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Gastroenterology - public patients

Purpose

This page contains information for general practitioners on how to refer patients aged 16 years and over to Gastroenterology services at Mater Hospital Brisbane. These services are offered in our specialist outpatient clinics and for eligible patients aged between 16 and 25 years at Mater Young Adult Health Centre Brisbane. 

Scope of Service

This service includes referrals for:

  • Chronic liver disease, such as HBV and HCV
  • IBD
  • Suspected bowel cancer, pancreatic cancer and upper GI cancer
  • ERCP, pancreatic and biliary disorders

This service does not include referrals for:

Please see our Pre-Referral Guidelines below for information on when to refer for these conditions, as well as recommendations for conservative management.

Referral Criteria

Please include all of the minimum referral requirements and:

See Pre-Referral Guidelines below for suggested work-up by condition and information required for appropriate triaging.

Mater Adult Referral Form

Referrals can be faxed to 07 3163 8548.

Referral Categorisation

Available appointments are provided to our patients based on clinical priority

This should be used as a general guideline only – categorisation will be based on the individual referral

PRIORITY SEMI-URGENT ROUTINE

-  Strong suspicion of bowel cancer: + FOB or iron deficiency anaemia

-  Suspected cancer on imaging: pancreas, bowel, stomach or oesophagus

-  Exacerbation Crohn’s and UC

-  Acute/sub-acute or chronic liver failure

-  Iron deficiency anaemia

-  Significant dyspepsia or epigastric pain with red flags

-  Hepatitis B and C

-  Chronic liver disease with cirrhosis

-  New change in bowel habit with no red flags

-  Dyspepsia with no red flags

-  Constipation with no red flags

-  Haemochromatosis

-  Irritable Bowel Syndrome with no red flags

Mater endeavours to see all priority patients within 30 days from GP referral

Mater endeavours to see all semi urgent patients within 3 months from GP referral

Mater endeavours to see all routine referrals within 12 months from GP referral

Your patient may want to consider a referral to a private specialist.

Our Specialists

Dr Marianne Mortimore Director of Gastroenterology
Dr Johannes Wittmann Gastroenterolist/Interventional gastroenterology
Dr Linus Chang Gastroenterologist/Upper GI malignancy/Pancreaticobiliary disease
Dr Mazhar Haque Gastroenterologist/ Hepatologist
Dr Sylvia Vigh Gastroenterologist
Dr Jake Begun Gastroenterologist

 

Bulk Billed Clinics

Mater Health Services offers patients the opportunity to attend bulk billed clinics. To provide your patient with the opportunity to attend a bulk billed specialist clinic, please provide a named referral to one of our specialists listed above.

Contact Us

If you wish to discuss a referral with a medical officer from this specialty, please contact 07 3163 8111 and ask to speak with the gastroenterology registrar or a consultant. 

For Hepatology referrals, contact the Clinical Nurse Consultant on 07 3163 6703 or mobile 0434 569 389.

For IBD referrals, contact the Clinical Nurse Consultant on 07 3163 8054 or 0466 777 857.

Alternatively, contact the Clinical Nurse – Referrals and Appointments Management Service on 07 3163 6866.

Pre-Referral Guidelines

Abdominal Pain, Discomfort or Bloating

The following guideline is intended for consideration by the treating GP.  It is subject to the assessment of the patient’s clinical circumstances and in no way is intended to replace the clinical assessment and judgment of the GP.

Suggested workup

FBC

ELFT

CRP

Anti tTG + se IgA

Iron studies

Helicobacter breath test (off PPI for 4 weeks - may require funding by patient and if patient is able to fund)

Abdominal ultrasound

Family history

Symptom triggers?

History of smoking

Recommended pre-referral treatment

Before referral and / or endoscopy:

Lifestyle Changes:

Reduce fatty foods, avoid trigger foods (food diary), weight reduction, smoking cessation, limit alcohol.

