临床胃肠病学

Gastroenterology/Hepatology Referral Guidelines for MAP Provider Handbook

在您转诊之前，请咨询适当的GI和肝脏疾病算法. 如果算法建议进行影像学检查或随后的实验室检查，请在转诊前获得. 可能有条件或症状没有在这里列出，需要个别医生的判断.

Summary of Appropriate URGENT Outpatient referrals

紧急情况下 可以 需要 ER评价 包括:

• 急性吐血
• 大量便血或黑黑
• 顽固性恶心和呕吐
• 腹泻伴脱水
• Severe abdominal pain especially with 发热 or abdominal distension
• 黄疸，尤指伴有发烧的黄疸
• Profound anemia requiring transfusion (Hgb <7)
• 疑似肝性脑病
• Cirrhotic patients with ascites and new renal insufficiency
• 吞咽困难 with food impaction, GI foreign bodies

Referral for GI and Hepatic Symptoms and Conditions

1. 腹痛的初步评估: 绝大多数慢性疼痛患者可以通过仔细的病史来诊断，特别是如果有气体症状, 存在腹胀和排便习惯改变. Irritable bowel diagnosis accounts for the cause most of the time. Special populations requiring special attention include those with dysphagia, 减肥, 发热, 便血, HIV阳性或免疫抑制
   1. 实验室:
      • 如果是上腹部疼痛, 获得幽门螺杆菌尿素呼气试验，并开始质子泵抑制剂(PPI)试验4周
      • 如果超过50岁, 考虑患者以前是否有筛查结肠镜检查或粪便免疫化学试验(FIT).
   2. 诊断:
      • 如果疼痛是间歇性的, 在右上象限, 和食物有关, 做腹部超声检查，如果阴性, 进行胆囊收缩素(CCK) hda扫描
      • If pain is in the left lower quadrant and the patient has a 发热, 行CT扫描排除憩室炎
2. 既往评估患者腹痛 (许多肠易激综合征患者会经历腹痛复发，这通常是由于对治疗建议的依从性降低, 但有些可能需要额外的干预).
   1. 获取有关生活压力的详细记录, 低FODMAP饮食依从性, 便秘的处理, 增加生活中的焦虑, recent bout of gastroenteritis (post infectious irritable bowel syndrome (IBS)
   2. Re-acquaint patient with management strategies of diet, stress management
   3. 获得加拿大广播公司, CMP, lipase, stool studies if having diarrhea (see diarrhea evaluation).
   4. 偶尔需要腹部CT检查以使患者放心，或者如果症状提示憩室炎
   5. Obtain history of previous endoscopic evaluation and/or colon cancer screening.
3. 恶心和呕吐 (如伴有脱水或腹痛，见上文紧急或紧急转诊). Intermittent nausea and vomiting is usually associated with functional origin. 考虑以下特殊情况
   1. 询问四氢大麻酚或大麻的使用情况. 如果用热水浴或热水澡减轻了症状，并承认有大量使用大麻的历史，则怀疑大麻恶心和呕吐.
   2. Inquire about medication use, 尤其是阿片类药物
   3. If diabetic, assess Hgb A1C for adequacy of control and optimize control. 考虑胃排空研究
4. 胃食管反流病
   1. 典型的上腹至胸骨后烧灼症状应采用PPI治疗4周.
   2. 非典型症状包括声音嘶哑, 咳嗽, 没有其他解释的哮喘也应经验性地使用PPI试验4周.
   3. Those refractory to 4 weeks of PPI should be referred
   4. 需要长期PPI的患者, 尤其是白人男性, 肥胖病人, 或者50岁以上的病人, should be referred for EGD to screen for Barrett’s esophagus.
5. 吞咽困难
   1. Careful history to sort out esophageal from oropharyngeal dysphagia
   2. Obtain barium swallow to help identify any strictures, masses or dysmotility
   3. EGD with dilation 可以 be 需要d for esophageal dysphagia
   4. Consider modified barium swallow to assess for pharyngeal pooling and aspiration
   5. 所有的吞咽困难患者都应进行GI检查
6. Diarrhea (Chronic > 3 weeks duration)
   1. 仔细检查痉挛和腹胀的相关症状或改变为便秘的病史可能会对大多数患者进行肠易激综合征的诊断. 其他相关病史包括结肠或小肠切除术、胆囊切除术、减肥搭桥手术.
