Intro text
When considering the best test to request and/or sending in a referral or A&G request please mention the frequency of symptoms.
Palpitations and optimal cardiac monitoring.
When requesting cardiac monitoring, it’s key to ask the patient roughly how often the palpitations occur. The goal of monitoring is usually to identify what the cardiac rhythm is during an episode of palpitations to make a diagnosis. If palpitations occur every day then a 24 hour tape is the test of choice. If the palpitations are every 2-3 days then a 5 day monitor would be best for diagnostic yield. We can monitor for up to 28 days non-invasively. We can implant a loop recorder for infrequent palpitations with red flags in the history (e.g. LOC, HCM).
When (not) to use DOACs (Direct oral anticoagulants).
Understandably, we still get queries regarding use of DOACs in the setting of valvular heart disease. DOACs are indicated in “non-valvular AF” (NVAF) to reduce the risk of stroke. This terminology is unfortunately rather confusing. The “valvular” contra-indications for DOAC for stroke reduction in AF are the presence of a mechanical prosthetic heart valve (RE-ALIGN study was unfavourable) or the presence of moderate to severe mitral stenosis (excluded from all of the pivotal trials). DOACs can be used in all other “cardiac” scenarios including the presence of a biological prosthetic heart valve (implanted either surgically or transcatheter) or with co-existent valvular heart disease that is not mitral stenosis.
Only the presence of a mechanical valve prosthesis, or the presence of moderate to severe mitral stenosis are contra-indications to the use of a DOAC for reduction of stroke risk in AF.
Q: This patient has deranged LFTs should I refer?
It is important to first consider the likely cause, relevant drug history and then to conduct a full non-invasive liver screen prior to any referral. A full liver screen consists:
* Hepatitis B and C, AST, GGT, HbA1c, Iron studies, Ferritin, Alpha-1-Antitrypsin (once in life is enough), Caeruloplasmin, Immunoglobulins, Liver autoantibodies (ANA, ASMA, AMA), tTg, Ultrasound scan of the liver
A full GP pathway for referrals of deranged liver function tests is in the making.
Q: I feel my patient needs a Fibroscan, how do I go about getting one?
It is first of all important to address what is felt to be the likely aetiology. If fatty liver or alcohol, there are brilliant community clinics already set-up at The Willows abnormal LFT clinic which is on eRS and are run by our Hepatology Advanced Nurse Practitioner and operate as a one-stop with history, fibroscan and relevant advice. Plus where necessary onward referral to liver clinic can be facilitated from there. If the diagnosis is uncertain, a thorough history and full non-invasive liver screen should be conducted and then referral made directly to a liver clinic.
Q: I think this patient has diarrhoea predominant IBS but their faecal calprotectin is slightly raised. Should I refer?
Both NSAIDs and PPIs can increase FC to within the 100-200 range, so FC should be rechecked with the patient off of any NSAIDs or PPIs for at least several weeks, and if it is reducing or normalised no further action should be necessary. If the FC is greater than 200 then refer regardless. FC less than 200 is rarely associated with clinically significant inflammation but if it remains raised after stopping PPI/NSAIDs in the moderate 100-200 range with significant on-going symptoms then referral is reasonable on a routine basis. The current upper limit cut off of 60 is almost certainly too sensitive for significant inflammation and in the 60-100 range can just be repeated. FC should only be checked in patients with diarrhoea and not in patients whose main symptom is constipation or simply abdominal pain without bowel habit change or in asymptomatic patients with anaemia for whom FIT testing would be more appropriate in the latter.
Q: My patient gets symptoms from eating wheat, but their TTG antibody is negative. Should I refer for duodenal biopsies to rule out coeliacs?
A: No. TTG antibodies are highly sensitive and specific and so it is highly unlikely that coeliacs is being missed. More likely the patient is experiencing either “non-coeliac gluten sensitivity”, symptoms from other wheat components such as fructans, amylase-trypsin inhibitors, wheat germ agglutinin, or FODMAP intolerance of which wheat is one such FODMAP. If the patient is experiencing symptom relief from cutting out wheat or gluten they should simply be encouraged to continue to cut it out, reassuring them that they don’t have coeliacs but that it is commonly recognised that it can cause symptoms in patients also who don’t have coeliacs by different (non-immunological) mechanisms.
Is a raised caeruoplasmin significant for liver disease?
No. Caeruloplasmin is LOW in Wilsons disease. A raised level is of no significance.
What should I do about this small gallbladder polyp seen incidentally on USS?
Please follow the Greater Manchester gallbladder polyp pathway, below.
* Follow up can be done at Primary Care level, following discussion with GP and Hospital clinician.
Acne
Most patients with acne would benefit from an extended trial of an oral tetracycline plus a concomitant topical agent (e.g. EpiDuo) prior to referral into secondary care. Alternatives if these are contraindicated include erythromycin and trimethoprim. Given the long waiting times for a dermatology appointment, it is often appropriate to offer a trial of an alternative oral antibiotic plus topical agent whilst waiting for a dermatology outpatient appointment. Further guidance
Pigmented lesions
If you are referring a pigmented lesion, please clarify in your referral that you have no clinical concerns re melanoma. If you cannot do this, please make a 2ww referral.
You can find further guidance on common pathways on the Greater Manchester Medicines Management Group website