Download Referral Guidelines

REFREC007
GENERAL SURGERY REFERRAL RECOMMENDATIONS
Diagnosis / Symptomatology
Problems may be categorised under
the following groupings:
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Ano-rectal
Breast
Endocrine
Head and neck
Herniae
Lower GI
Oesophageal
Pancreas, biliary tree and liver
Skin
Small bowel
Stomach/duodenum
Last updated January 2006
Evaluation
A thorough history and examination is
required to determine a specific
diagnosis and its degree of urgency.
Some appropriate investigation by the
referrer may facilitate the referral
process.
Management Options
Referral Guidelines
Specific treatments depend on specific
problems identified as noted below.
Most general surgical diagnoses
require referral to specialist
management. However, these
guidelines are provided (below) to give
greater clarity in situations of the
primary/secondary interface of care.
Clearly, telephone/fax communication
would enhance appropriate treatment.
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REFREC007
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Ano-rectal
Haemorrhoids.
History of bleeding (with motions or
apart), mixed or on surface material).
Prolapse and thrombosis.
Evaluation:
 PR.
 Proctoscopy.
 Sigmoidoscopy.
 Age >40 years + possibility blood
mixed with stools, family history
colorectal cancer and delay > 4
weeks before clinic – barium
enema.
Lifestyle/dietary advice/modification.
Proprietary creams/suppositories.
Injection sclerosant therapy (if
appropriately trained to perform
procedure)
Refer for exclusion of other underlying
disease – Category 4.
Specialist management.
Refer for management and exclusion
of associated disease – Category 4.
Anal fistula.
History of recurrent perianal
abscesses, discharging sinus, and
previous drainage operation.
Evaluation:
 PR.
 Proctoscopy/sigmoidoscopy.
Xylocaine creams/suppositories.
Rectogesin (CTN) applied tds.
Refer for severity and chronicity
reasons – Category 4.
Anal fissure.
History of pain with and/or after.
Defaecation attacks may be
intermittent or prolonged.
Evaluation may be difficult due to
spasm.
Note anal tag.
Last updated February 2006
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REFREC007
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Breast Disease
Breast lump.
INVESTIGATIONS:
Women who can be managed, at least
initially by their General Practitioner.
Note:

Conditions that require referral to a
surgeon with a special interest in
breast disease (General Surgeons) –
Category 2 - 3.
(NHS Breast Screening
Programme “Guidelines for
Referral of Patients with Breast
Problems”.)

Screening detected abnormality

RACS “Guidelines for the Surgical
Management of Breast Cancer”
3.1 Pages 19-20.
Breast pain.
Further imaging and investigation
should be directed by Specialist
Triple assessment:

Clinical examination.

Imaging (mammography and/or
ultrasound).

Fine needle aspiration cytology (
core biopsy).
Unilateral persistent mastalgia:

Mammography or ultrasonography.
Refer to Specialist for further
evaluation.
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
Young women with tender, lumpy
breasts and older women with
symmetrical nodularity, provided
that they have no localised
abnormality.
Women with minor moderate
degrees of breast pain who do not
have a discrete palpable lesion.
Lump:

Any new discrete lump.

New lump in pre-existing
nodularity.

Asymmetrical nodularity that
persists at review after
menstruation.

Abscess.

Cyst persistently refilling or
recurrent cyst*.
Pain:

If associated with a lump Category 3

Intractable pain not responding to
reassurance, simple measures
such as wearing a well supporting
bra, and common drugs - Category
4
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Unilateral persistent pain in postmenopausal women - Category 4
Localised areas of painful nodularity:

Mammography and/or
ultrasonography.
Focal lesions:
Last updated February 2006

Mammography and/or ultrasound.

Fine needle aspiration cytology.
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REFREC007
Nipple discharge.
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Clinical examination.
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Mammography and ultrasound.
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Women aged under 50 who have
nipple discharge that is from more
than one duct or is intermittent and
is neither bloodstained nor
troublesome.
Nipple discharge:
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All women aged 50 and over.
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Women under 50 with:
– Bilateral discharge sufficient to
stain clothes - Category 4
– Blood-stained - Category 3
Nipple retraction.
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Clinical examination.
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Mammography and ultrasound.
– Persistent single duct - Category
3
Nipple retraction or distortion, nipple
eczema - Category 3
Change in skin contour.

Clinical examination.

Mammography.