   2. Consider trial of low FODMAP diet, probiotics initially if IBS suspected
   3. 如试验失败，取CBC, CMP，大便作C&S, O & P和贾第虫抗原，或粪便白细胞，艰难梭菌毒素测定腹腔检查，FIT.
   4. If any above positive or if symptoms persist, refer
   5. If any 便血, 减肥, refer sooner
7. Constipation (Chronic > 3 weeks duration)
   1. 仔细记录症状持续时间, constipating药物, 尤其是阿片类药物, 相关直肠出血, age >50 with no previous colon screening, 伴有腹痛或腹胀, 体重减轻和对泻药的反应.
   2. 无相关告警现象, 不需要结肠筛查的患者，可进行腹部x光片或腹部CT检查以排除梗阻，或开始PEG 3350 (Miralax/Glycolax)的临床试验。, 胶原蛋白或纤维补充剂. 如无回应，请参考.
8. 丙型肝炎 在使用直接抗病毒药物的时代，丙型肝炎的评估和治疗变得更加直接. This is a rapidly changing landscape, so this guidance will not go into treatment). If population-based HCV screen is + or +HCV found by liver enzyme elevation:
   1. Obtain HCV RNA by PCR quantitative and HCV genotype
   2. CMP, CBC, HIV抗体
   3. 甲肝病毒总抗体
   4. HBsAg, HBsAb, HBcAb (Vaccinate if neg for immunity or infection)
   5. Abdominal US (possible Fibroscan as available to evaluate fibrosis
   6. Refer for treatment suitability and choice of Direct Antiviral
9. 乙型肝炎
   1. HBsAg, HBsAB, HBeAg, HBeAb, HBV DNA quantitative
   2. 甲肝病毒总抗体
   3. 丙型肝炎 Antibody (HCV RNA by PCR quant if +)
   4. 腹部超声评估肝硬化
   5. Refer for treatment suitability and choice of Direct Antiviral
10. 怀疑因胃肠道失血引起的贫血. Anemias from chronic GI blood loss are typically iron deficiency anemia. These are typically hypochromic microcytic anemias, but not always. 这是贫血的潜在原因的含义，导致内镜评估的紧迫性
    1. 测定粪便铁/TIBC、铁蛋白和FIT. 参考缺铁性贫血的评价.
    2. Begin trial of iron replacement (oral for mild iron deficiency and consider iron infusion for Hgb <8).
    3. Provide reports of any previous endoscopic evaluations.
11. 炎症性肠病. These patients are best followed conjointly with GI specialty support. The severity and frequency of symptoms dictate the urgency
    1. 需要皮质类固醇治疗的复发性IBD患者应考虑使用生物制剂和/或免疫抑制剂来维持缓解
    2. Patients managed on remission maintenance medications should be conjointly followed, but their medical home should be in the GI clinic
12. 伴有代偿丧失症状的肝硬化. Hepatic decompensation can present as ascites and edema, 门体静脉的脑病, 或者胃肠道出血. Clinical discretion is 需要d to determine suitability for outpatient management. 失代偿期肝硬化患者应由GI/肝病诊所联合随访
    1. 仔细的酒精使用史, 静脉注射药物, transfusions in remote past or family history to determine origin
    2. 所有不需要住院治疗的失偿病例都应紧急转诊
    3. 获得加拿大广播公司, PT /印度卢比, CMP, 甲型肝炎病毒, HBsAg, HBcAb, HBsAb, HCV (with reflex testing for HCV RNA quant if +), 铁，TIBC和铁蛋白
    4. 腹部超声检查是否存在腹水，排除肝细胞癌。. Occasionally CT or MRI are 需要d if ultrasound is inconclusive.
13. Elevated liver enzymes (Moderate-Severe 5x->15x nl) or Jaundice (bili >5)
