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REFREC007 GENERAL SURGERY REFERRAL RECOMMENDATIONS Diagnosis / Symptomatology Problems may be categorised under the following groupings: 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. Page 1 of 12 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 Page 2 of 12 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. 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 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. Page 3 of 12 REFREC007 Nipple discharge. Clinical examination. Mammography and ultrasound. 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: All women aged 50 and over. Women under 50 with: – Bilateral discharge sufficient to stain clothes - Category 4 – Blood-stained - Category 3 Nipple retraction. Clinical examination. 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. Page 4 of 12 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. Consider HIV/intradermal TB/Paul Bunnell (if indicated). 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. Page 5 of 12 REFREC007 Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Herniae Inguinal/femoral hernia. Incisional hernia. Last updated February 2006 Pain in groin sometimes precedes lump. Pain may be colicky and associated with vomiting (intestinal obstruction). Lump in groin – may be intermittent/ reducible. Social impact. 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. Page 6 of 12 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. Exaggerated gastro colic reflex. Ascites. Mass. Tenesmus. Personal history of malignancy. Blood, pus, mucus (PR). Consider infectious/tropical diseases. Altered bowel habits. Fever. Flatus. 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. Large bowel obstruction. Diverticulitis with evidence of systemic sepsis. Severe bleeding. Suspected appendicitis. Fulminant colitis. Outpatient referrals: 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 Page 7 of 12 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. 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 Loss of weight. Anaemia. Progressive dysphagia. Liquids vs solids. Reflux. Goitre. Scleroderma. Page 8 of 12 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. 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