+/-Ultrasound.
Note: It is recommended that
mammography for women > 35 years
are the investigations of choice.
For women with a positive family
history, it is recommended that their
baseline mammography is carried out
10 years before the age at which the
mother was diagnosed.
Last updated February 2006
Change in skin contour/ evidence of
tethering or associated lump.
Family History:
Request for assessment by a woman
with a strong family history of breast
cancer (referral to a family cancer
genetics clinic where possible).
* If the patient has recurrent multiple
cysts and the General Practitioner has
the necessary skills, then aspiration is
acceptable.
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REFREC007
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Management Options
Referral Guidelines
Endocrine
eg, Thyroid masses.
Cross refer to Endocrinology Referral
Recommendations.
Diagnosis / Symptomatology
Evaluation
Head and Neck
Painful mass (inflammatory).
Painless mass (non inflammatory).
Last updated February 2006
Complete head and neck exam
indicated for site of infection:

FBE.

Cultures when indicated.
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Consider HIV/intradermal TB/Paul
Bunnell (if indicated).
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Consider possible cat scratch
disease/Toxoplasmosis.
Complete head and neck exam
indicated for site of primary:

TFTs if thyroid mass.

FNA may be appropriate
Appropriate antibiotic trial (of ENT
referral recommendations).
Referral indicated if mass persists for
two weeks without improvement. Semi
Urgent referral if painless, progressive
enlargement or highly suspicious of
malignancy – Category 3.
Refer to appropriate specialist –
Category 3.
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REFREC007
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Herniae
Inguinal/femoral hernia.
Incisional hernia.
Last updated February 2006
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Pain in groin sometimes precedes
lump. Pain may be colicky and
associated with vomiting (intestinal
obstruction).
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Lump in groin – may be
intermittent/ reducible.
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Social impact.
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Conservative management may
possibly be considered in the very
elderly +/- infirm.
Herniae should be referred to a
General Surgeon – Category 4.
If episode of irreduciblity or major
social impact- Category 3
Nature and time previous
operation.
Weight reduction (reduces probability
of future occurrence).
Refer – Category 4.

Factors associated: poor wound
healing (diabetes, malignancy,
malnutrition, steroids, obesity).
Corset if symptomatic, delay in repair,
or treating conservatively.

Co-morbidity.
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REFREC007
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Lower gastro intestinal tract
(c.f. Gastroenterology Referral
Recommendations.)

Pain (site, acute/chronic,
continuous/ episodic).

Weight loss.

Medications.
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Exaggerated gastro colic reflex.

Ascites.
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Mass.
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Tenesmus.
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Personal history of malignancy.
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Blood, pus, mucus (PR).
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Consider infectious/tropical
diseases.
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Altered bowel habits.
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Fever.
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Flatus.
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Incomplete rectal emptying.

Family history of inflammatory
bowel disease, polyposis or
cancer.
INVESTIGATIONS:
Rectal examination:
Last updated February 2006

Stool culture (M, C and S,
parasites).

FBE.

Rigid sigmoidoscopy (private
rooms if delay).

?Barium enema if delay in
obtaining colonoscopy.
Patients who have vague lower
abdominal pain or change in bowel
habits (to constipation) should be
referred for Barium Enema/
colonoscopy after rigid sigmoidoscopy.
Consider iron replacement while
awaiting investigations.
Cases of known inflammatory bowel
disease ( with a non acute problem)
can be managed by GPs in liaison with
specialists.
Acute mild diverticulitis: antibiotics,
fibre, antispasmodics.
Prolonged/obstinate constipation:
standard investigations and referral
when normal medical therapy
inadequate.
Acute admission: Category 1.
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Large bowel obstruction.

Diverticulitis with evidence of
systemic sepsis.
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Severe bleeding.
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Suspected appendicitis.
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Fulminant colitis.
Outpatient referrals:
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Patients who have diarrhoea,
bleeding or change in bowel habit
(to looseness) should be referred
for colonoscopy – Category 3.
Barium enema if delay > 4 weeks.

Patients with diagnosed recurrent
attacks of diverticulitis should be
referred for specialist opinion –
Category 4.
Guidelines for screening flexible
sigmoidoscopy/ colonoscopy.
Normal risk
Age > 55 years – Gastro Unit
High risk
Screening colonoscopy – Gastro Unit
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REFREC007
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Oesophageal
Dysphagia.
May include history or findings of:
Diagnostic studies may include:
(c.f. Gastroenterology Referral
Recommendations.)

Foreign body ingestion.
Lab studies for auto-immune disorders.

Gastro-oesophageal motility
disorder.
Thyroid studies.

Neoplasm.
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Nocturnal choking or coughing
attacks.
Soft tissue imaging studies of the neck
(Appropriate ones often best left to the
Surgeon).
Ba swallow/meal.
Refer to appropriate specialty service
depending on results.
Refer to Endoscopy Service –
Category 3.
Particularly important is any history of:
Last updated February 2006
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Loss of weight.

Anaemia.

Progressive dysphagia.

Liquids vs solids.

Reflux.

Goitre.

