Endoscopy

Upper and Lower GI endoscopy

Emergency Endoscopy

Patients with upper GI bleed or other emergencies should be referred via the on call team and not to direct access services.

Endoscopy for Suspected Cancer

Please refer via USC/2WW pathways for patients with possible Upper GI cancer or lower GI cancer.

Direct Access Endoscopy (non-2WW) via eRS

Please submit requests for direct access endoscopy via eRS using one of the generic forms as below (available as templates in EMIS):

• Upper GI endoscopy
• Lower GI endoscopy

Referrals will be seen in clinical priority order. It is important that results of appropriate tests are included (e.g  bloods, Coeliac Screen, FIT, Faecal Calprotectin, Helicobacter Pylori stool antigen test) as this will help with the prioritisation of patients. Referrals with incomplete information or not on the correct form may be returned

The current direct access options for referral are as follows and patients will be offered a choice of provider unless otherwise requested: 

1. Community Diagnostic Centre (operated by InHealth Group and NBT). See below for advice on exclusion criteria*.
2. Practice Plus Group (PPG) (Emersons Green). See below for advice on exclusion criteria*

*Exclusion Criteria for community endoscopy services (exclusion criteria may vary between providers so the list below is only a guide):

• Abusive, violent or threatening patients without a security escort.
• Under 16 years of age.
• History of obstructive sleep apnoea.
• Patients who are very overweight - For CDC - maximum weight is 220kg (although see also BMI criteria below). For PPG -maximum weight is 135kg.
• Patients with BMI over 40 (For CDC - people with high BMI are at higher risk with sedation. If patient is planning to proceed without sedation then they may be suitable, otherwise they may run the risk of being cancelled by the endoscopist on the day - please therefore indicate that patient is willing to proceed without sedation if referring a patient with BMI > 40).
• ASA unstable 3, 4 or 5
• eGFR <30

The CDC (InHealth) also has the following exclusions:

• Mobility – patient must be able to transfer from chair to trolley and turn 180 degrees (left to right hand side on trolley).
• Barrett’s Surveillance– long segment Barrett’s (ie 3cm or more) is for secondary care surveillance unless contractually agreed.
• Large Polyps-these will be clinically assessed if safe for removal in a community site according to size, site and type of polyp. A size guide is listed in the acceptance criteria.

*Please see the InHealth Service guide for full list of exclusions

For community colonoscopy patients should also be:

• able to tolerate the bowel preparation which can be quite severe. Beware renal impairment.
• reasonably fit to tolerate the sedation. Beware significant cardio-respiratory disease.
• relatively mobile - during colonoscopy patients turn several times to facilitate onward movement of the scope

Referrals to Secondary Care

Patients who do not fulfil criteria for USC/2WW or Direct access endoscopy may need to be referred to secondary care. However, NBT and UHBW do not accept direct referrals for endoscopy. If a patient does not meet criteria for USC/2WW or a direct access referral then please consider the following options:

• Consider appropriate Advice and Guidance services available at NBT and UHBW.  
• Referral letter to appropriate specialty via eRS detailing the patients history and investigations. PLEASE DO NOT REQUEST A DIRECT ACCESS ENDOSCOPY OR USE THE STANDARD FORM AS THIS IS LIKELY TO LEAD TO A REJECTION OF YOUR REFERRAL.  These referrals will be triaged and seen in clinic or directed to endoscopy as appropriate.
• Referral to Community gastroenterology (InHealth) via eRS.

1. UHBW (Bristol) – If patient does not fulfil referral criteria for one of the direct access endoscopy services, refer via e-RS into the appropriate speciality e.g. gastro, GI etc. by referral letter, explaining why the patient is unsuitable for direct access. Referrals must not be on the BNSSG endoscopy form. A consultant will then review the request and either refer the patient for endoscopy internally, see the patient in clinic or arrange an alternative test. For PEG insertion please see section below.
2. NBT - Direct referrals for endoscopy are not permitted. If a patient does not fulfil referral criteria for one of the direct access endoscopy services, then a referral letter should be submitted via e-RS to gastroenterology or lower GI clinic. Referrals must not be on the BNSSG endoscopy form which NBT do not recognise. For PEG insertion please see section below
3. UHBW (Weston) - If patient does not fulfil referral criteria for one of the direct access endoscopy services, refer via e-RS into the appropriate speciality e.g. gastro, colorectal etc. Please attach a letter, explaining why the patient is unsuitable for AQP. A consultant will then review the request and either refer the patient for endoscopy internally, see the patient in clinic or arrange an alternative test.
4. RUH - Routine referrals are accepted for patients from Bath facing practices. Referral forms are available and should be used where appropriate. Please see the Service guide for further details.

