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 upper gastrointestinal (GI) tract bleeding
  • oesophageal obstruction by foreign body or food bolus
  • severe vomiting with dehydration

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 

Exclusions

Stable reflux disease controlled with proton pump inhibitors (PPIs) – if symptoms recur on cessation of therapy, recommence at the lowest effective dose.

Triage categories

Category 1 — appointment clinically indicated within 30 days

  • relevant upper gastrointestinal (GI) symptoms with any red flags:
    • overt GI bleeding
    • unintentional weight loss ≥ 10% in previous 3 to 6 months
    • dysphagia which does not fully resolve with 2 weeks PPI therapy
    • persistent vomiting
    • iron deficiency
    • suspected oesophageal or gastric cancer on imaging

Category 2 — appointment clinically indicated within 90 days

  • volume regurgitation with suspected aspiration/history of aspiration pneumonia

Category 3 — appointment clinically indicated within 365 days

  • previous diagnosis of Barrett’s oesophagus for consideration of surveillance
  • consideration of anti-reflux surgery
  • symptoms which are not relieved by double dose PPI and may require physiologic function testing to clarify the cause of symptoms (pH and/or manometry/impedance)
  • request a single “one off” upper GI endoscopy in person/s with relevant upper GI symptoms > 50 years of age to exclude Barrett’s and allay concerns – there is no evidence that this improves symptom control or prolongs survival

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 symptoms - location, character, radiation, time course, pattern (duration from initial onset, and frequency of episodes), precipitating or relieving factors (food, exertion, antacids, proton pump inhibitors (PPIs))
  • presence or absence of red flags:
    • persistent or progressive dysphagia (solids/liquids)
    • odynophagia
    • unintentional weight loss
    • nocturnal cough or choking
    • haematemesis
    • anaemia
  • medical management to date, including response to twice a day (BD) PPIs
  • past medical history, including documented Barrett’s oesophagus
  • family history
  • current and previous prescription medications including aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), novel oral anticoagulants (NOACs) and warfarin
  • volume regurgitation with suspected aspiration/history of aspiration pneumonia
  • smoking and alcohol
  • stress and anxiety
  • allergies

Examination

  • examination findings e.g. epigastric mass or lymph nodes
  • body mass index (BMI)

Investigations (include if performed) 

  • complete blood examination (CBE)
  • urea, electrolytes, creatinine (UEC)
  • iron studies if haemoglobin (Hb), or if mean corpuscular volume (MCV) are low
  • previous endoscopic findings with histology, if performed
  • barium contrast swallow (dysphagia)
  • abdominal computed tomography (CT) (weight loss)
  • ultrasound (US) (suspected biliary colic)
  • oesophageal manometry/pH monitoring, if performed
  • Helicobacter pylor (H. pylori) stool Ag test for dyspepsia only
  • C14 Urease breath test

Clinical management advice

Most people with typical reflux (heartburn/acid regurgitation) or indigestion/dyspepsia symptoms can be safely managed in the community. This is especially true for people with long standing symptoms in the absence of red flags.

Most patients with atypical reflux symptoms (chronic cough, asthma or throat symptoms) do not have objective evidence of gastroesophageal acid reflux – such cases should only be referred by specialists (Respiratory/ENT) after ruling out other causes of symptoms.

Most upper gastrointestinal (GI) symptoms are functional in nature and respond well to reassurance, after a structured history and clinical examination with limited basic investigations.

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.

The appropriate dosing for proton pump inhibitor therapy is before the morning meal. If twice daily dosing the second dose should be before the evening meal.

Some patients with ongoing typical reflux symptoms may respond to the addition of night-time dosing of a histamine receptor antagonist, before bed.

If referring for consideration of anti-reflux surgery, please ensure you discuss willingness to consider a surgical treatment option with patient before referring.

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.

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.