    1. 急性酒精摄入史和检查，近期服用的药物包括草药，补充剂. 评估肝功能衰竭的迹象
    2. AST/ALT ratio of >3:1 suggestive of alcoholic hepatitis
    3. CBC w /血小板, CMP, PT /印度卢比, HBsAg, HBcAb, HBsAb, HCV (HCV RNA通过PCR if +, 甲型肝炎病毒 IgM(急性甲型肝炎的诊断), HBcAb IgM(急性乙肝评估), HSV, EBV, 巨细胞病毒, 血浆铜蓝蛋白, 安娜, ASMA, 抗LKM, 免疫球蛋白, 血清药物检查和尿液毒理学检查.
    4. 腹部超音波
14. 大肠癌筛查
    1. 平均风险、高风险和监测结肠镜检查指南见附表
15. Screening for Adenocarcinoma of Esophagus (Barrett’s)
    1. The ideal candidate is a > 50, male, white, with chronic GERD with elevated BMI, and smoker.
    2. Screening EGD can be performed easily at the time of a screening colonoscopy.
    3. 40%的巴雷特患者没有胃反流症状，因此指南质量不高
16. 异常/偶然的测试结果
    1. 脂肪酶升高: Low grade lipase elevation usually does not imply pancreatitis.
    2. Abnormal CT showing gastric or intestinal wall thickening: Although referral is recommended, endoscopic work up is usually negative
    3. 胰腺囊肿: These usually 需要 referral but small serous cysts are usually benign. 更大更复杂的囊肿, 或者如果病人感到疼痛或体重减轻, 需要更多紧急转诊.
    4. 肝酶升高(轻度至边缘性)
       1. 病史和检查慢性肝病的证据和肝酶升高的潜在原因(重点是对乙酰氨基酚病史). 停止使用有毒药物和酒精.
       2. CBC/血小板，CMP, PT /印度卢比, HBsAg, HBcAb, HBsAb, HCV (HCV RNA通过PCR +)，铁/TIBC，腹部US
       3. If above negative, observe for 3-6 months and repeat testing
       4. 如持续升高，参照
    5. Elevated liver enzymes (Cholestatic – Alkaline phosphatase or bilirubin)
       1. Isolated elevation of bilirubin < 3 mg/dl with other liver enzymes normal is indicative of Gilbert’s syndrome.
       2. Predominantly elevated alkaline phosphatase can be due to drug induced hepatitis, 胆道梗阻或浸润性疾病.
       3. 获取GGT以区分骨源
       4. In middle aged females, obtain AMA to diagnose PBC
       5. 腹部超声检查排除胆道梗阻或CT检查浸润性疾病
    6. 肝脏肿块和囊肿
       1. 孤立单纯性囊肿，无分隔，小于4厘米，通常为良性，可随访超声以确定稳定性，很少需要转诊. 更复杂的肿块需要转诊
       2. 坚实的群众
          1. 肝血管瘤 是最常见的，在女性中更常见吗. 获得血管瘤的CT扫描(寻找周围增强，然后是一个界限清晰的低密度肿块的中央填充)
          2. 局灶性结节增生. 以三四十岁的女性为例. CT检查中央星状瘢痕，静脉期呈高密度，静脉期呈等致密. 通常不需要干预
          3. 肝腺瘤. 肝细胞癌很难从影像学上鉴别，但获得甲胎蛋白能有所帮助吗. 没有星状疤痕.
          4. 肝细胞癌. Usually intentionally discovered through screening. Increased vascularity during arterial phase of contrast with washout. 常伴有AFP升高.
          5. 转移 – Usually multiple and associated with elevated alkaline phosphatase. Refer to interventional radiology for biopsy along with oncology. GI evaluation for primary source 可以 be 需要d.

 Documentation 需要d for scheduling an appointment:

• 既往病史(PMH)
• 当前用药清单
• Most recent progress note describing condition for which patient is being referred
• Recent pertinent labs (appropriate labs per worksheet, 在过去一个月内绘制的, 证实障碍. 请发送实验室流程表，如果有的话.)
• 最近的相关扫描或成像报告