PEDIATRIC GASTROENTEROLOGY

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PEDIATRIC

GASTROENTEROLOGY

May 2015

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IntroductIon

PEDIATRIC GI

Alberta referral Pathways for Pediatric GI Services has

been a collaborative project. the referral guidelines

have considered the roles of family physicians, general

pediatricians, pediatric GI subspecialists and nutrition

services to provide the most appropriate pathway for

referral to the pediatric GI services of children and

adolescents with gastrointestinal and liver symptoms

and/or disease indications. representatives from

primary care, pediatrics, nutrition services, feeding and

swallowing services, pediatric weight management

services, together with Alberta’s two pediatric GI

and hepatology services in calgary and Edmonton,

have participated in developing this provincial referral

pathway.

the purpose of this document is to provide referring

providers with a guide that clearly outlines referral

processes and key information necessary for

appropriate triage and acuity assessment. It also aims

to provide the referring physicians approximate wait

time for their patients to be seen by the GI services.

to allow for the best use GI services resource, some

of the referred indication may best be seen first by

pediatricians and other services such as nutrition

services and pediatric weight management services.

Wait times were determined by each of the services

based on the available man power resources in

February 2015. They do not define a standard of care,

nor should they be interpreted as regulatory or legal

advice. Variations in practice may be necessary and

appropriate based on the needs of the individual patient,

resources and limitations unique to the institution or

type of practice.

Hopefully these guidelines will enable timely access

of children to appropriate levels of services and help

improve communications between service providers.

Similar pathway development in Bc has been

quite successful and meshes with progressive It

communication and EMr system developments. the

use of general pediatrician expertise is essential in

helping our more complex patients in receiving timely

access to tertiary care services.

Hien Q. Huynh, MBBS, FRACP, FRCPC(Hon)

Associate Professor and Head

Division of Pediatric GI Nutrition

Department of Pediatrics, Stollery Children’s Hospital, University of Alberta

Steven R. Martin MD, FRCP(C)

Professor and Head, Section of Gastroenterology, Hepatology & Nutrition,

Department of Pediatrics, University of Calgary, Alberta Children’s Hospital

Robert R. Moriartey, BSc, MD, FRCP(C)

Clinical Professor and Head, Division of Community Pediatrics

Department of Pediatrics, University of Alberta

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PEDIATRIC GI

INTRODUCTION

GENERAL INFORMATION

WHAT IS ALBERTA REFERRAL PATHWAYS?

HOW TO USE THESE GUIDELINES

REFERRAL ELEMENTS

REFERRAL REQUIREMENTS

EMERGENCY REFERRAL INFORMATION

MANDATORY REQUIREMENTS FOR ALL NON-EMERGENCY REFERRALS

REASONS FOR REFERRAL

Abdominal imaging: abnormal finding

10 Abdominal pain

10 Celiac screen: Positive finding

11 chronic diarrhea

11 constipation 12

Diet / texture progression difficulty

13 Dysphagia or odynophagia

13 Enlarged liver

14 Failure to thrive

15 Fatty liver with elevated BMI

16 Fatty liver without elevated BMI

16 Feeding difficulty with suspected aspiration 17

Feeding difficulty without failure to thrive

18 Food allergy or food intolerance

19 Gastroesophageal reflux

19 Hematemesis (normal hemoglobin)

19 Hepatitis: Acute

20 Hepatitis B, c serology positive

20 Hyperbilirubinemia (conjugated)

20 Hyperbilirubinemia (unconjugated)

21 Inflammatory bowel disease

21 Iron deficiency anaemia

22 Liver disease (chronic) / portal hypertension 22

Liver enzymes

23 Nutrition / nutrient deficiency

23 Pancreatitis

23 Persistent vomiting / nausea

24 Polyposis, family history

24 rectal bleeding age <12 months

24 Rectal bleeding age ≥ 1 year

24 CONTACT INFORMATION

APPENDIX A: APPROXIMATE WAIT TIMES

APPENDIX B: PRIORITY LEVELS

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HOW TO USE THESE GUIDELINES

THIS DOCUMENT IS DIVIDED INTO THE FOLLOWING SECTIONS: IntroductIon

A letter of introduction from the clinical champions leading the pediatric gastroenterology referral pathway

GEnErAL InForMAtIon

Information about Alberta referral Pathways, how to use these guidelines, elements of a referral (see below), and emergency referral information

rEFErrAL rEQuIrEMEntS

Mandatory requirements for all non-emergency referrals, and alphabetically listed reasons for referral with accompanying referral recommendations, contact inforamtion and required investigations

contAct InForMAtIon

Additional contact information for services listed within the reference

APPEndIcES

Supplementary information outlining the approximate wait times for each service, and the priority level for referrals to pediatric gastroenterology listed by reason for referral.