Medical Management:

  • HP treatment if serology or breath test is positive
  • Treatment with PPI for 3 months to assess for empirical efficacy
When to refer

Red flags: Weight loss, iron deficiency anaemia, dysphagia, odynophagia, mild haemetemesis, family history of GO malignancy.

Urgent referral to Emergency Department if significant GI bleeding or haemodynamic instability.

  • First presentation of unexplained or persistent symptoms where onset is >50yo
  • Severe or persistent symptoms despite lifestyle and medical management for at least 4 to 12 weeks
  • Suspected surgical problem, including bowel obstruction
What to include
  • List and quantify any red flags
  • Initial work-up results
Useful links

GESA Guideline - Gastro-Oesophageal Reflux Disease (2011):

 

Dyspepsia / Heartburn / Reflux

The following guideline is intended for consideration by the treating GP.  It is subject to the assessment of the patient’s clinical circumstances and in no way is intended to replace the clinical assessment and judgment of the GP.

Suggested workup

FBC

ELFT

CRP

Anti tTG + se IgA

Iron studies

Helicobacter breath test (off PPI for 4 weeks – may require funding by patient and if patient is able to fund)

Abdominal ultrasound

Family history

Symptom triggers e.g. alcohol, caffeine, bending, stress, spicy or fatty foods, smoking

Previous endoscopic procedures (date and report)

History of smoking

Recommended pre-referral treatment

Before referral and / or endoscopy:

Lifestyle Changes:

Reduce fatty foods, avoid trigger foods (food diary), weight reduction, smoking cessation, limit alcohol.

Medical Management:

If positive Helicobacter breath-test, treat Helicobacter and monitor.

Otherwise:-

  • Cease any aggravating medications if possible e.g. NSAIDS, aspirin
  • A symptom based diagnosis for gastroesophageal reflux can be supplemented by a 2-4 week trial of high dose PPI which  has a sensitivity and specificity for reflux disease comparable to oesophageal pH monitoring and superior to endoscopy
  • Long term proton pump inhibitors should not be necessary long-term for dyspepsia, but may be necessary for severe and / or recurrent GORD, gastric protections with NSAIDS, or Barrett’s oesophagus.
When to refer

Red flags: weight loss, dysphagia, odynophagia, haematemesis, family history of GO malignancy, iron deficiency anaemia.

  • First presentation of unexplained or persistent symptoms where onset is >50yo
  • Persistent symptoms despite lifestyle and medical management for at least 4 to 12 weeks
  • Suspected surgical problem, including bowel obstruction
What to include
  • List and quantify any red flags
  • Initial work-up results
Useful links

GESA Guideline - Gastro-Oesophageal Reflux Disease (2011):

 

PR Bleeding

The following guideline is intended for consideration by the treating GP.  It is subject to the assessment of the patient’s clinical circumstances and in no way is intended to replace the clinical assessment and judgment of the GP.

Suggested workup

PR exam - digital rectal exam

Describe bleeding – distinguish between dark blood coating or mixed with stool; or bright red blood passed after the motion or on the paper

Examination for abdominal and rectal masses

FBC

ELFT

CRP

Iron studies

History – of colorectal cancer and previous endoscopic procedures including results and histology

Family history

Recommended pre-referral treatment

Medical Management:

  • Treat constipation
When to refer

Red flags: weight loss, abdominal mass, iron deficiency anaemia, blood mixed with stool, family or personal history of CRC.

  • Overt bleeding and / or a recent change in bowel habit should have been present for at least 6 weeks prior to referral.
What to include
  • List and quantify any red flags
  • Initial work-up results
  • Indicate whether dark blood (coating or mixed with stool) or bright red blood (passed after the motion or on the paper)
  • Details of family history

 

Polyp Surveillance

The following guideline is intended for consideration by the treating GP.  It is subject to the assessment of the patient’s clinical circumstances and in no way is intended to replace the clinical assessment and judgment of the GP.

