REFERRAL INFORMATION (Please Tick Appropriate Boxes)

Mid Yorkshire Hospitals Trust Suspected Upper GI Cancer Referral Form

Only refer when patient is available to attend an appointment within the next 14 days

GENERATE a Choose & Book request, insert the Unique Booking Request Number (UBRN) in the space below

OR FAX this form within 24 HOURS to the Fast Track Office on 01924 542746

Telephone enquiries 01924 212507

GP Practice: / Tel:
GP Name: / Fax:

Patient Details

Name / Male / Female
Address
Postcode / D O B
Age
Tel:
Mobile
Has patient previously visited this hospital / Yes / Interpreter required? / Yes
Hospital No: (if known) / First Language
NHS No:

Current Medication:______

Referral Information (please tick appropriate boxes):
For URGENT UPPER GI ENDOSCOPY
Dysphagia
Aged 55 and over with SIGNIFICANT weight loss AND any of the following:
· Upper abdominal pain
· Reflux
· Dyspepsia
Significant weight loss: more than 5% body weight in 6 months / For URGENT CLINIC REVIEW +/- IMAGING / ENDOSCOPY
Upper abdominal mass consistent with stomach cancer
Aged 40 and over with jaundice

Guidelines for Suspected Upper GI Cancer Referrals
· These cancers have poor prognosis and tend to be diagnosed late, so use safety netting
· Check FBC and platelets (please note thrombocytosis itself carries a higher risk of positive predictive value), eGFR, LFTs at initial presentation
· H. pylori testing should not affect the decision to refer for suspected cancer
· Consider direct access urgent CT scan for suspected pancreatic cancer
· Consider an urgent direct access ultrasound scan to assess for gall bladder or liver cancer in people with an upper abdominal mass consistent with an enlarged gall bladder or liver.

PLEASE CONSIDER DIRECT ACCESS TO UPPER GI ENDOSCOPY IF APPROPRIATE (insert hyperlink to referral form)

If direct access to endoscopy is available locally, the same information should be provided to patients about reason for referral.

Information given to patients 1. Is the patient aware of this cancer referral and been given a leaflet?

Links to Pt Leaflet: - https://www.midyorks.nhs.uk/cancer-information-and-resources

- http://nww.northkirkleesccg.nhs.uk/for-practices/clinical-guidelines-pathways/

2. Is the patient available within the next 14 days?

3. Has the patient given consent for their information to be accessed by

Healthcare professionals involved in their care?

GP Signature: Date:

REFERRAL GUIDELINES FOR SUSPECTED UPPER GASTROINTESTINAL CANCER

Pancreatic Cancer

Consider an urgent direct access CT scan, or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following:

· diarrhoea

· back pain

· abdominal pain

· nausea

· vomiting

· constipation

· new-onset diabetes

Stomach Cancer

Consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people with haematemesis.

Consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people aged 55 or over with:

· treatment-resistant dyspepsia or

· upper abdominal pain with low haemoglobin levels or

· raised platelet count with any of the following:

- nausea

- vomiting

- weight loss

- reflux

- dyspepsia

- upper abdominal pain, or

· nausea or vomiting with any of the following:

- weight loss

- reflux

- dyspepsia

- upper abdominal pain.

*Creutzfeldt-Jakob Disease:

The CJD/CJDv risk assessment form should be completed for all patients undergoing endoscopy procedures and the outcome documented on the fast track referral form.

UPPER GI FINAL VERSION May 2016