REFERRAL ELEMENTS

REaSON FOR REFERRaL

These guidelines are organized by reason for referral. Use the table of contents to find the reason for referral, and

click the reason to take you directly to the referral information

PROCESS

this information recommends whom or where to send the referral, and provides contact information for each suggestion.

MaNDaTORy INFORMaTION

The mandatory information is patient specific and required for the referral to be appropriately triaged. This

information is required in addition to the comorbidities and demographics previously outlined.

SUGGESTED TIME FRaME & INVESTIGaTIONS

the recommended assessments and essential investigations are required to be completed within the suggested time frame.

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4 WHAT IS ALBERTA REFERRAL PATHWAYS?

A patient’s journey often seems like a confusing maze of uncertain choices and endless waiting. Patients and health care

providers want seamless and efficient transitions between primary and specialty care.

the AHS Provincial Access team is collaborating with the Strategic clinical networks, primary care, Primary care networks, the Alberta Medical Association and Alberta Health to lead referral transformation. Alberta referral Pathways is a provincial

program that builds connections between primary and specialty care to support clinicians and administrators to define

standards and introduce processes to improve Alberta’s referral experience.

Each referral pathway is led by medical co-champions and representatives of both primary and specialty care. the working group is populated by representatives from every point in a patient’s care pathway. determined and reviewed over a nine-month process, the resulting provincial referral guidelines include clinical content, referral processes, triage priority levels and approximate wait times. they are then widely distributed for physician review, feedback and adoption.

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MANDATORY REQUIREMENTS FOR ALL NON-EMERGENCY REFERRALS

PATIENT DEMOGRAPHICS

• Patient last name, first name, given names

• PHn/uLI • Gender

• Home address including city and postal code • Home phone, other phone (multiple contact numbers

preferred)

• Emergency contact name and phone

• Guardian name & phone, and relation to patient

REFERRING PROVIDER

• name

• Address, including city and postal code • Phone & fax

FAMILY PHYSICIAN

• name

• Indicate if same as referrer or if patient has no primary care provider

• Address including city and postal code • Phone & fax

RELEVANT INFORMATION

• Summary of medical and treatment history • current medications

• Languages - indicate if an interpreter is required and for which language

• Physical limitations

• Economic and social / psychological factors • Special considerations

GROWTH CHART (OR AT LEAST CURRENT WEIGHT AND HEIGHT)

• It is recommended to have at least current weight and height but preferably a record of multiple measures over time. All measures should be plotted on recommended growth charts.

• BMI should be calculated and plotted for children ages 2-17 years

• More information can be found at www.albertahealthservices.ca/cgm.asp

EMERGENCY REFERRAL INFORMATION

For all emergencies, refer directly to the Emergency Department or

contact rAAPId

north: 1-800-282-9111 or 780-735-0811 South: 1-800-661-1700 or 403-944-4486

REASON FOR REFERRAL SUGGESTED TIME FRAME & _{INVESTIGATIONS} APPROXIMATE TIME _{TO BE SEEN}

ACUTE DIARRHEA WITH DEHYDRATION

< 24 HourS

ACUTE LIVER FAILURE (INR > 1.5)

Within 24 hours:

• ALt • Inr

• description of symptoms (e.g. altered level of consciousness)

< 24 HourS

ACUTE PANCREATITIS

< 24 HourS

ACUTE SIGNIFICANT

GASTROINTESTINAL BLEEDING / MELENA

< 24 HourS

CAUSTIC INGESTION

< 24 HourS

ESOPHAGEAL FOREIGN BODY / FOOD IMPACTION

< 24 HourS

rEFErrAL rEQuIrEMEntS

PEDIATRIC GI

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FOR REFERRaL PROCESS

MaNDaTORy INFORMaTION

SUGGESTED TIME FRaME & INVESTIGaTIONS

ABDOMINAL IMAGING: ABNORMAL FINDING

consider contacting pediatric gastroenterology service directly to determine the optimal approach