Suggested workup

Examination for abdominal and rectal masses

FBC

ELFT

CRP

Iron studies

Family or personal history of hereditary cancers

History - of colorectal cancer and previous endoscopic procedures including results and histology

Recommended pre-referral treatment

Lifestyle Changes:

  • Review dietary and exercise changes and ongoing management.
When to refer

Red flags: weight loss, abdominal mass, iron deficient anaemia, blood mixed with stool, PR bleeding, family or personal history of CRC and polyps.

In the absence of any red flags, the following timeframes are recommended for polyps surveillance:

5 years - If <3 polyps (excluding diminutive rectosigmoid hyperplastic polyps) provided that all polyps are “simple” as defined by dimensions (≤10mm) and histopathology (no high-grade dysplasia or villous change).

3 years - If 3 or more polyps (excluding diminutive rectosigmoid hyperplastic polyps) or if one or more polyps is “advanced” as characterised by dimensions (>10mm) and/or histopathology (presence of high-grade dysplasia or villous change).

Within 12 months – If required, a baseline colonoscopy may need to be repeated in cases of poor bowel preparation (immediate rescheduling), possible incomplete excision of a large polyp (often at 3 months) or the presence of multiple adenomas (>10) to ensure complete clearance.

Source: GESA Guideline - Bowel Cancer - Early Detection, Screening and Surveillance (2011) http://www.gesa.org.au/professional.asp?cid=9&id=52

What to include
  • List and quantify any red flags
  • Initial work-up results
  • Details of family history of hereditary cancers
Useful links

Bowel Cancer - Early Detection, Screening and Surveillance (2011):

 

Iron Deficiency Anaemia

The following guideline is intended for consideration by the treating GP.  It is subject to the assessment of the patient’s clinical circumstances and in no way is intended to replace the clinical assessment and judgment of the GP.

Suggested workup

Examination for abdominal and rectal masses

FBC

ELFT

CRP

Anti tTG + se IgA

Iron studies

History of bleeding from any orifice, including menstrual history

Recommended pre-referral treatment

Lifestyle Changes:

If dietary, modify diet and / or refer to dietician

Medical Management:

Establish and treat the cause e.g. Menorrhagia, dietary.

Treatment with oral iron prior to referral:

  • Preparations with elemental iron 80mg-325mg per tab are absorbed better if taken with vitamin C 50mg
  • Take one tablet daily of iron + vitamin C and in the presence of anaemia continue for 3 months after haemglobin has been corrected to replenish stores
  • Treat constipation and warn of iron effects on stool
When to refer

Red flags: Urgent referral to Emergency Department if unwell due to blood loss (Hb < 80 g/L), haemodynamic compromise or cardiorespiratory compromise.

  • Severe symptomatic IDA with no obvious cause
  • When combined with at least one of the following – overt GI bleeding, abdominal pain and new change in bowel function
  • Patients <40 y.o. with no other concerning symptoms, treat for likely cause prior to referral e.g. menorrhagia or dietary deficiency
What to include
  • List and quantify any red flags
  • Initial work-up results
Useful links

GESA Guideline - Iron Deficiency (2008):

 

Constipation and Fluctuating Bowel Habit (including IBS)

The following guideline is intended for consideration by the treating GP.  It is subject to the assessment of the patient’s clinical circumstances and in no way is intended to replace the clinical assessment and judgment of the GP.

Suggested workup

History – Frequency, consistency, presence of alternating diarrhoea

Abdominal palpitation

ELFT

CRP

Anti tTG + se IgA

Iron studies

Helicobacter breath test (may require funding by patient and if patient is able to fund)

Consider Faecal Calprotectin for patient <40yo (may require funding by patient and if patient is able to fund)

Recommended pre-referral treatment

Lifestyle Changes:

Increase dietary fibre if lacking and fluid intake. Rapid response to urge to defaecate.  Regular exercise.

