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Colonoscopy

ADULT

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


Upper GI endoscopy

  • Potentially life-threatening symptoms suggestive of:
    • acute upper GI tract bleeding (bright red blood, PR bleeding, melena, hematemesis)
    • acute severe lower GI tract bleeding
  • Oesophageal foreign bodies/food bolus
  • Displaced gastrostomy tube 

Colonoscopy

  • Potentially life-threatening symptoms suggestive of:
    • acute severe colitis*
    • bowel obstruction
    • abdominal sepsis
  • Severe vomiting and/or diarrhoea with dehydration

 

*Acute severe colitis as defined by the Truelove and Witts criteria – all patients with ≥ 6 bloody bowel motions per 24 hours plus at least one of the following:

  • Temperature at presentation of > 37.8°C,
  • Pulse rate at presentation of > 90 bpm,
  • Haemoglobin at presentation of < 105 gm/l, CRP >20mg/dl at presentation (or ESR > 30 mm/hr)

NB: If a patient who has been fully investigated 2 years prior to referral.  Then the referrer and the receiving clinician will need to exercise clinical decision making in triaging and or value in repeat endoscopy / colonoscopy procedures.

NB: Faecal calprotectin is a useful test in distinguishing patients with inflammatory bowel disease and irritable bowel syndrome but has no role in detecting colorectal cancer. There is currently no Medicare Benefits Scheme (MBS) rebate for calprotectin.

Clinical resources

 Patient resources

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Mass palpable on abdominal or rectal examination
    • Positive faecal occult blood test (iFOBT) asymptomatic
    • Severe abdominal pain with presence of concerning features or significant impact on activities of daily living
    • Anaemia or iron deficiency with no obvious cause and/or persisting despite correction of potential causative factors and /or presence of concerning features
    • Altered bowel habits with progressive or persistent symptoms that are significantly impacting activities of daily living despite medical management and with presence of concerning features
    • Rectal bleeding with presence of concerning features
    • Unexplained weight loss and presence of concerning features
    • Abnormal radiology

     

    Presence of following concerning features

    • Dark blood coating or mixed with stool
    • Bloody or nocturnal diarrhoea
    • Weight loss, ≥5% of body weight in previous 6 months
    • Abdominal / rectal mass on clinical examination or abnormal imaging
    • Persistent abdominal pain
    • Iron deficiency in males and postmenopausal women or unexplained iron deficiency in premenopausal women
    • Patient and family history of bowel cancer (1st degree relative <55 years old)
    • iFOBT or calprotectin +ve

    NB: For patients with symptoms suggestive of colorectal cancer, the total time from first healthcare presentation† to diagnostic colonoscopy should be no more than 120 days. Diagnostic intervals greater than 120 days are associated with poorer clinical outcomes.

    †First healthcare presentation is defined as the date of presentation in general practice with symptoms suggestive of colorectal cancer or positive iFOBT for screening. (Cancer Council Australia, 2017)

  • Category 2
    (appointment within 90 calendar days)
    • Anaemia or iron deficiency with no obvious cause and/or persisting despite correction of potential causative factors and in the absence of concerning features
      • Dark blood coating or mixed with stool
      • Bloody or nocturnal diarrhoea
      • Weight loss, ≥5% of body weight in previous 6 months
      • Abdominal / rectal mass on clinical examination or abnormal imaging
      • Persistent abdominal pain
      • Iron deficiency in males and postmenopausal women or unexplained iron deficiency in premenopausal women
      • Patient and family history of bowel cancer (1st degree relative <55 years old)
      • iFOBT or calprotectin +ve
    • Altered bowel habits with progressive or persistent symptoms that are significantly impacting activities of daily living despite medical management and in the absence of concerning features
    • Rectal bleeding in the absence of concerning features
    • Unexplained weight loss in the absence of concerning features
  • Category 3
    (appointment within 365 calendar days)
    • Family history of colorectal cancer with either:
      • One first degree relative diagnosed with CRC <55yrs old
      • Two first degree relatives diagnosed with CRC at any age
      • One first degree plus at least two second degree relatives with CRC at any age

     

    NB: these relatives with CRC can be taken from both sides of the family i.e. they do not have to be all on the same side.

     

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • Family or personal history of colorectal cancer and any genetic diagnosis
  • Symptom profile
  • Previous endoscopic procedures (date, report and histology)
  • Rectal examination (not required for surveillance referrals and patients with symptoms)
  • ELFT, FBC, iron studies results

3. Additional referral information Useful for processing the referral

  • Recent relevant imaging (USS, CT, MRI)
  • iFOBT
  • Faecal calprotectin

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A chane in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.