Calgary: alberta Children’s hospital PH 403-955-7747 FX 403-955-7639

edmonton: stollery Children’s hospital

PH 780-248-5420 FX 1-888-353-1157 (toll free)

Growth chart or at least current weight and height oPtIonAL: Image finding ABDOMINAL PAIN (chronic or recurrent) refer to pediatrician

Collegeof physiCians & surgeonsof alberta

http://www.cpsa.ab.ca/

• Find your local pediatrician

• Growth chart or at least current weight and height • description of symptoms if relevant • Red flags: » weight loss » diarrhea ± blood » vomiting » nocturnal waking » fever » fatigue

» age <3 years old refer to pediatric gastroenterology (if required by pediatrician)

PH 780-248-5420 FX 1-888-353-1157 (toll free)

• Growth chart or at least current weight and height • description of symptoms if relevant • Red flags: » weight loss » diarrhea ± blood » vomiting » nocturnal waking » fever » fatigue

» age <3 years old

< 6 MontHS • Pediatric consult • celiac screen on gluten • cBc, ESr/crP • Albumin • ALt, GGt, Bili

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CELIAC SCREEN: POSITIVE FINDING

refer to pediatric gastroenterology

PH 780-248-5420 FX 1-888-353-1157 (toll free)

• Growth chart or at least current weight and height

• description of symptoms (e.g. weight loss, diarrhea) < 6 MontHS • celiac screen on gluten • cBc • Ferritin CHRONIC DIARRHEA (duration >4 weeks)

consider referral to pediatrician

Growth chart or at least current weight and height

PH 780-248-5420 FX 1-888-353-1157 (toll free)

• Growth chart or at least current weight and height • Red flag: >5% weight loss < 1 MontH • cBc, ESr/crP • total protein/albumin • Electrolytes,tco2 • Iron studies • celiac screen on gluten

• Stool o&P, culture • c. diff toxin

(age >1 year)

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CONSTIPATION refer to pediatrician

refer to pediatric gastroenterology (if required by pediatrician)

In Calgary, simple constipation is triaged initially to constipation teaching sessions. Four sessions are currently offered in a year.

PH 780-248-5420 FX 1-888-353-1157 (toll free)

Growth chart or at least current weight and height < 6 MontHS • Pediatric consult • description of stool • treatment (dose, duration, results) • Electrolytes, tco2 • ca • tSH • celiac screen on gluten

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DIET / TEXTURE PROGRESSION DIFFICULTY

refer to pediatrician

Consider referral to Nutrition Services if ≥1 food groups are missing from the diet or very low food variety with suspected nutrient deficiency

nutrition Counselling (dietitian) pediatriC

www.informalberta.ca

• KEYWord SEArcH: nutrition counselling Pediatric

• Call specific clinic to request a referral form

For feeding issue, refer to Feeding and Swallowing Services

Calgary feeding Coordinator

PH 403-955-7464 FX 403-955-3261

edmonton: children with typical development

stollery Children’s hospital

PH 780-407-8859 FX 780-407-6586

edmonton: children with developmental/neurological issues

glenrose rehabilitation hospital PH 780-735-6066 FX 780-735-7930

DYSPHAGIA OR ODYNOPHAGIA

PH 780-248-5420 FX 1-888-353-1157 (toll free)

• Growth chart or at least current weight and height • description of symptoms

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FAILURE TO THRIVE consider referral to both pediatrician and nutrition Services

• KEYWord SEArcH: nutrition counselling Pediatric • Call specific clinic to request a referral form

Refer to Feeding and Swallowing Services when there is difficulty eating due to an anatomical or developmental concern or when there is a swallowing difficulty.

PH 403-955-7464 FX 403-955-3261

PH 780-407-8859 FX 780-407-6586

• Pediatric and/or nutrition Services consult

For case with suspected GI causes, refer to pediatric gastroenterology

PH 780-248-5420 FX 1-888-353-1157 (toll free)

Growth chart or at least current weight and height < 3 MONTHS • Pediatric and/or nutrition Services consult • cBc/ESr/crP • Electrolytes, Bun, creat.

