Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • potentially life threatening of symptoms of:
    • acute upper gastrointestinal (GI) tract bleeding
    • oesophageal obstruction foreign body/food bolus
    • dysphagia with inability to maintain oral hydration/nutrition

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Exclusions

Oropharyngeal dysphagia may be best assessed by neurology or speech pathology in the first instance.

Triage categories

Category 1 — appointment clinically indicated within 30 days

  • new onset dysphagia especially if unresponsive to proton pump inhibitor (PPI) therapy
  • progressive dysphagia for solids (especially in > 50 male obese smokers)
  • dysphagia with significant recent weight loss ≥ 10% in previous 3 to 6 months
  • dysphagia with recent food bolus obstruction
  • referral for feeding tube insertion for progressive neurological disease
  • dysphagia with abnormal imaging suggestive of malignancy (consider contacting gastroenterology registrar on call to discuss)
  • dysphagia with symptoms suggestive of aspiration (consider contacting gastroenterology registrar on call to discuss, or referral to speech pathology)

Category 2 — appointment clinically indicated within 90 days

  • all other dysphagia referrals

Category 3 — appointment clinically indicated within 365 days

  • nil

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

History

  • description of swallowing symptoms including:
    • type (solids/liquids/both)
    • frequency (intermittent/progressive/every time/stable)
  • pain whilst swallowing (odynophagia)?
    • if yes, immunosuppression - inhaled steroids for asthma indicated.
    • did the condition resolve with proton pump inhibitor (PPI) therapy? Consider referral if Ear, Nose and Throat (ENT) is indicated
  • response to PPI therapy if not previously started
  • past history of gastro-oesophageal reflux disease (GORD), Barrett’s and family history of gastrointestinal (GI) cancer
  • weight loss associated with swallowing difficulty within the past 3 months
  • recurrent aspiration pneumonia or symptoms of aspiration (choking/cough)
  • neurological history including – cerebral vascular accident, transient ischaemic attack, risk factors
  • atopy including eczema, hay fever, asthma (eosinophilic oesophagitis in younger people)
  • smoking, body mass index (BMI) and alcohol intake

Examination

  • presence or absence of palpable epigastric mass, lymph nodes
  • nutritional assessment including hydration status if dysphagia severe

Investigations

  • complete blood examination (CBE)
  • iron studies
  • computed tomography (CT) chest/abdomen/pelvis if significant weight loss in older patient > 50 with new dysphagia (consider contacting gastroenterology registrar on call to discuss)

Additional information to assist triage categorisation

  • relevant imaging reports
  • barium swallow in progressive dysphagia (solids)

Clinical management advice

Please note that referrals can be managed by the following specialist services:

A careful structured history is vital to identify people with dysphagia requiring urgent attention and those who can be reassured or have care via the ambulatory care setting.

New dysphagia, especially for solids, over liquids and not fully responsive to proton pump inhibitor (PPI) therapy - warrants an urgent barium swallow and referral for endoscopy. The highest risk group for oesophageal cancer is older, obese male smokers.

However, the most common causes of dysphagia are:

  • gastro-oesophageal reflux disease (GORD) in younger people which should fully resolve with <2 weeks PPI therapy.
  • dysmotility in older people affecting both liquids and solids typically non-progressive and associated with other risk factors for vascular disease.

Where dysphagia is associated with other significant or progressive neurological diseases such as Parkinson’s disease, multiple sclerosis (MS), and motor neurone disease (MND), dysphagia management is best coordinated via the patient’s current neurologist assisted by a speech pathologist/dietitian.

Speech pathology assessment is warranted if concerns are around of oropharyngeal dysphagia alone.

The role of Gastroenterology in this setting is for insertion of feeding tubes to support nutrition and maintain airway safety after the patient and their primary care team have come to a consensus.

Category 3 referrals are accepted at the discretion of the triaging clinician. If you are concerned that your patient requires specialist review, but the referral is declined, you are encouraged to contact the triaging clinician to discuss your concerns.

If a patient has been fully investigated within last 2 years and symptoms remain unchanged, clinician discretion is needed to appropriately refer and triage. In general, there is little value in repeat specialist assessment and/or endoscopic procedures in this scenario.

Consumer resources

Reason for request

  • to establish a diagnosis
  • for treatment or intervention
  • for advice and management
  • for specialist to take over management
  • for a specified test/investigation the General Practitioner cannot order
  • for other reason (e.g. rapidly accelerating disease progression)
  • transfer of care from another tertiary service
  • clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

  • full name, including aliases
  • date of birth
  • residential and postal address
  • telephone contact number/s – home, mobile and alternative
  • Medicare number, where eligible
  • name of the parent or caregiver, if appropriate
  • preferred language and interpreter requirements
  • identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

  • impact on employment
  • impact on education
  • impact on home
  • impact on activities of daily living
  • impact on ability to care for others
  • impact on personal frailty or safety
  • identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery, where surgery is a likely intervention.
  • Choice to be treated as a public or private patient.
  • Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
  • Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
  • Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  • Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
  • A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
  • All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.