Information for referring doctors

How to refer

Secure electronic referral is preferred, through HealthLink chabelvi or Argus cha for the Norwest and Rouse Hill rooms, which also receive referrals by fax on (02) 8080 8115. Referrals can also be faxed or emailed to any of the four consulting locations. Please address referrals to A/Prof Viraj Kariyawasam.

A referral that includes the following saves the patient a trip and speeds up any procedure:

• the presenting problem, how long it has been present and any red flags present or absent
• relevant results: full blood count, iron studies, faecal test, calprotectin, coeliac serology, liver tests and imaging
• previous endoscopy reports and histology, particularly of polyps
• anticoagulants and antiplatelets, diabetes medication including insulin and GLP-1 agonists, and cardiorespiratory conditions relevant to sedation
• family history of bowel cancer, including the age at diagnosis

Which referrals are prioritised

• positive faecal occult blood test, whether through the national program or requested in practice
• rectal bleeding, particularly persistent, mixed with stool or in a patient with other symptoms
• iron deficiency, with or without anaemia, in men and postmenopausal women, and unexplained in younger women
• suspected new inflammatory bowel disease and flares in known disease
• dysphagia
• large or complex colonic polyps referred for endoscopic resection

For a positive screening test, please note it clearly on the referral. For suspected acute severe colitis, gastrointestinal bleeding with haemodynamic compromise or obstruction, the emergency department remains the right place.

Direct-access colonoscopy for privately insured patients can be arranged where the indication is clear and the patient is fit for the procedure. Phone the rooms to discuss.

Public patients with inflammatory bowel disease

For patients with Crohn's disease or ulcerative colitis, or with suspected inflammatory bowel disease, who need to be seen in the public system, referrals can be addressed to A/Prof Viraj Kariyawasam at the Concord Hospital inflammatory bowel disease clinic, Ambulatory Care and Endoscopy Unit, Level 1, Multi Building (Building 5), Concord Hospital, Hospital Road, Concord NSW 2139. Phone (02) 9767 6111, fax (02) 9767 6767. Appointments there are made by the hospital rather than through the private rooms, and there is no fee. The clinic takes inflammatory bowel disease referrals only; other gastroenterology referrals go to the hospital's general clinics or to the private rooms.

How to use faecal tests in practice

The FOBT is a screening test, not a rule-out for symptoms

In an asymptomatic patient the iFOBT every two years from 45 is the right test. In a patient with red flag symptoms (rectal bleeding persisting beyond four to six weeks, a change in bowel habit, unexplained iron deficiency, weight loss or a mass), a negative FOBT does not exclude cancer and should not delay referral.

Never repeat a positive kit

Bleeding from polyps and cancers is intermittent. A negative repeat does not cancel a positive result, and patients who repeat the kit are much less likely to reach colonoscopy. One positive result is enough to refer. There is more on this, written for patients, on the page about a positive screening test.

FIT as triage in symptomatic younger patients

In a large English primary care cohort of more than 38,000 symptomatic patients aged 18 to 49, a faecal immunochemical test at 10 micrograms of haemoglobin per gram had a sensitivity of 92.4 per cent for early-onset colorectal cancer, with performance best in patients in their forties. It is a useful triage test in lower-risk presentations, but patients with a mass, unexplained iron deficiency or persistent bleeding should be referred directly whatever the result.

FIT and calprotectin answer different questions

Faecal haemoglobin addresses neoplasia; calprotectin addresses inflammation. In a primary care study of patients with bowel symptoms, undetectable faecal haemoglobin had a negative predictive value of 100 per cent for colorectal cancer, and adding calprotectin found further cases of inflammatory bowel disease but no additional cancers. A normal calprotectin is therefore not a cancer rule-out.

Which tests are worth doing before referral

None of these are required before referring, and nothing here should delay a referral when a red flag is present. They are simply the results that most often change what happens at the first appointment or that let a procedure be booked from it.

• Rectal bleeding or a change in bowel habit: full blood count, ferritin and iron studies. A faecal occult blood test adds little once symptoms are present.
• Iron deficiency: ferritin, iron studies, full blood count, coeliac serology and a check of diet, blood donation and menstrual history. In men and postmenopausal women it warrants both a gastroscopy and a colonoscopy.
• Suspected inflammatory bowel disease: full blood count, C-reactive protein, albumin, ferritin, faecal calprotectin and stool culture including Clostridioides difficile where there is diarrhoea.
• Chronic diarrhoea: coeliac serology while still eating gluten, thyroid function, faecal calprotectin, stool microscopy and culture, and a medication review.
• Suspected coeliac disease: tissue transglutaminase IgA with total IgA, taken while the patient is still on a normal gluten-containing diet. Once gluten has been stopped the serology and the biopsies can both be falsely normal.
• Abnormal liver tests: a liver screen (hepatitis B and C serology, iron studies, autoimmune serology, caeruloplasmin where age appropriate), an ultrasound and the metabolic picture: weight, waist, lipids and HbA1c.
• Reflux or dyspepsia: Helicobacter pylori testing, and a full blood count and ferritin where there are alarm features.
• Suspected irritable bowel syndrome: full blood count, C-reactive protein, coeliac serology and faecal calprotectin are usually enough to support a positive diagnosis in a patient without red flags.