• ca., Phos., ALt • total protein/albumin • celiac screen on

gluten

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FATTY LIVER WITH ELEVATED BMI (BMI-for-age ≥85th

percentile)

refer to Provincial Pediatric Weight Management Services

alberta health serviCes Central aCCess PH(toll free) 1-877-414-2665 / 780-401-2665 FX(toll free) 1-866-979-3553 / 780-735-3553

• Age: 2-17 years old • Options for referral:

» outpatient dietitian counselling » multidisciplinary specialty care

referral form www.albertahealthservices.ca/2807.asp

• BMI

PH 780-248-5420 FX 1-888-353-1157 (toll free)

< 6 MontHS

• Abdominal u/S • ASt, ALt,GGt, ALP • BIL, ALB

• Lipid profile FATTY LIVER WITHOUT

ELEVATED BMI (BMI ≤ 85th percentile)

PH 780-248-5420 FX 1-888-353-1157 (toll free)

< 6 MontHS

• Abdominal u/S • ASt, ALt,GGt, ALP • BIL, ALB • Lipid profile

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FEEDING DIFFICULTY WITH SUSPECTED ASPIRATION

refer to Feeding and Swallowing Services

PH 403-955-7464 FX 403-955-3261

PH 780-407-8859 FX 780-407-6586

May require a prior referral to pediatrician and/or nutrition Services for a clinical assessment

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FEEDING DIFFICULTY WITHOUT FAILURE TO THRIVE

Consider referral to Nutrition Services if ≥1 food groups are missing from the diet or very low food variety with suspected nutrient deficiency

If child is not able to eat anatomically/developmentally, refer to Feeding and Swallowing Services

PH 403-955-7464 FX 403-955-3261

PH 780-407-8859 FX 780-407-6586

Pediatric and/or nutrition Services consult

For suspected eating disorder, consider refer to adolescent medicine (in calgary) or psychiatry (in Edmonton)

Calgary: eating disorder program PH 403-955-7700 FX 403-955-3066

edmonton : Childand adolesCent psyChiatry,

aCute Care, royal alexandra hospital PH 780-735-4635 FX 780-735-5315

Growth chart or at least current weight and height calgary referral Form: www. albertahealthservices. ca/4208.asp

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FOOD ALLERGY OR FOOD INTOLERANCE

• Pediatrician may consider referral to nutrition Services for overall assessment and/or to pediatric

allergist for allergy confirmation

• History and type of allergy

GASTROESOPHAGEAL REFLUX

Persistent, complicated* or medication-dependent GE reflux may be referred to pediatric gastroenterology for long term management

*Complicated: failure to thrive, hematemesis, respiratory symptoms

PH 780-248-5420 FX 1-888-353-1157 (toll free)

Growth chart or at least current weight and height < 1 MontH • Pediatric consult HEMATEMESIS (NORMAL HEMOGLOBIN)

PH 780-248-5420 FX 1-888-353-1157 (toll free)

< 1 MontH

• cBc

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HEPATITIS: ACUTE

(ALt >10x normal, normal Inr)

PH 780-248-5420 FX 1-888-353-1157 (toll free)

Growth chart or at least current weight and height < 1 WEEK • ALt, ASt, GGt • Bili t/d • Inr • cBc HEPATITIS B, C SEROLOGY POSITIVE

PH 780-248-5420 FX 1-888-353-1157 (toll free)

HYPERBILIRUBINEMIA (CONJUGATED)

PH 780-248-5420 FX 1-888-353-1157 (toll free)

Growth chart or at least current weight and height < 1 WEEK • Stool colour • ALt, ASt, GGt • Bili t/d • Inr • Abdominal u/S REaSON

HYPERBILIRUBINEMIA (UNCONJUGATED)

• Pediatrician may consider a referral to hematology

PH 780-248-5420 FX 1-888-353-1157 (toll free)

Growth chart or at least current weight and height < 1 MontH • Pediatric consult • Bili t/d • cBc INFLAMMATORY BOWEL DISEASE (active/ suspected/ inactive)

PH 780-248-5420 FX 1-888-353-1157 (toll free)

• Growth chart or at least current weight and height • description of symptoms (active: abnormal labs; suspected: normal labs) < 1 MontH • cBc • ESr/crP • Albumin • Ferritin/Iron studies • ALt, GGt, lipase • Stool c&S, o&P • C. difficile toxin

