Upper GI - USC (2WW) - (DRAFT) (2)

Overview

***STOP PRESS - From 11.8.25 direct to test referrals via ICE will be available for USC upper GI endoscopy for UHBW (already available at NBT).***

Services are provided by UHBW (at Bristol Royal Infirmary and Weston General Hospital) and by NBT (at Southmead Hospital). The services are for patients who meet the Upper Gastrointestinal Urgent Suspected Cancer criteria.

Please see the following: 

• BNSSG Suspected UPPER GI Cancer Referral Form - link to form to be added
• NICE Cancer Guidelines 2015 - Upper GI Tract Cancers(1)

Iron Deficiency Anaemia (IDA)

Please note that iron deficiency anaemia (IDA) alone is not an indication for USC upper GI referral. In these cases it is advised that lower GI investigations should be prioritised. Please see the lower GI 2WW criteria initially as an USC lower GI endoscopy or FIT test may be indicated depending on age and other symptoms. 

Please see the Anaemia (Iron Deficiency) page for further advice on investigation of IDA.

If upper GI endoscopy is required outside of the USC pathway then referrals should be sent to a community endoscopy provider. Please see the Endoscopy page for details.

Referral

Direct to Test

ICE referral (direct to test) is available for Upper GI USC (2WW) referrals requiring endoscopy (from 11.8.25 now available at UHBW and NBT). Please use this route for suitable patients who meet criteria.

At time of referral please issue the relevant patient information leaflet and ensure that appropriate blood tests are arranged. Do not delay referral while awaiting blood test results.

USC Referral via eRS

Use the USC form and submit via eRS for patients who meet criteria for USC referral but do not meet criteria for direct to test (see further advice in sections below).

Patients may have a diagnostic test as their first appointment i.e. OGD, CT, USS, MRCP.

At time of referral please issue the relevant patient information leaflet and ensure that appropriate blood tests are arranged. Do not delay referral while awaiting blood test results.

MDT Referral

If advised to refer into MDT, then please submit a USC referral via eRS to the relevant secondary care team who will ensure that all the required information is available to enable an effective MDT discussion.

Contact details ADULT USC:

NBT - Tel on 0117 414 0522 / 0536 / 0537 / 0538 or email to cancerservices@nhs.net

UHBW - Tel on 0117 342 7641 / 2 / 3 / 4 or email to Ubh-tr.fast-trackreferrals@nhs.net

Oesophago-gastric Cancer

USC Referral Criteria for oesophago-gastric cancer (1)

• Dysphagia
• Patients over 55 with weight loss and at least one of the following; upper abdominal pain, heartburn, reflux
• Upper abdominal mass consistent with stomach cancer

The first line investigation is upper GI endoscopy which should be accessed as a direct access USC endoscopy referral on ICE unless the patient does not meet criteria or is unable/unfit to go straight to test.

There is also significant overlap with HPB malignancy, so please consider whether an USS or CT abdomen is indicated (see sections below).

Indications for non-urgent upper GI endoscopy

NICE (1) suggests NON-URGENT direct access upper gastrointestinal endoscopy for

• Haematemesis (if stable) - see Upper GI Bleed page for further guidance.
• Aged 55 and over with treatment resistant dyspepsia.
• Aged 55 and over with upper abdominal pain and anaemia.
• Aged 55 and over with raised platelets and any of; nausea, vomiting, weight Loss, reflux, dyspepsia, upper abdominal pain.
• Aged 55 and over with nausea and/or vomiting and any of; weight loss, reflux, dyspepsia, upper abdominal pain.

Please see the Endoscopy page for details.

See the following pages for further advice:

• Dyspepsia and Reflux
• Gallstones (and polyps)
• Anaemia (Iron Deficiency)

Pancreatic Cancer

USC Referral Criteria for pancreatic cancer (1)

• Patients aged 40 yo and over with jaundice - refer via eRS USC pathway using upper GI cancer form.

• Patients aged 60 yo and over with weight loss and any of the following; diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, new‑onset or rapidly worsening diabetes.  - refer for direct access CT scan (on ICE) to be done within 2 weeks or on eRS USC pathway.

• Bilirubin >40 (not deranged LFTS alone)* - request urgent direct access CT scan via ICE (to be performed within 2 weeks) and refer on Upper GI USC pathway. *Deranged LFTs +/- Bilirubin <40 is not a USC referral; see Liver disease page for further advice.

• Bilirubin >100 - refer via an emergency surgical service as these patients need a CT within 24 hours which cannot be delivered on an USC pathway.

• Pancreatic cancer suggested on imaging (e.g CT or USS) - refer via eRS USC pathway, please perform suggested blood tests and attach imaging report if not available on BNSSG ICE.

Pancreatic cancer can present with a number of different symptoms, and there are often multiple symptoms simultaneously. Symptoms include pain, loss of appetite, and loss of weight. Lesions near the head of the pancreas may lead to obstructive jaundice. Endocrine cancers may produce symptoms from secretion of hormones such as insulin.

For screening advice see the Pancreatic Cancer Surveillance Programme page.

Pancreatic cysts

• Refer all patients with pancreatic cysts on imaging using the Upper GI USC pathway via eRS unless the patient is not well enough for, or declines further investigation/treatment. Please attach imaging report and ensure clinical details are included.

This information will be used to guide whether the pancreatic cyst has a high risk of malignancy. If on review of the imaging the risk is agreed to be low, patients will be downgraded to a non cancer pathway and will be informed of this before being followed up in an urgent clinic appointment to discuss interval follow up imaging.

The following criteria will be used to guide the risk of malignancy;

Cyst with high risk factors:

• Obstructive Jaundice and cysts in Head of Pancreas
• Main pancreatic duct ≥ 10 mm in size
• Enhancing mural nodule ≥ 5 mm

Cyst with Worrisome factors:

• Cysts > 3cm
• Main pancreatic duct ≥ 5 mm in size
• Abrupt change in calibre of pancreatic duct with distal pancreatic atrophy
• Enhancing mural nodule < 5 mm or thick walled cysts
• Cysts with regional Lymphadenopathy
• Increased serum level of CA-19-9
• Cyst growth rate ≥ 5 mm / 2 years

Liver or Gallbladder Cancer

USC Referral Criteria for liver or gall bladder cancer (1)

• Upper abdominal mass consistent with enlarged liver or gall bladder - refer for a direct access USS iva ICE (to be done within 2 weeks) and refer on Upper GI USC pathway via eRS.

• Liver or gall bladder cancer suspected on imaging - refer on Upper GI USC pathway via eRS.

Gall Bladder Polyps

• Gall bladder polyps >2cm should be referred on the Upper GI USC pathway via eRS - please also request urgent direct access CT scan (to be performed within 2 weeks) for HPB MDT discussion

The majority of gall bladder polyps do not require USC referral - see Gallstones (and polyps) page for further advice.

Required Blood Tests

Please ensure that the following recent blood results are made in parallel with the referral (less than 8 weeks old):

• Suspected UGI fast track patients: FBC, LFT, U&E
• Suspected pancreatic and biliary cancers: FBC, LFT, U&E, CA 19-9, Clotting
• Suspected liver cancer: FBC, LFT, U&E, Ca19-9, alpha feto protein (AFP), CEA & Clotting

Resources

(1) Suspected cancer: recognition and referral | Upper GI - NICE

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.

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