Suspected upper gastrointestinal cancer 2 week wait referral Date of decision to Date referral received at Trust: Surname: First Name: Title: Gender: DOB: / / NHS Number: Ethnicity: Language: Interpreter required: Transport required: Patient Address: Postcode: Contact numbers: Home: Mobile: Email: Usual GP Name: Practice Name : Practice Address: Practice Code: Direct line to the practice (Bypass) : Main: Fax: Email: Referring Clinician: Hematemesis may be a medical emergency and should be considered for emergency assessment in secondary care. SUSPECTED CANCER 2WW REFERRAL TO CLINIC recent investigation (please append result) suggests diagnosis of upper GI cancer ☐ upper abdominal mass ☐ jaundice and (advise LFTs and consider viral titres) please include USS report if available ≥40yrs ☐ SUSPECTED CANCER 2WW REFERRAL TO ENDOSCOPY Dysphagia ☐ yrs with weight loss Upper abdominal pain ≥55 ☐ ☐ and any of ☐ Reflux ☐ Dyspepsia Iron deficiency anaemia - direct referral for investigation of should be made via local pathway for RBCH Hospital. For all other trusts, please complete the box below: Iron deficiency with or without anaemia in men and post-menopausal woman* ☐ Please include most recent results for: Hb: MCV: Ferritin: Iron /TIBC % sat: *Pre-menopausal women to be considered for referral on individual case basis. Please ensure the following recent blood results are available (less than 6 weeks old): FBC eGFR Clotting U&E LFTs ☐ ☐ ☐ ☐ ☐ ☐Ferritin ADVISORY GUIDANCE (NON 2WW PATHWAY) CONSIDER REFERRAL DIRECT TO URGENT IMAGING TO EXCLUDE PANCREATIC CANCER WHEN: Diarrhoea Back pain Patients with weight Abdominal pain ≥60yr loss AND any of: Nausea / vomiting Constipation New onset diabetes Enlarged liver or gall bladder REFER DIRECT TO NON-URGENT OGD: Treatment resistant dyspepsia ≥55yrs Dyspepsia and with Nausea/vomiting ≥55yr Raised platelet count Nausea/vomiting and Abdominal pain ≥55yr with Weight loss Dyspepsia Raised platelet count
Suspected upper gastrointestinal cancer 2 week wait referral Date of decision to Date referral received at Trust: Surname: First Name: Title: Gender: DOB: / / NHS Number: Ethnicity: Language: Interpreter required: Transport required: Patient Address: Postcode: Contact numbers: Home: Mobile: Email: Usual GP Name: Practice Name : Practice Address: Practice Code: Direct line to the practice (Bypass) : Main: Fax: Email: Referring Clinician: Hematemesis may be a medical emergency and should be considered for emergency assessment in secondary care. SUSPECTED CANCER 2WW REFERRAL TO CLINIC ☐ recent investigation (please append result) suggests diagnosis of upper GI cancer ☐ upper abdominal mass ☐ jaundice and ≥40yrs (advise LFTs and consider viral titres) please include USS report if available SUSPECTED CANCER 2WW REFERRAL TO ENDOSCOPY ☐ Dysphagia ☐ ≥55 yrs with weight loss and any of ☐ ☐ ☐ Upper abdominal pain Reflux Dyspepsia Iron deficiency anaemia - direct referral for investigation of should be made via local pathway for RBCH Hospital. For all other trusts, please complete the box below: ☐ Iron deficiency with or without anaemia in men and post-menopausal woman* Please include most recent results for: Hb: MCV: Ferritin: Iron /TIBC % sat: *Pre-menopausal women to be considered for referral on individual case basis. Please ensure the following recent blood results are available (less than 6 weeks old): ☐ FBC ☐ eGFR ☐ Clotting ☐ U&E ☐ LFTs ☐Ferritin ADVISORY GUIDANCE (NON 2WW PATHWAY) CONSIDER REFERRAL DIRECT TO URGENT IMAGING TO EXCLUDE PANCREATIC CANCER WHEN: Patients ≥60yr with weight loss AND any of: Diarrhoea Back pain Abdominal pain Nausea / vomiting Constipation New onset diabetes Enlarged liver or gall bladder REFER DIRECT TO NON-URGENT OGD: Treatment resistant dyspepsia ≥55yrs Dyspepsia and ≥55yr with Nausea/vomiting Raised platelet count Nausea/vomiting and ≥55yr with Abdominal pain Weight loss Dyspepsia Raised platelet count
Urgent-suspected-upper-GI-cancer-referral-form.docx