Gastroenterology Clinic

Gastroenterology/Hepatology Referral Guidelines for MAP Provider Handbook

在您转诊之前，请咨询适当的GI和肝脏疾病算法. 如果算法建议进行影像学检查或随后的实验室检查，请在转诊前获得. 可能有条件或症状没有在这里列出，需要个别医生的判断.

Summary of Appropriate URGENT Outpatient referrals

Emergent conditions that 五月 需要 ER评价 包括:

• 急性吐血
• Large volume hematochezia or melena
• Intractable nausea and vomiting
• Diarrhea with dehydration
• Severe abdominal pain especially with 发热 or abdominal distension
• Jaundice, especially with 发热
• Profound anemia requiring transfusion (Hgb <7)
• Suspected hepatic encephalopathy
• Cirrhotic patients with ascites and new renal insufficiency
• 吞咽困难 with food impaction, GI foreign bodies

Referral for GI and Hepatic Symptoms and Conditions

1. Initial Evaluation of Abdominal pain: 绝大多数慢性疼痛患者可以通过仔细的病史来诊断，特别是如果有气体症状, 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, 减肥, 发热, 便血, HIV + or immunosuppressed
   1. 实验室:
      • 如果是上腹部疼痛, 获得幽门螺杆菌尿素呼气试验，并开始质子泵抑制剂(PPI)试验4周
      • 如果超过50岁, 考虑患者以前是否有筛查结肠镜检查或粪便免疫化学试验(FIT).
   2. 诊断:
      • If pain is intermittent, in the right upper quadrant, 和食物有关, 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 发热, obtain CT scan to rule out diverticulitis
2. Abdominal pain in patient previously evaluated (许多肠易激综合征患者会经历腹痛复发，这通常是由于对治疗建议的依从性降低, but some 五月 需要 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. 获得加拿大广播公司, CMP, lipase, stool studies if having diarrhea (see diarrhea evaluation).
   4. 偶尔需要腹部CT检查以使患者放心，或者如果症状提示憩室炎
   5. Obtain history of previous endoscopic evaluation and/or colon cancer screening.
3. 恶心和呕吐 (如伴有脱水或腹痛，见上文紧急或紧急转诊). Intermittent nausea and vomiting is usually associated with functional origin. Consider following special circumstances
   1. Inquire about use of THC or marijuana. 如果用热水浴或热水澡减轻了症状，并承认有大量使用大麻的历史，则怀疑大麻恶心和呕吐.
   2. Inquire about medication use, 尤其是阿片类药物
   3. If diabetic, assess Hgb A1C for adequacy of control and optimize control. Consider Gastric Emptying study
4. GERD (Gastroesophageal Reflux Disease)
   1. 典型的上腹至胸骨后烧灼症状应采用PPI治疗4周.
   2. Atypical symptoms include hoarseness, 咳嗽, 没有其他解释的哮喘也应经验性地使用PPI试验4周.
   3. Those refractory to 4 weeks of PPI should be referred
   4. Those requiring long term PPI, especially white males, 肥胖病人, 或者50岁以上的病人, should be referred for EGD to screen for Barrett’s esophagus.
5. 吞咽困难
   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 五月 be 需要d 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. 仔细检查痉挛和腹胀的相关症状或改变为便秘的病史可能会对大多数患者进行肠易激综合征的诊断. 其他相关病史包括结肠或小肠切除术、胆囊切除术、减肥搭桥手术.
   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和贾第虫抗原，或粪便白细胞，艰难梭菌毒素测定腹腔检查，FIT.
   4. If any above positive or if symptoms persist, refer
   5. If any 便血, 减肥, refer sooner
7. Constipation (Chronic > 3 weeks duration)
   1. Careful history of duration of symptoms, constipating medications, 尤其是阿片类药物, associated rectal bleeding, age >50 with no previous colon screening, associated abdominal pain or distension, 减肥 and response to laxatives.
   2. If no associated alarm symptoms, 不需要结肠筛查的患者，可进行腹部x光片或腹部CT检查以排除梗阻，或开始PEG 3350 (Miralax/Glycolax)的临床试验。, Colace or Fiber supplementation. 如无回应，请参考.
