk and surveillance colonoscopy guidelines
15. Screening for Adenocarcinoma of Esophagus (Barrett’s)
    1. The ideal candidate is a > 50, male, white, with chronic GERD with elevated BMI, and smoker.
    2. Screening EGD can be performed easily at the time of a screening colonoscopy.
    3. 40% of patients with Barrett’s do not have GERD symptoms, so guidelines are not of high quality
16. Abnormal/incidental testing results
    1. Lipase elevation: Low grade lipase elevation usually does not imply pancreatitis.
    2. Abnormal CT showing gastric or intestinal wall thickening: Although referral is recommended, endoscopic work up is usually negative
    3. Pancreatic cysts: These usually require referral but small serous cysts are usually benign. Larger and more complex cysts, or if the patient is in pain or has weight loss, require more urgent referral.
    4. Elevated liver enzymes (Mild to Borderline)
       1. History and exam for evidence of chronic liver disease and potential causes of elevated liver enzymes (focus on acetaminophen history). Discontinue toxic medications and alcohol.
       2. CBC/platelets, CMP, PT/INR, HBsAg, HBcAb, HBsAb, HCV (HCV RNA by PCR if +), iron/TIBC, Abdominal US
       3. If above negative, observe for 3-6 months and repeat testing
       4. If persistent elevation, refer
    5. Elevated liver enzymes (Cholestatic – Alkaline phosphatase or bilirubin)
       1. Isolated elevation of bilirubin < 3 mg/dl with other liver enzymes normal is indicative of Gilbert’s syndrome.
       2. Predominantly elevated alkaline phosphatase can be due to drug induced hepatitis, biliary obstruction or infiltrative disease.
       3. Obtain GGT to differentiate from bone source
       4. In middle aged females, obtain AMA to diagnose PBC
       5. Obtain abdominal US to rule out biliary obstruction or CT to evaluated for infiltrative disease
    6. Hepatic masses and cysts
       1. Solitary simple cysts without septation and less than 4 cm usually benign and can be followed with follow up US to establish stability and rarely require referral. More complex masses require referral
       2. Solid masses
          1. Hemangiomas are most common, more frequent in women. Obtain CT with hemangioma protocol (look for peripheral enhancement followed by central filling in of a well demarcated hypodense mass)
          2. Focal Nodular Hyperplasia. Consider in women in 30’s and 40’s. Obtain CT for features of central stellate scar and hyperdense with contrast then isodense in venous phase. Usually does not require intervention
          3. Hepatic Adenoma. Can be difficult to differentiate from Hepatocellular carcinoma with image but Obtaining alpha fetoprotein can help. No stellate scar.
          4. Hepatocellular carcinoma. Usually intentionally discovered through screening. Increased vascularity during arterial phase of contrast with washout. Associate with elevated AFP usually.
          5. Metastasis – Usually multiple and associated with elevated alkaline phosphatase. Refer to interventional radiology for biopsy along with oncology. GI evaluation for primary source may be required.

Documentation required for scheduling an appointment:

• Past Medical History (PMH)
• Current medication list
• Most recent progress note describing condition for which patient is being referred
• Recent pertinent labs (appropriate labs per worksheet, drawn within the past month, substantiating the disorder. Please send lab flow sheets if they exist.)
• Recent pertinent scans or imaging reports