Medical Management:

  • Bulk forming laxatives e.g. Metamucil – must maintain adequate fluid intake and will likely take several days for effect
  • Stimulant laxatives e.g. coloxyl with senna or bisacodyl – increase intestinal mobility but not suitable for intestinal obstruction
  • Osmotic laxatives e.g. lactulose – increase the water in the large bowel but not suitable for intestinal obstruction
  • Consider pelvic floor dysfunction and pelvic floor physiotherapist management
  • Consider Prucalopride for treatment of constipation in women by a clinician with experience in treating chronic constipation (potential drug side effects)
When to refer

Red flags: Progressive and unintentional weight loss, iron deficiency anaemia and vomiting, family history bowel or ovarian cancer, new onset age >50.

  • Referrals for constipation not accepted at the present time due to demand, unless associated with abnormal bloods and / or positive FOB x 3, or other red flags
  • For pelvic floor dysfunction, refer to appropriate physiotherapist
What to include
  • Initial work-up results
Useful links

NICE guidelines – Quick Reference Guide : Irritable bowel syndrome in adults:

Dietary Advice for IBS – Irritable Bowel Syndrome and Diet – The British Dietetic Association:

Guidelines for Use of Prucalopride – NICE Prucalopride for the treatment of chronic constipation in women:

 

Diarrhoea

The following guideline is intended for consideration by the treating GP.  It is subject to the assessment of the patient’s clinical circumstances and in no way is intended to replace the clinical assessment and judgment of the GP.

Suggested workup

History – Frequency, detail period of monitoring prior to referral

Abdominal palpation

ELFT

CRP

Anti tTG + se IgA

Iron studies

Stool MCS x3

C.difficile testing of stool if recent antibiotics

Consider Faecal Calprotectin for patient <40yo and / or pancreatic elastase stool test (may require funding by patient and if patient is able to fund)

Recommended pre-referral treatment

Lifestyle Changes:

  • Dietary review

Medical Management:

  • Consider constipation and overflow
  • Consider faecal incontinence
  • Consider trial of anti-diarrhoeals – monitor as may be contraindicated if idiopathic IBD
When to refer

Red flags: Acute severe diarrhoea, weight loss.

Urgent referral to Emergency Department if bloody diarrhoea.

  • For moderate chronic diarrhoea (>6 bowel motions per day), refer after four weeks.
What to include
  • Initial work-up results

 

Suspected Coeliac Disease

The following guideline is intended for consideration by the treating GP.  It is subject to the assessment of the patient’s clinical circumstances and in no way is intended to replace the clinical assessment and judgment of the GP.

Suggested workup

Serology must be run while patient is on a diet containing gluten (e.g. four pieces of bread per day for four weeks).

serum tTG

serum IgA

FBC

Ferritin

Folate

Vitamin B12

Note: If patients are on a gluten-free diet, encourage them to add gluten to their diet for four weeks for the following tests and diagnosis.  If not viable to return gluten to the diet, arrange a HLA DQ gene test.
Recommended pre-referral treatment

Lifestyle Changes:

Following diagnosis of Coeliac’s disease, a strict life-long gluten free diet must be maintained for life.

Post Diagnosis Management:

  • Monitor for compliance with serum tTG and serum IgA every 6 to 12 months. 
  • Baseline bone mineral densitometry.
When to refer
  • Refer for gastroscopy and small bowel biopsy if positive serology.
  • Following diagnosis, a referral to a dietician is highly recommended
  • Refer patient to support from Coeliac Queensland www.coeliac.org.au.
What to include
  • Initial work-up results
Useful links

Coeliac Disease (2007)

Coeliac Australia

 

Bowel Cancer Screening

Asymptomatic bowel cancer screening through the National Bowel Cancer Screening Program (NBCSP) is currently not provided by Mater Hospital. 

Patients with positive FOBT results outside of the National Bowel Cancer Screening program can be referred to the Mater, and will be given a priority.