8. 丙型肝炎 在使用直接抗病毒药物的时代，丙型肝炎的评估和治疗变得更加直接. 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. 甲肝病毒总抗体
   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. 乙型肝炎
   1. HBsAg, HBsAB, HBeAg, HBeAb, HBV DNA quantitative
   2. 甲肝病毒总抗体
   3. 丙型肝炎 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. 这是贫血的潜在原因的含义，导致内镜评估的紧迫性
    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. 需要皮质类固醇治疗的复发性IBD患者应考虑使用生物制剂和/或免疫抑制剂来维持缓解
    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 需要d to determine suitability for outpatient management. 失代偿期肝硬化患者应由GI/肝病诊所联合随访
    1. Careful history of alcohol use, 静脉注射药物, transfusions in remote past or family history to determine origin
    2. 所有不需要住院治疗的失偿病例都应紧急转诊
    3. 获得加拿大广播公司, PT /印度卢比, CMP, 甲型肝炎病毒, HBsAg, HBcAb, HBsAb, HCV (with reflex testing for HCV RNA quant if +), iron and TIBC and ferritin
    4. 腹部超声检查是否存在腹水，排除肝细胞癌。. Occasionally CT or MRI are 需要d if ultrasound is inconclusive.
13. Elevated liver enzymes (Moderate-Severe 5x->15x nl) or Jaundice (bili >5)
    1. 急性酒精摄入史和检查，近期服用的药物包括草药，补充剂. Evaluate for signs of hepatic failure
    2. AST/ALT ratio of >3:1 suggestive of alcoholic hepatitis
    3. CBC w /血小板, CMP, PT /印度卢比, HBsAg, HBcAb, HBsAb, HCV (HCV RNA by PCR if +, 甲型肝炎病毒 IgM (eval for acute Hep A), HBcAb IgM (eval for acute Hep B), HSV, EBV, 巨细胞病毒, 血浆铜蓝蛋白, 安娜, ASMA, 抗LKM, 免疫球蛋白, serum drug panel and urine toxicology panel.
    4. 腹部超音波
14. Screening for Colon Cancer
    1. 平均风险、高风险和监测结肠镜检查指南见附表
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%的巴雷特患者没有胃反流症状，因此指南质量不高
16. Abnormal/incidental testing results
    1. 脂肪酶升高: 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. 胰腺囊肿: These usually 需要 referral but small serous cysts are usually benign. Larger and more complex cysts, or if the patient is in pain or has 减肥, 需要 more urgent referral.
    4. Elevated liver enzymes (Mild to Borderline)
       1. 病史和检查慢性肝病的证据和肝酶升高的潜在原因(重点是对乙酰氨基酚病史). Discontinue toxic medications and alcohol.
       2. CBC/血小板，CMP, PT /印度卢比, HBsAg, HBcAb, HBsAb, HCV (HCV RNA通过PCR +)，铁/TIBC，腹部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. 腹部超声检查排除胆道梗阻或CT检查浸润性疾病
    6. Hepatic masses and cysts
       1. 孤立单纯性囊肿，无分隔，小于4厘米，通常为良性，可随访超声以确定稳定性，很少需要转诊. More complex masses 需要 referral
       2. 坚实的群众
          1. 肝血管瘤 are most common, more frequent in women. 获得血管瘤的CT扫描(寻找周围增强，然后是一个界限清晰的低密度肿块的中央填充)
          2. Focal Nodular Hyperplasia. Consider in women in 30’s and 40’s. CT检查中央星状瘢痕，静脉期呈高密度，静脉期呈等致密. Usually does not 需要 intervention
          3. 肝腺瘤. 肝细胞癌很难从影像学上鉴别，但获得甲胎蛋白能有所帮助吗. 没有星状疤痕.
          4. Hepatocellular carcinoma. Usually intentionally discovered through screening. Increased vascularity during arterial phase of contrast with washout. Associate with elevated AFP usually.
          5. 转移 – Usually multiple and associated with elevated alkaline phosphatase. Refer to interventional radiology for biopsy along with oncology. GI evaluation for primary source 五月 be 需要d.

 Documentation 需要d 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

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