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IRON DEFICIENCY ANAEMIA

For anemia with suspected GI cause, refer to pediatric gastroenterology

PH 780-248-5420 FX 1-888-353-1157 (toll free)

Growth chart or at least current weight and height < 1 MontH • cBc • Iron studies • ESr/crP • celiac screen on gluten

• Potential reason for

deficiency Refer to Nutrition Services if ≥1 food groups are missing from the diet or very low food variety with suspected nutrient deficiency

LIVER DISEASE (CHRONIC) / PORTAL HYPERTENSION

PH 780-248-5420 FX 1-888-353-1157 (toll free)

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LIVER ENZYMES

(abnormal on 2 occasions

over 3 to 6 months)

PH 780-248-5420 FX 1-888-353-1157 (toll free)

Growth chart or at least current weight and height < 1 MontH • cBc • ALt,GGt, Bili t/d • Albumin • Inr • IgG • cK • Abdominal u/S • Viral hepatitis screen

(B & c)

NUTRITION / NUTRIENT DEFICIENCY

consider referral to both pediatrician and nutrition Services

PANCREATITIS

(chronic/ recurrent)

PH 780-248-5420 FX 1-888-353-1157 (toll free)

< 1 MontH

• Abdominal u/S • Lipase

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PERSISTENT VOMITING / NAUSEA

PH 780-248-5420 FX 1-888-353-1157 (toll free)

Red flag: bilious

vomiting (emergency)

• Pediatric

gastroenterologists may refer to surgery for confirmed malrotation < 6 MontHS • cBc • Electrolytes • Abdominal u/S • Barium swallow POLYPOSIS, FAMILY HISTORY

refer to pediatric gastroenterology **May require referral to medical genetics

PH 780-248-5420 FX 1-888-353-1157 (toll free)

• Growth chart or at least current weight and height • Family history (mutation and/or names of polyps if available) oPtIonAL: Previous screening / colonoscopy if available RECTAL BLEEDING AGE <12 MONTHS (without constipation) refer to pediatrician

PH 780-248-5420 FX 1-888-353-1157 (toll free)

Growth chart or at least current weight and height < 1 MontH • Pediatric consult • cBc • Albumin • ESr/crP RECTAL BLEEDING AGE ≥ 1 YEAR (without constipation)

Calgary: alberta Children’s hospital Growth chart or at < 1 MontH

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SPECIaLTy CLINICS/DIRECTORIES PHONE FaX

PedLink telephone consultation

Services

Service will provide 8 AM to 8 PM (including

weekends) access to the pediatrician telephone consultation service in calgary. Family physicians leave a message and the on-call pediatrician will return the call within an hour.

(403) 955-1098

community Pediatrics

college of Physicians & Surgeons of Alberta

Find your local pediatrician

nutrition Services

nutrition counselling (dietitian) Pediatric

Call specific clinic to request a

referral form

• KEYWord SEArcH:

nutrition counselling Pediatric

Provincial Pediatric Weight

Management Services

Alberta Health Services central Access referral form: www.albertahealthservices.ca/2807.asp 1-877-414-2665 (toLL FrEE) (780) 401-2665 1-866-979-3553 (toLL FrEE) (780) 735-3553

Feeding and Swallowing

Services

In calgary, please contact Feeding

coordinator 403) 955-7464 MAIN: (403) _955-3261

For questions about videofluorscopic swallow

studies (VFSS), call Feeding coordinator. For

referral to VFSS, fax to (403) 955-2535.

VFSS: (403) 955-2535 Children with typical development:

Stollery children’s Hospital

Unit 1G1.11, Speech and Audiology 8440 112 Street, Edmonton, Alberta T6G 2B7

(780) 407-8859 (780) 407-6586

Children with developmental/neurological issues:

Glenrose rehabilitation Hospital Pediatrics -

(780) 735-6066 (780) 735-7930

contAct InForMAtIon

PEDIATRIC GI

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SPECIaLTy CLINICS/DIRECTORIES PHONE FaX

Pediatric Gastroenterology,

Hepatology and nutrition*

Alberta children’s Hospital

Level 3, GI/Metabolic/Endocrine Clinics 2888 Shaganappi Trail NW, Calgary, Alberta T3B 6A8

(403) 955-7747 (403) 955-7639

Pediatric Gastroenterology and

nutrition*

Stollery children’s Hospital

Edmonton clinic Health Academy (EcHA)

4th floor, Room 4-594

11405 - 87th Avenue, Edmonton, Alberta

t6G 1c9

(780) 248-5420 1-888-353-1157 (toLL FrEE)

*Note: Patients aged 17-18 years in Calgary and 16-17 years in Edmonton should be triaged by pediatric

gastroenterology services but referrals may be redirected to adult gastroenterology.

