Download 2WW Upper GI Nov 2016

Upper GI
Fast Track Referral – 2 Week Wait
Please refer via the e-Referral Service
Patient Details:
Patient Name
Address
DOB
Home Tel. No.
Mobile Tel. No.
Preferred Tel. No.
Main Spoken
Language
Transport needed?
NHS No.
Gender
Ethnicity
Email Address
Interpreter needed?
Registered GP Details:
Practice Name
Registered GP
Registered GP
Address
Tel No.
Email
Usual GP
Fax No.
Practice Code
Please use separate children’s proforma for patients under 16
Dear Colleague, I would be grateful for your opinion on the patient named above who presents with clinical findings I
consider suspicious of malignancy.
I have discussed the possibility of cancer with this patient. Has the patient confirmed that they can be available to
attend an appointment within the next two weeks? Yes
No
Order urgent direct access OGD (follow Gastroscopy Flow Chart
v1.0 for decision making see below page 6)
Tick if Criteria
applies
Dysphagia
Aged ≥55y with weight loss with any of;
Upper abdominal pain
Reflux/ Dyspepsia
Consider non – urgent direct access OGD (follow Gastroscopy Flow
Chart v1.0 for decision making see below page 6)
Tick if Criteria
applies
Haematemesis
Aged ≥ 55y with:

Treatment resistant dyspepsia

Upper abdominal pain and low haemoglobin

Raised platelet count AND any of;
o
Nausea
o
Vomiting
o
Weight loss
o
Reflux
Form to be reviewed annually
Page 1 of 5
Revised: August 2016

o
Dyspepsia
o
Upper abdominal pain
Nausea and vomiting AND any of;
o
Weight loss
o
Reflux
o
Dyspepsia
o
Upper abdominal pain
Consider urgent direct access CT scan (or urgent USS if CT not
available)
Tick if Criteria
applies
≥60y with weight loss and any of:

Diarrhoea

Back pain

Abdominal pain

Nausea/vomiting

Constipation

New onset diabetes
Tick if Criteria
Consider urgent direct access USS
applies
Upper abdominal mass consistent with an enlarged gallbladder
Upper abdominal mass consistent with an enlarged liver
Tick if Criteria
2ww Referral if:
applies
OGD findings suggest Oesophageal or gastric cancer
CT or USS findings suggest Pancreatic cancer
Refer using suspected cancer pathway if aged ≥40y and have jaundice (The evidence did
not distinguish obstructive jaundice. Other causes of jaundice were considered more likely
if <40y)
USS findings suggest Gallbladder cancer
USS findings suggest Liver cancer
Clinical Information
Medical History
Current Medications
Form to be reviewed annually
Page 2 of 5
Revised: August 2016
Known Allergies
Family History
Patient Anxiety Level
Patient information and support needs
Information given to the patient
Other information
WHO performance status: (please tick)
0 – normal activity
1 – restrictive light work
2 – self-care but no work > 50% of working day
3 – limited self-care – confined to bed/chair > 50% of waking day
4 – completely disabled – totally confined to bed/chair
To be completed by the Data Team
Date of decision to refer
Date of appointment
Date of earliest offered appointment
(if different to above)
Specify reason if not seen at earliest
offered appointment
Periods of unavailability
Booking number (UBRN)
Final Diagnosis:
Form to be reviewed annually
Malignant
Benign
Page 3 of 5
Revised: August 2016
Summary of the NICE 2015 suspected cancer guidelines
Gastrointestinal cancers
Oesophageal and gastric cancer
Consider cancer
 Upper abdominal mass consistent with stomach cancer.
pathway referral
Urgent direct
 Dysphagia
access OGD
 Aged ≥55y with weight loss with any of upper abdominal
pain/reflux/dysphagia.
Consider nonurgent direct access
OGD
Pancreatic cancer
Refer via cancer
pathway
Consider urgent
direct access CT
scan (or urgent
USS if CT not
available)


Haematemesis (Clearly use your clinical judgement here!)
Aged ≥55y with:
o Treatment resistant dyspepsia.
o Upper abdominal pain and low haemoglobin
o Raised platelet count AND any of nausea/vomiting/weight
loss/reflux/dyspepsia/upper abdominal pain.
o Nausea and vomiting AND any of weight loss/reflux/
dyspepsia/upper abdominal pain.

Refer using suspected cancer pathway if aged ≥40y and have
jaundice. (The evidence did not distinguish obstructive from nonobstructive jaundice. Other causes of jaundice were considered
more likely if <40y)

≥60y with weight loss and any of:
o Diarrhoea.
o Back pain.
o Abdominal pain.
o Nausea/vomiting.
o Constipation.
o New onset diabetes.
(USS only images the head of the pancreas, CT images the whole
pancreas and may detect other cancers.)
Gallbladder cancer
Consider urgent
direct access USS
Liver Cancer
Consider urgent
direct access USS
Form to be reviewed annually

Upper abdominal mass consistent with an enlarged gallbladder.

Upper abdominal mass consistent with an enlarged liver.
Page 4 of 5
Revised: August 2016
Form to be reviewed annually
Page 5 of 5
Revised: August 2016