Additional Support for Endoscopy UHBW

If patients have additional needs eg Autism, Learning Disabilities, Mental health issues and Dementia there is a Care Navigator for endoscopy at UHBW (Trudy.Reed@uhbw.nhs.uk) who will support patients to understand and undertake their procedure. This is only available for patients who are under the care of UHBW and therefore GPs cannot refer directly from primary care.

Duodenal Biopsy

Please see the Coeliac disease page for advice on investigation of possible coeliac disease.

If duodenal biopsy is required to confirm a diagnosis, then refer via eRS for direct access endoscopy using the BNSSG upper GI endoscopy form  (also available in EMIS).

The following providers offer a duodenal biopsy service:

• Community Diagnostic Centre (operated by InHealth Group and NBT)
• Practice Plus Group  (Emersons Green Treatment Centre) 

Patients must be eating a diet containing gluten.

For patients who do not meet criteria or are excluded from a direct access service, then please consider the secondary care options as listed above.

PEG Insertion

UHB

PEG insertions at UHB can be requested on ICE - search for Upper GI OG Waiting List Form.

For practices that do not have access to ICE please refer directly to Queens Day Unit on their Upper GI referral proforma.

NBT

PEG insertions/removals/replacement in adults at NBT can be requested by emailing an urgent referral to: gastroenterologyandhepatologysecretaries@nbt.nhs.uk  they will be triaged by the ward consultant. The procedure will be booked on your behalf; however, please ensure the patient’s capacity to consent is documented on the referral.

If the patient lacks capacity to consent, please could the outcome of best interest discussions be included in the referral.

Please note that Gastrostomy A&G is available from NBT. See the Gastro A&G page for further details.

WGH

PEG insertions should be requested on the referral form and emailed to wnt-tr.endoscopybookingteam@nhs.net where they will be sent for triage. A patient information leaflet is also available.

BURIED BUMPER SYNDROME (BBS)

The attached information leaflet has been produced by Nutricia and is aimed specifically at GPs who may be asked to make decisions about feeding through PEG tubes that are potentially buried, and to make emergency referrals for PEG change before the problem progresses.

Oesophageal Stricture

Patients with a known benign oesophageal stricture who start to experience recurrent symptoms should be referred via eRS (or letter directly to consultant if previously advised) to the hospital department where they were originally seen if possible. (Please see update below for most recent position regarding urgency of referral). They will need to be reviewed in an outpatient clinic (face to face or remotely) to discuss suitability for further dilatation before this can be booked. Occasionally, patients  who need frequent dilatations may have access to patient initiated follow up where this is appropriate and previously agreed. 

If a patient presents with dysphagia, upper abdominal mass or weight loss and malignancy needs to be excluded then an Upper GI - USC (2WW) Referral should be considered instead.

Patients with strictures should not be referred to direct access endoscopy services (CDC or PPG/EGTC) as these providers are unable to carry out dilatation procedures.

Barrett's Surveillance

Please see the Barrett's Oesophagus page.

Endoscopy under Sedation or GA

Sedation

Discussions around sedation are best had with the patient and an endoscopy nurse or endoscopist and not with the GP. Patients requesting sedation for endoscopy should be advised that this will be discussed with the endoscopist prior to their procedure.

The community diagnostic centre (CDC) also advises the following:

'Some patients may be able to tolerate a trans nasal endoscopy better than a traditional OGD which could be done with or without sedation at the CDC. For some patients who are frail, it is unsafe to give any sedation and always ultimately down to the endoscopist to decide (with discussion with the patient). This would be true wherever they attend for endoscopy.'

Referrers should therefore refer in the usual way and should avoid stating that a patient needs deep sedation as this can cause confusion.

If further advice is required on appropriateness of community endoscopy for an individual patient then please consider requesting gastroenterology advice and guidance or refer to the community gastroenterology clinic.

You can also contact the community providers using the contact details in the section below.

General Anaesthetic

As detailed above, community endoscopy providers can generally give just as deep a sedation as secondary care providers. The only difference is that community services cannot give propofol or General Anaesthetic.

GA or propofol is only available in secondary care and is only necessary for complex therapeutic procedures (these are not referred from primary care) or for patients with severe learning difficulties where ability to cooperate during a procedure is in doubt. 

If uncertain about need for GA then please request gastroenterology advice and guidance initially. 

Referrals requesting endoscopy under sedation or  GA sent to secondary care may be returned with the above advice.

Contact details

Referrers can contact the lead endoscopist to discuss referrals on the following numbers:

• Practice Plus Group Hospitals (formerly Care UK); 0117 906 1800
• InHealth (formerly PRIME); 0117 910 3790

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.