NBCSP is conducted at other hospitals and community clinics, with more information available at http://www.health.qld.gov.au/metrosouth/specialty/bowel.asp.

For general information on FOBT and the National Bowel Cancer Screening Program go to www.cancerscreening.gov.au or see the GESA Guideline - Bowel Cancer - Early Detection, Screening and Surveillance (2011) - http://www.gesa.org.au/professional.asp?cid=9&id=52.

Other asymptomatic bowel cancer screening will be considered based on familial colorectal cancer risk with High Risk Patients as per GESA Guideline - Bowel Cancer - Early Detection, Screening and Surveillance (2011) (Table 2 category 3) receiving priority.

Back

Established or Suspected Inflammatory Bowel Disease

The following guideline is intended for consideration by the treating GP.  It is subject to the assessment of the patient’s clinical circumstances and in no way is intended to replace the clinical assessment and judgment of the GP.

Suggested workup

FBE

ESR & CRP

Faecal specimen for M,C & S

Iron studies

Family history

Where and when diagnosed

Specific diagnosis

Histology if available

Past surgery

Consider Faecal Calprotectin if unsure of diagnosis (may require funding by patient and if patient is able to fund)

Recommended pre-referral treatment

Lifestyle Changes:

  • Smoking cessation for Crohn’s disease
When to refer

Red flags: PR bleeding, significant weight loss, anaemia, obstructive symptoms.

  • Initial diagnosis of IBD
  • Established IBD - currently stable and requires CRC screening
  • Established IBD – symptomatic and unwell
What to include
  • Initial work-up results
  • Reason for referral
Useful links

 

Abnormal Liver Function Tests

The following guideline is intended for consideration by the treating GP.  It is subject to the assessment of the patient’s clinical circumstances and in no way is intended to replace the clinical assessment and judgment of the GP.

Suggested workup

Hepatitis serology – Hep A IgM, Hep B sAb, Hep B cAb, HCV Ab

Immunoglobulins

Auto antibodies (ANA, SMA, AMA)

Iron studies

Copper and caeruloplasmin

Lipid profile

Blood glucose

BMI

Upper abdomen ultrasound

Alcohol and drug history

Record of last normal liver function test (if available)

Recommended pre-referral treatment Cease unnecessary medications, natural or herbal remedies

Lifestyle Changes:

For fatty liver: Dietary and exercise review and education, alcohol abstinence.

Medical Management:

  • Screening of high risk groups for HBV and HCV – if positive see additional referral guidelines
  • If fatty liver indicated through abdominal US, manage metabolic risk factors
  • Cease medications that may be temporarily related e.g. NSAIDs
  • Discuss cessation of other liver toxins
When to refer
Urgent referral to Emergency Department if suspected acute, severe or fulminant hepatic failure, severe clinical or biochemical hepatocellular jaundice.

Red flags: Suspected cirrhosis with decompensation, acute hepatitis with decompensation.

  • ALT >1000, abnormal INR, encephalopathy
  • Clinical or biochemical hepatocellular jaundice
  • Obstructive jaundice (dilated ducts)
  • Suspected chronic liver disease
What to include
  • Initial work-up results

 

Hepatitis B Virus

The following guideline is intended for consideration by the treating GP.  It is subject to the assessment of the patient’s clinical circumstances and in no way is intended to replace the clinical assessment and judgment of the GP.

Suggested workup

(HBsAg, aHBs, aHBc, HBeAg, HBeAb), HBVDNA quant, HIV Antibody Screen, Hep A (IgG, IgM), Hep C, HDVIgG, FBC, Coags, Fe Studies, TFT, α fetoprotein, ELFT's.

Abdominal Ultrasound

Recommended pre-referral treatment

Lifestyle Changes:

  • Healthy weight range, healthy diet, avoid or minimise alcohol intake, cease smoking ,exercise regularly, manage stress effectively, avoid liver toxic medications and herbal preparations.
  • Education regarding: natural history of disease, transmission, family and close contact immunisation, lifelong monitoring of disease, treatment options, disclosure.

