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.

  • acute severe ulcerative colitis (ASUC) ≥ 6 bloody bowel stools per 24 hours (Truelove and Witts criteria) as well as any of the following:
    • temperature > 37.8°C
    • pulse rate > 90 beats per minute (BPM)
    • haemoglobin < 105 g/l
    • C-reactive protein (CRP) > 30mg/L at presentation or erythrocyte sedimentation rate (ESR) > 30 mm
  • suspected bowel obstruction – vomiting, significant distention, lack of passage of flatus, obstipation
  • acute surgical pathology, e.g. evidence of peritonism, systemic toxicity
  • acute gynaecological/ obstetric pathology
  • raised lipase 3x above the upper limit of normal
  • obstructive liver function tests (LFT) (raised alkaline phosphatase (ALP)/Gamma-glutamyl transferase (GGT) and bilirubin) +/- fever

Please contact the on-call registrar to discuss your concerns prior to referral.

For clinical advice, please telephone the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Regional health networks 

Category 1 — appointment clinically indicated within 30 days

  • abdominal pain with the following red flags:
    • unintentional weight loss ≥ 10% in previous 3 to 6 months
    • past history of intra-abdominal malignancy within the last 5 years
    • iron deficiency or other abnormal blood tests (haemoglobin (Hb), C-reactive protein (CRP), obstructive LFT)
    • abdominal mass on examination
    • abnormal imaging
    • nocturnal symptoms disturbing sleep
  • positive immunological faecal occult blood test (iFOBT )/faecal immunochemical test (FIT)/faecal human haemoglobin (FHH) - refer to Colorectal Cancer Screening - Adult CPC
  • faecal calprotectin in excess of 100ug/g

Category 2 — appointment clinically indicated within 90 days

  • multiple emergency department presentations (from ED only)

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

  • detailed description of the abdominal pain including site, radiation, severity, character, pattern, precipitating or relieving factors, duration of symptoms, associated symptoms, functional impact, presentations to emergency departments
  • presence or absence of red flags:
    • progressive or nocturnal symptoms
    • fever
    • unintentional weight loss
    • change in bowel habits
    • bloody stools
    • abdominal mass
    • anaemia
  • past relevant medical history, including past gastrointestinal (GI) cancer, endometriosis, laparoscopies, or abdominal surgery
  • current medication especially non-steroidal anti-inflammatory drugs (NSAIDs), opioids, anti-depressants, selective serotonin reuptake inhibitors (SSRIs), anticoagulants, antiplatelets
  • family history of GI disease in first degree relative – cancer, inflammatory bowel disease (IBD), coeliac disease
  • mental health and/or chronic pain issues
  • drug and alcohol consumption

Examination

  • abdominal examination and weight/body mass index (BMI)

Investigations

  • complete blood examination (CBE)
  • urea, electrolytes, creatinine (UEC)
  • liver function tests (LFTs)
  • lipase
  • C-reactive protein (CRP), if IBD suspected
  • iron studies
  • faecal calprotectin if diarrhoea > 6 weeks
  • infectious stool screen (viral and bacterial if < 6 weeks), Clostridium difficile toxin and parasite PCR if > 6 weeks)
  • faecal occult blood testing if age ≥ 45
  • most recent endoscopy and colonoscopy results
  • consider imaging:
    • ultrasound abdomen, for upper abdominal pain
    • computed tomography (CT) abdomen/pelvis with contrast if there is a reasonable suspicion of neoplastic process, gastrointestinal obstruction, complicated diverticulitis, pancreaticobiliary pathology

Additional information to assist triage categorisation

  • previous investigations and reports of presenting abdominal pain, e.g. endoscopy, radiological reports

Clinical management advice

Most abdominal pain is functional in nature or related to bloating, and constipation. This resolves with attention to diet, exercise and stress and often does not require specialist medical input.

When associated with high levels of anxiety or somatisation, consider referral to a psychologist.

It is worth considering the possibility of pregnancy as a cause for symptoms.

Most cases where specialist review is indicated will be clearly identified by the presence of red flags.

Avoid opioid prescriptions in chronic abdominal pain – in many cases opioids exacerbate chronic abdominal pain through causing constipation and hyperalgesia (narcotic bowel syndrome).

Abdominal pain without red flag is a low yield indication for colonoscopy, so unless there is a positive immunochemical faecal occult blood test (iFOBT)/faecal immunochemical test (FIT)/faecal human haemoglobin (FHH) or a raised faecal calprotectin level to suggest inflammatory bowel disease (IBD), referrals for this indication are unlikely to be accepted.

If you are concerned that your patient requires specialist review, but the referral is declined, you are encouraged to contact the triaging clinician or Gastroenterology Registrar on call to discuss your concerns.

If a patient has been fully investigated within last 5 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.

Refer to relevant CPC for:

Clinical resources

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.