Scleroderma.
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REFREC007
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Pancreas, Biliary Tree and Liver
(c.f. Gastroenterology Referral
Recommendations.)

Pain (site, acute/chronic,
continuous/episodic).
}
Known gallstones.

Jaundice.
1. Low fat diet.
2. Short attacks of biliary colic can be
managed symptomatically.
3. Acute cholecystitis or known CBD
stones with jaundice, acute
pancreatitis – urgent referral:
Category 1.
}
Charcot’s

Fever
} triad
– Nausea and vomiting.
– Weight loss.
– Medications.
– Post prandial fullness.
– Ascites.
Immediate admission – Admission
Category 1.
Acute pancreatitis, unremitting pain,
patients with shock.
Urgent referral: (phone call) –
Outpatient Category 2.

Obstructive jaundice.

CBD stones.
Advise specialist if already on waiting
list for gallbladder surgery.
– Mass.
– Pre-existing hepatitis.
– History of malignancy or
gallstones.
– Steatorrhoea.
– Alcohol intake.
Pancreas, biliary tree and liver
(continued)
Last updated February 2006
INVESTIGATIONS:

FBE.

Liver function tests.
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Amylase.

Proven pancreatitis – avoid alcohol.
Other referrals: (Outpatient)

Pancreatic or liver mass –
Category 3.

Symptomatic cholelithiasis –
Category 3.
Hepatitis serology, if indicated.


Ultrasound, if available with full
report.
Ultrasound abnormalities requiring
further elucidation – Category 3.


ie, alpha FP screening in HepB.
Elevated alpha FP – see
Gastroenterology – Category 3.

Prothrombin Time if jaundiced.

Liver Metastases – Category 3.
Page 9 of 12
REFREC007
Diagnosis / Symptomatology
Reflux symptoms.
Evaluation
Management Options
May include history of findings of:
Lifestyle modification.

Heartburn.
Antacid +/- H2 blockers.

Water brash.

Nocturnal choking or coughing
attacks.

Odynophagia.

Dysphagia

Anaemia
Stomach-duodenum.

Pain (site, acute/chronic,
continuous/episodic).
(c.f. Gastroenterology Referral
Recommendations.)

Nausea and vomiting.

Weight loss.

Haematemesis and/or melaena.

Anaemia.

Medications.

Post prandial fullness.

Alcohol intake.
Last updated February 2006

Chronic Pancreatitis – See
General Medicine – Category 3.

Hydatid disease – Category 3.
Referral Guidelines
Refer if symptoms are poorly
controlled, complications, or if
symptoms of weight loss or intermittent
dysphagia are evident – Category 3 or
4.
If there is a history of weight loss/
anaemia/progressive dysphagia –
Refer Category 2 - 3.
Non-acute: Treat with full dose H2
blockers for two months. If no
resolution in symptoms, refer for
endoscopy. Note that ulcers normally
respond in ten days to full dose H2
blockers.
Review other medications, eg NSAIDs,
Prednisone.
Lifestyle modifications.
Acute: Refer for immediate admission
(suspected perforation, haematemesis/
melaena) – Category 1.
Non-acute: Refer for endoscopy–
Category 3.
Pain with weight loss or pain with
anaemia – Category 3.
Post prandial vomiting: Refer for
endoscopy – Category 3.
Page 10 of 12
REFREC007
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Management Options
Referral Guidelines
Skin
Cross refer Dermatology/Plastic
Surgery Referral Recommendations.
Diagnosis / Symptomatology
Evaluation
Small Bowel
(c.f. Gastroenterology Referral
Recommendations.)

Family/personal history of Crohn’s.

Pain (site, acute/chronic,
continuous/episodic).

Vomiting.

Weight loss.

Diarrhoea/constipation.

Fever.

Abdominal mass.

History of previous surgery
(adhesions or malignancy).

Anaemia and melaena.

Steatorrhoea.

Atrial fibrillation/recent MI.

Previous arterial embolus.

Last passed flatus, distension if
obstruction suspected.
Cases of known Crohn’s disease can
be managed by GPs in liaison with
specialists.
Attempted conservative management
of recurrent incomplete small bowel
obstruction, eg antispasmodics, clear
fluids, simple analgesia.
Acute admission: Category 1.

Complications of Crohn’s.

Intestinal obstructions with colic,
vomiting, distension and no
passage of flatus.

Peritonitis.

Ischemia.
Referral: (outpatients)

Suspected Crohn’s – Category 4.

Suspected recurrent incomplete
small bowel obstruction – Category
2.
INVESTIGATIONS:
Last updated February 2006

FBE and CRP.

B12.
Page 11 of 12
REFREC007
Last updated February 2006

Folate.

Fe studies.

Plain A xR (erect/supine) if
obstruction suspected.
Page 12 of 12