Medical Management:

When to refer

Red flags: family history of Hepatocellular cancer, Presence of advanced liver disease and cirrhosis, co-infection with HCV, HDV or HIV, longer duration of infection.

 

  • Acute Hepatitis B: elevated prothrombin time, INR or Serum Bilirubin, signs of decompensated liver disease(encephalopathy, ascites), uncharacteristically lengthy illness
  • Chronic Hepatitis B elevated ALT, Elevated HBVDNA , signs of advanced liver disease,( elevated INR, decreased Platelet, ascites)
  • Pregnant women with HBVDNA > 7 log IU/mL
  • Patients with positive anti- HBs and Anti-HBc who are considering immunosuppression

 

What to include
  • Pathology results
  • Abdominal Ultrasound results
  • Comorbidities
  • History of alcohol intake, smoking, medication and herbal preparation
  • Physical examination results
  • Caseworker details (for Refugee Health patients)
Useful links

GESA-  Australian and New Zealand Chronic Hepatitis B Recommendations:

ASHM (Australasian Society for HIV Medicine):

 

 

Hepatitis C Virus

The following guideline is intended for consideration by the treating GP.  It is subject to the assessment of the patient’s clinical circumstances and in no way is intended to replace the clinical assessment and judgment of the GP.

Suggested workup

Investigations needed:

HCV Screening  Bloods: HIV Antibody Screen, Hep A (IgG, IgM) & Hep B (HBsAg, aHBs, aHBc) Screen, FBC, Coags, Copper, Ceruloplasmin, α-1-antitrypsin, Fe Studies,  TFT,  ANA, α fetoprotein,  AMA, SMA, HCV PCR Quantitative, ELFT's, HCV genotyping, Abdominal Ultrasound.

Recommended pre-referral treatment

Lifestyle Changes:

  • Healthy weight range, healthy diet, avoid or minimise alcohol intake and risk taking behaviours, cease smoking ,exercise regularly, manage stress effectively, avoid liver toxic medications and herbal preparations.
  • Education regarding: natural history of disease, transmission, surveillance, disclosure, treatment options.

Medical Management:

  • Discuss alcohol as a major risk factor for progression of HCV cirrhosis and recommend cessation of alcohol, refer patient to support services such as ATOD’s.  Remove alcohol as a major risk factor for progression of HCV cirrhosis.
  • Vaccination for Hepatitis A and B
  • Dental Health Check Plan
  • Psychological assessment/ support- mental health plan
  • Social assessment
  • Hepatocellular Carcinoma screening of patients with cirrhosis including α fetoprotein, ELFT's, and Abdominal Ultrasound
When to refer

Red flags: Presence of advanced liver disease and cirrhosis, co-infection with HCV, HDV or HIV, longer duration of infection.

  • Acute Hepatitis C: elevated prothrombin time, INR or Serum Bilirubin, signs of decompensated liver disease(encephalopathy, ascites), uncharacteristically lengthy illness
  • Chronic Hepatitis C: HCVPCR positive, or  signs of advanced liver disease,( elevated INR, decreased Platelet, ascites)
  • If referring for Treatment please see information regarding this at -
  • http://www.som.uq.edu.au/about/academic-disciplines/general-practice/hiv-hcv-education-projects/hepatitis-primary-care-resource.aspx
What to include
  • Pathology results
  • Abdominal Ultrasound results
  • Comorbidities
  • History of alcohol intake, smoking, medication and herbal preparation
  • Physical examination results
  • Psychosocial history
  • Caseworker details (for Refugee Health patients)
Useful links

ASHM (Australasian Society for HIV Medicine):

UQ School of Medicine:

Hepatitis Queensland  Patient Resources:

Content reviewed 23/12/15

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