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.

  • severe/uncontrolled abdominal and/or rectal pain unresponsive to first-line management
  • potentially life-threatening, significant, or uncontrolled per rectum (PR) bleed evidenced by:
    • hypotension
    • syncope
    • large volume ongoing bleeding
  • acute severe ulcerative colitis ≥ 6 bloody bowel stools per 24 hours (Truelove and Witts criteria) as well as any of the following
    • temperature >37.8°C
    • pulse rate >90bpm
    • haemoglobin (Hb) <105 gm/L
    • C-reactive protein (CRP) >30gm/L at presentation or erythrocyte sedimentation rate (ESR) >30mm
  • suspected large bowel obstruction, potential symptoms include:
    • inability to pass any bowel motions or gas
    • significant change in bowel habits
    • distended abdomen, abdominal pain and cramping
    • nausea/vomiting

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

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

  • Second opinions for conditions already seen by the same specialty

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • per rectum (PR) bleeding with any concerning features:
    • age >40
    • new onset, not previously investigated
    • symptoms suggestive of inflammatory bowel disease (IBD), colitis
    • new change in bowel habit
    • new tenesmus
    • obstipation or nocturnal diarrhoea
    • dark blood coating or mixed with stool
    • unexplained weight loss of at least 5-10% in previous 3-6 months
    • palpable or visible abdominal/rectal mass, digital rectal exam (DRE) mandatory
  • iron deficiency in males and postmenopausal women or unexplained iron deficiency in premenopausal women, exclude inadequate iron intake, menorrhagia
  • relevant patient and or family history of bowel cancer, 1st degree relative less than 55 years old

Category 2 (appointment clinically indicated within 90 days)

  • persistent or recurrent PR bleeding without concerning features
  • previously investigated less than two years or recurrent rectal bleeding with a known cause for example:
    • radiation therapy
    • IBD
    • anal fissure
    • haemorrhoids
  • suspected haemorrhoidal bleeding, refer to ‘clinical management advice and resources’
  • suspected anal fissure, refer to ‘clinical management advice and resources’

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.

  • smoking/alcohol and other drug status
  • age

History

  • detailed history of bleeding including volume, frequency, duration, bowel habit, constipation, straining, associated bowel symptoms, blood alone or mixed with stools, clots, mucous, tenesmus, recurrent per rectum (PR) bleeding previously investigated
  • associated red flags:
    • change in bowel habit
    • weight loss
    • new onset of anal or abdominal pain
    • abdominal or rectal mass
  • specific patient and family history of gastrointestinal disease including age at diagnosis and specific relationship to the patient/family tree including cancer, specimens, inflammatory bowel disease, coeliac disease, irritable bowel syndrome, haemorrhoids
  • previous management trialled and efficacy - including previous admission/s to hospital for those with recurrent or previous rectal bleeding
  • current medications including aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), novel oral anticoagulants and warfarin
  • dietary history if iron deficient
  • menstrual history if iron deficient and female
  • frailty, cognitive function, ability to use a digital “self-service” pathway

Examination

  • body mass index
  • abdominal and digital rectal examination (DRE) required for all rectal bleeding referrals
  • general cardiorespiratory exam including fitness for endoscopic procedures

Investigations

  • haemoglobin (Hb)
  • relevant previous imaging, endoscopy, colonoscopy, histology reports and pathology of specimens removed

Additional information to assist triage categorisation

As appropriate to patient frailty, age, and comorbidities

  • chest-abdomen-pelvis computed tomography (CT)
  • faecal occult blood test (FOBT) results indicating whether this was complete through the National Bowel Cancer Screening Program.
  • iron studies 
  • complete blood examination (CBE)
  • electrolytes urea and creatinine (EUC)
  • liver function test (LFT)

Clinical management advice

If concerns regarding diagnosis please discuss with Colorectal/General surgery or Gastroenterology registrar dependent on Local Health Network.

Patients residing in the Central Adelaide Local Health Network catchment can be referred directly via the Routine Endoscopic Pathway electronic form CALHN Public Request Form if they require a routine endoscopy or colonoscopy. This new single service pathway allows for better access to routine endoscopic procedures.

Every patient with overt rectal bleeding needs a digital rectal exam (DRE) before referral.Unless previously or recently investigated, all overt rectal bleeding generally requires a flexi-sigmoidoscopy (< 40 years) or colonoscopy for older persons, or those presenting with other risk factors.

National standards recommend a colonoscopy or other total colonic examination is performed within 120 days of an appropriately performed immunological faecal occult blood testing (iFOBT)/faecal immunochemical test (FIT)/faecal human haemoglobin (FHH).

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.

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.