SPECIaLTy aPPROXIMaTE WaIT TIMES

COMMUNITY PEDIATRICS Preferable WItHIn 1 MontH but not longer than 6 WEEKS

NUTRITION SERVICES 2 WEEKS to 4 MontHS

(Wait times may vary depending on the zone and reason for referral)

PROVINCIAL PEDIATRIC WEIGHT MANAGEMENT SERVICES

TyPE OF REFERRaL APProXIMAtE WAIt tIMES

outpatient dietitian counselling 2 WEEKS TO 3 MONTHS

(Wait times may vary depending on zone capacity) Multi-disciplinary Specialty care

(Pediatric centre for Weight and Health)

< 3 MONTHS

(Wait times may vary depending on clinic capacity and family readiness/schedule)

FEEDING AND

SWALLOWING SERVICES

aLBERTa CHILDREN’S

HOSPITaL STOLLERy CHILDREN’S HOSPITaL REHaBILITaTION GLENROSE HOSPITaL**

PrIorItY

LEVEL APProXIMAtE WAIt tIMES PrIorItY LEVEL APProXIMAtE WAIt tIMES PrIorItY LEVEL APProXIMAtE WAIt tIMES

urgent IMMEdIAtELY -

2 WEEKS urgent IMMEdIAtELY - 2 WEEKS High (urgent) 6 - 7 WEEKS

1 2 - 6 WEEKS High 1 - 2 MontHS Medium 4 MontHS

2 6 - 12 WEEKS Medium 3 MONTHS Low (routine) 6 MontHS

Low 4 - 6 MontHS

PEDIATRIC

GASTROENTEROLOGY

PrIorItY

LEVEL aPPROXIMaTE WaIT TIMES IN _CaLGaRy* aPPROXIMaTE WaIT TIMES IN _EDMONTON*

urgent

IMMEdIAtELY - 2 WEEKS

1

2 WEEKS - 5 MontHS

2 WEEKS - 2 MontHS

2

5 MontHS - 10 MontHS

3 MONTHS - 7 MONTHS

3

10 MONTHS - 18 MONTHS

8 MONTHS - 14 MONTHS

*note: the listed wait times are as of 2015-02-24

**note: the listed wait times are as of January 2015 in Glenrose rehabilitation Hospital

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APPEndIX A: APProXIMAtE WAIt tIMES

PEDIATRIC GI

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REaSON FOR REFERRaL PRIORITy LEVEL

ABDOMINAL IMAGING: ABNORMAL FINDING 1-3 DEPENDING ON THE LESION

ABDOMINAL PAIN (CHRONIC OR RECURRENT) rEd FLAGS = 1

NO RED FLAGS = 3

CELIAC SCREEN: POSITIVE FINDING SYMPtoMS = 1 no SYMPtoMS = 2

CHRONIC DIARRHEA (DURATION >4 WEEKS) >5% WEIGHt LoSS = EMErGEncY - 1

UNCOMPLICATED = 2-3

CONSTIPATION AGE <1 MontH = 1

AGE >1 MONTH = 3

DYSPHAGIA OR ODYNOPHAGIA 1-2

ENLARGED LIVER 1

FAILURE TO THRIVE (WITH SUSPECTED GI CAUSES) InFAntS/SEVErE = EMErGEncY - 1 uncoMPLIcAtEd = 2

FAMILY HISTORY OF POLYPS 1-2 dEPEndInG on AGE/SYndroME FATTY LIVER WITHOUT ELEVATED BMI (BMI ≤ 85TH

PERCENTILE)

1-2

FATTY LIVER WITH ELEVATED BMI (BMI ≥ 85TH

PERCENTILE)