Which medicines need managing before endoscopy

Most medicines are continued. The ones that need a decision before a procedure are these, and the rooms will confirm the plan for each patient when the procedure is booked.

• Antiplatelets and anticoagulants: aspirin is usually continued. Clopidogrel, direct oral anticoagulants and warfarin depend on the reason they are prescribed and on what the procedure is likely to involve, so this is decided case by case, in consultation with the prescriber where the thrombotic risk is high. Please note the indication and any recent stent or thromboembolic event on the referral.
• GLP-1 receptor agonists (including semaglutide and tirzepatide): these slow gastric emptying and food can remain in the stomach despite standard fasting. Patients are asked to take clear fluids only for 24 hours before the procedure and nothing by mouth for six hours. The medicine itself does not routinely need to be withheld.
• Diabetes medicines: insulin and sulfonylureas need adjusting on the day of preparation and on the day of the procedure. SGLT2 inhibitors are withheld for three days around a colonoscopy, that is the two days before plus the day of the procedure, because carbohydrate restriction during bowel preparation can precipitate euglycaemic ketoacidosis. The brands named here are examples rather than a register, so the generic stem is the safer check. Worth looking at the combination products (Xigduo, Jardiamet, Segluromet, Glyxambi, Qtern, Steglujan), where patients often do not know an SGLT2 inhibitor is included. For gastroscopy, where there is no bowel preparation, the day of the procedure alone is sufficient.
• Iron tablets: stopped about a week before a colonoscopy, since they darken the stools and make small lesions harder to see.
• Immunosuppression and biologic therapy: continued. Please note the agent and the timing of the last dose.

How to approach symptoms in younger patients

Colorectal cancer is increasing in Australians under 50, and the delay from first presentation to diagnosis is longer in younger patients. The same symptoms warrant the same work-up at 35 as at 65: history including family history, abdominal and rectal examination, full blood count and ferritin, and referral for colonoscopy where red flags are present. Iron deficiency in a young woman should not be attributed to menstruation without considering the gut. There is more on the page about bowel cancer under 50.

How to read a colonoscopy report

Colonoscopy quality varies and is documented. When a report comes back, these are the points worth checking:

• Completion: caecal intubation or terminal ileal intubation, with photodocumentation
• Bowel preparation: usually a Boston Bowel Preparation Scale score. A total of 6 or more, with each segment at least 2, is adequate. Less than that shortens the surveillance interval
• Withdrawal time: at least six minutes of inspection on the way out
• Polyps: number, size, location, whether removed completely and the histology when it returns
• Recommended surveillance interval, based on the national guidelines

A patient on a surveillance program does not need interval FOBT, and a patient with a normal high-quality colonoscopy within the past few years gains little from one.

How shared care works after referral

A letter is sent to the referring doctor after each consultation and procedure. For patients on biologic or immunosuppressive therapy, shared care is built around a monitoring schedule for bloods, calprotectin and drug levels, with a clear plan for flares and for vaccinations.

Monitoring for patients on immunosuppressive or biologic therapy usually means a full blood count, liver tests and C-reactive protein at a set interval, faecal calprotectin as a marker of mucosal inflammation and drug levels where the answer would change treatment. Vaccination is worth settling before immunosuppression starts: influenza and COVID-19 each year, pneumococcal, hepatitis B where non-immune and shingles where indicated. Live vaccines are avoided during immunosuppression. Skin checks and cervical screening should continue on schedule, and thiopurine users should be counselled about sun protection.

Pregnancy is planned rather than managed after the event where possible. Most inflammatory bowel disease therapies are continued through pregnancy, because active disease carries the greater risk, and the timing of later doses is adjusted around delivery. Patients planning a pregnancy are worth referring back for review rather than stopping treatment in the interim.

For clinical questions about a patient, or to discuss whether a referral is needed, phone the rooms and ask for a call back. A/Prof Kariyawasam is also happy to speak at practice education meetings on inflammatory bowel disease, bowel cancer screening and endoscopy, through IBD Sydney or directly.

Where your patients will be seen

A/Prof Viraj Kariyawasam is a consultant gastroenterologist and hepatologist whose practice is focused on inflammatory bowel disease. Referrals are accepted for consultation in Norwest, Rouse Hill, Pennant Hills and Macquarie Park.

Endoscopy is performed at Norwest Private Hospital, Macquarie University Hospital and Pennant Hills Day Surgery. Referrals can be sent to any of the four consulting locations, and the rooms will offer the earliest appointment across them if that is faster.