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Barrett’s oesophagus surveillance

ADULT

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 symptoms suggestive of:
    • acute upper GI tract bleeding

    • acute severe lower GI tract bleeding

    • oesophageal foreign bodies/food bolus

    • Acute Severe Colitis*

    • bowel obstruction

    • abdominal sepsis

  • Severe vomiting and/or diarrhoea with dehydration

  • Acute/fulminant liver failure (to be referred to a centre with dedicated hepatology services

  • Biliary sepsis (to be referred to a centre with ERCP service)

 

* Acute severe colitis as defined by the Truelove and Witts criteria – all patients with ≥ 6 bloody bowel motions per 24 hours plus at least one of the following:

  • temperature at presentation of > 37.8°C,
  • pulse rate at presentation of > 90 bpm,
  • haemoglobin at presentation of < 105 gm/l, CRP >30mg/dl at presentation (or ESR > 30 mm/hr)

Australian clinical practice guidelines for the diagnosis and management of Barrett's oesophagus and early oesophageal adenocarcinoma (2015) recommended screening endoscopy schedules


No dysplasia on endoscopic assessment and Seattle protocol biopsy

  • Short (< 3 cm) segment – repeat endoscopy in 3–5 years
  • Long (≥ 3 cm) segment – repeat endoscopy in 2–3 years

If there has been previous low-grade dysplasia, see low-grade dysplasia protocol.

Seattle protocol—biopsy of any mucosal irregularity and quadrantic biopsies every 2 cm unless known or suspected dysplasia then quadrantic biopsies every 1 cm.

 

Indefinite for dysplasia on biopsy
The changes of indefinite for dysplasia on biopsy should be confirmed by a second pathologist, ideally an expert gastrointestinal pathologist. If indefinite for dysplasia is confirmed, then the following endoscopic surveillance is recommended:

  • Repeat endoscopy in 6 months with Seattle protocol biopsies for suspected dysplasia (biopsy of any mucosal irregularity and quadrantic biopsies every 1 cm) on maximal acid suppression
  • If repeat shows no dysplasia, then follow as per non-dysplastic protocol
  • If repeat shows low-grade or high-grade dysplasia or adenocarcinoma, then follow protocols for these respective conditions
  • If repeat again shows confirmed indefinite for dysplasia, then repeat endoscopy in 6 months with Seattle protocol biopsies for suspected dysplasia.


Low-grade dysplasia on biopsy
The changes of low-grade dysplasia on biopsy should be confirmed by a second pathologist, ideally an expert gastrointestinal pathologist. If low-grade dysplasia is confirmed, then the following endoscopic surveillance is recommended (or refer to an expert centre for assessment):

  • Repeat endoscopy every 6 months with Seattle protocol biopsies for dysplasia (biopsy of any mucosal irregularity and quadrantic biopsies every 1 cm.
  • If 2 consecutive 6-monthly endoscopies with Seattle dysplasia biopsy protocol show no dysplasia, then consider reverting to a less frequent follow up schedule.


High-grade dysplasia or adenocarcinoma on biopsy
Referral to a centre that has integrated expertise in endoscopy, imaging, surgery and histopathology

NB: If a patient who has been fully investigated 2 years prior to referral.  Then the referrer and the receiving clinician will need to exercise clinical decision making in triaging and or value in repeat endoscopy / colonoscopy procedures

  •  Refer to Healthpathways or local guidelines

 

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • See 'other useful information for referring practitioners'
  • Category 2
    (appointment within 90 calendar days)
    • See 'other useful information for referring practitioners'
  • Category 3
    (appointment within 365 calendar days)
    • See 'other useful information for referring practitioners'

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

 

2. Essential referral information Referral will be returned without this

  • Previous endoscopic procedures (date, report and histology)

3. Additional referral information Useful for processing the referral

  • No additional information

4. Request

Patient's 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

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

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.)
  • Please note that 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 becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • 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.