2-3

GASTROESOPHAGEAL REFLUX

COMPLICATED: FAILURE TO THRIVE, HEMATEMESIS, RESPIRATORY SYMPTOMS

1

HEMATEMESIS (NORMAL HEMOGLOBIN) 1

HEPATITIS (ACUTE: ALT >10X NORMAL, NORMAL INR) 1

REaSON FOR REFERRaL PRIORITy LEVEL

HYPERBILIRUBINEMIA (CONJUGATED OR UNCONJUGATED) EMErGEncY - 1

INFLAMMATORY BOWEL DISEASE (ACTIVE/ SUSPECTED/ INACTIVE)

ActIVE = EMErGEncY SuSPEctEd = 1 - 2

IRON DEFICIENCY ANAEMIA (WITH SUSPECTED GI CAUSES) 1

LIVER DISEASE (CHRONIC)/ PORTAL HYPERTENSION 1

LIVER ENZYMES (ABNORMAL ON 2 OCCASIONS OVER 3 TO 6 MONTHS)

EMErGEncY - 1

PANCREATITIS (CHRONIC / RECURRENT) EMErGEncY - 1

PERSISTENT VOMITING/NAUSEA coMPLIcAtEd = 1

UNCOMPLICATED = 2-3

RECTAL BLEEDING 1

Although reasonable efforts were made to confirm the accuracy of the information, Alberta Health Services does not make

any representation or warranty, express, implied or statutory, as to the accuracy, reliability, completeness, applicability

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PEDIATRIC GASTROENTEROLOGY

PEDIATRIC

GASTROENTEROLOGY

May 2015

IntroductIon

IntroductIon

PEDIATRIC GI

Alberta referral Pathways for Pediatric GI Services has

been a collaborative project. the referral guidelines

have considered the roles of family physicians, general

pediatricians, pediatric GI subspecialists and nutrition

services to provide the most appropriate pathway for

referral to the pediatric GI services of children and

adolescents with gastrointestinal and liver symptoms

and/or disease indications. representatives from

primary care, pediatrics, nutrition services, feeding and

swallowing services, pediatric weight management

services, together with Alberta’s two pediatric GI

and hepatology services in calgary and Edmonton,

have participated in developing this provincial referral

pathway.

the purpose of this document is to provide referring

providers with a guide that clearly outlines referral

processes and key information necessary for

appropriate triage and acuity assessment. It also aims

to provide the referring physicians approximate wait

time for their patients to be seen by the GI services.

to allow for the best use GI services resource, some

of the referred indication may best be seen first by

pediatricians and other services such as nutrition

services and pediatric weight management services.

Wait times were determined by each of the services

based on the available man power resources in

February 2015. They do not define a standard of care,

nor should they be interpreted as regulatory or legal

advice. Variations in practice may be necessary and

appropriate based on the needs of the individual patient,

resources and limitations unique to the institution or

type of practice.

Hopefully these guidelines will enable timely access

of children to appropriate levels of services and help

improve communications between service providers.

Similar pathway development in Bc has been

quite successful and meshes with progressive It

communication and EMr system developments. the

use of general pediatrician expertise is essential in

helping our more complex patients in receiving timely

access to tertiary care services.

Hien Q. Huynh, MBBS, FRACP, FRCPC(Hon)

Associate Professor and Head

Division of Pediatric GI Nutrition

Department of Pediatrics, Stollery Children’s Hospital, University of Alberta

Steven R. Martin MD, FRCP(C)

Professor and Head, Section of Gastroenterology, Hepatology & Nutrition,

Department of Pediatrics, University of Calgary, Alberta Children’s Hospital

Robert R. Moriartey, BSc, MD, FRCP(C)

Clinical Professor and Head, Division of Community Pediatrics

Department of Pediatrics, University of Alberta

contEntS

PEDIATRIC GI

INTRODUCTION

GENERAL INFORMATION

WHAT IS ALBERTA REFERRAL PATHWAYS?

HOW TO USE THESE GUIDELINES

REFERRAL ELEMENTS

REFERRAL REQUIREMENTS

EMERGENCY REFERRAL INFORMATION

MANDATORY REQUIREMENTS FOR ALL NON-EMERGENCY REFERRALS

REASONS FOR REFERRAL

Abdominal imaging: abnormal finding

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Abdominal pain

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Celiac screen: Positive finding

11

chronic diarrhea

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constipation 12

Diet / texture progression difficulty

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