Pediatric Gastroenterology Referral Guidelines

Suggested Pre-Referral Workup

This is a general suggestion of possible testing to confirm a suspected diagnosis. Although referrals will be accepted without the suggested work up being complete, to ensure referrals are processed timely we do require that items listed in the Referral Documentation section be submitted with the initial referral. In addition to the suggested Pre-Referral Workup in the tables below, it is recommended that the following information is also provided:

• Referring physician name, office address, and phone number
• Patient demographics and parent contact information
• Reason for referral with notes
• Requested department or physician name for the referral
• Insurance information for patient
• Authorization (when required)

If the referral is a second opinion evaluation, please include prior endoscopic reports, pathology reports, relevant clinical documentation, and names of prior specialty physicians.

Diagnoses listed

Urgent diagnoses

• Melena/hematochezia/hematemesis
• Hyperbilirubinemia or jaundice
• Rule-out biliary atresia, complaints of white or gray colored stool
• Elevated liver enzymes
• Ingestion of a foreign body
• Hepatitis

Other diagnoses

• Abdominal pain
• Constipation
• Esophageal reflux
• Failure to thrive
• Diarrhea
• Vomiting alone
• Celiac disease
• Inflammatory bowel disease (IBD)
• Crohn’s disease/Ulcerative colitis
• Eosinophilic esophagitis (EoE)

Abdominal Pain – ICD-10: R10.*

When to refer

• Abdominal pain persistent or recurrent with routine care measures
• Pain associated with weight loss or poor growth
• Pain waking patient at night
• Pain associated with: fevers, vomiting, diarrhea, GI bleeding
• Patient < 5 years of age
• History of previous abdominal surgery or midline congenital abnormalities
• Abnormal radiologic studies

Suggested pre-referral workup

• Urine analysis
• Stool guaiac (occult blood)
• Stool O&P and Giardia antigen
• Stool H. pylori specific antigen
• Complete blood count (CBC)
• Sedimentation rate (ESR) and C-reactive protein (CRP)
• Comprehensive metabolic panel
• Serum IgA
• Celiac panel
• Abdominal ultrasound (optional)

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes

Constipation – ICD-10: K59.00

When to refer

• Failure to stool in the first 24 hours of life
• Constipation associated with:
• Recurrent rectal bleeding
• Growth failure or poor weight gain
• Persistent abdominal pain
• Sacral dimple, umbilical hernia, hypotonia, developmental delay
• Encopresis

Suggested pre-referral workup

• Stool guaiac (occult blood)
• Thyroid function tests
• Serum IgA
• Tissue transglutaminase IgA

Referral Documentation Requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes

Esophageal Reflux – ICD-10: K21.9

When to refer

• Unexplained nausea, vomiting, or abdominal pain unresponsive to therapy
• Persistent nausea, vomiting, or abdominal pain associated with weight loss or growth failure
• Unexplained apnea, choking, swallowing, or feeding problems
• Unexplained chronic cough, wheezing, halitosis, hoarseness of voice, dental enamel erosion, recurrent otitis media or sinusitis
• Unexplained dysphagia
• History of previous abdominal surgery or midline congenital abnormalities

Suggested pre-referral workup

• Infants < 1 year of age: no additional work-up suggested
• Children > 1 year of age:
  • Urine analysis
  • Stool guaiac (occult blood)
  • Stool H. pylori antigen
  • Complete blood count (CBC)
  • Sedimentation rate (ESR) and C-reactive protein (CRP)
  • Comprehensive metabolic panel (CMP)

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes

Failure to Thrive – ICD-10: R62.50, R62.59

When to refer

• Growth failure unexplained by endocrine abnormalities or constitutional growth
• Poor weight gain unresponsive to adequate nutritional intake
• Inability to sustain adequate nutritional intake
• Inadequate growth or weight gain associated with vomiting, diarrhea, abdominal pain, fevers, arthralgia, or perianal lesions

Suggested pre-referral workup

• Urine analysis
• Stool guaiac (occult blood)
• Qualitative fecal fat
• Stool reducing substances
• Fecal elastase or stool trypsin
• Stool alpha-1 antitrypsin
• Stool O&P and Giardia antigen
• Complete blood count (CBC)
• Comprehensive metabolic panel (CMP)
• TSH and T4
• Serum IgA and tissue transglutaminase IgA
• Sweat chloride test

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes
• Parental heights
• Please indicate if:
• Patient has a feeding tube in place (e.g., gastrostomy tube, nasogastric tube)
• Registered dietician consult is also requested

Diarrhea – ICD-10: R19.7

When to refer

• Diarrhea unresponsive to dietary manipulations that might include lactose restriction and addition of dietary fiber
• Diarrhea associated with rectal bleeding, weight loss or growth failure, joint pains, rashes, or fever
• Diarrhea that awakens patient from a sound sleep at night

Suggested pre-referral workup

• Stool cultures, including O&P, Giardia antigen, C. difficile toxin
• Stool guaiac (occult blood)
• Complete blood count (CBC)
• Comprehensive metabolic panel
• Sedimentation rate (ESR) and C-reactive protein (CRP)

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes

Liver disease – ICD-10: K76.9

When to refer

• Jaundice
• Pale or gray colored stools
• Elevated liver enzymes
• Elevated bilirubin levels
• Easy bleeding, easy bruising
• History of prior abdominal surgery

Suggested pre-referral workup

• Stool guaiac (occult blood)
• Complete blood count (CBC)
• Comprehensive metabolic panel
• GGT
• Direct bilirubin
• Coagulation studies (PT/INR)
• Abdominal ultrasound

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes

Vomiting alone – ICD-10: R11.10

When to refer

• Persistent nausea and vomiting
• Persistent nausea, vomiting, or abdominal pain associated with weight loss, growth failure, or other symptoms
• Vomiting associated with headaches
• Dysphagia
• Chest pain with swallowing
• Recurrent evidence of H. pylori infection
• History of foreign body ingestion or caustic ingestion
• History of dry swallowing pills
• History of previous abdominal surgery

Suggested pre-referral workup

• Urine analysis
• Stool guaiac (occult blood)
• Stool H. pylori antigen
• Complete blood count (CBC)
• Comprehensive metabolic panel
• Sedimentation rate (ESR) and C-reactive protein (CRP)
• Lipase
• Upper GI study

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes

Celiac disease, abnormal celiac panel – ICD-10: K90.0, R89.4

When to refer

• Abnormal celiac markers or normal serum markers with low total IgA
• Unexplained growth failure or weight loss
• Chronic diarrhea
• Abdominal pain
• Family history of celiac disease

Suggested pre-referral workup

• Celiac panel, including serum IgA
• Stool O&P and Giardia antigen
• Stool guaiac (occult blood)
• Complete blood count (CBC)
• Comprehensive metabolic panel
• Sedimentation rate (ESR) and C-reactive protein (CRP)
• Do not limit gluten intake prior to GI evaluation

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes
• Celiac panel, including serum IgA

Hematochezia – ICD-10: K92.1

When to refer

• Painless rectal bleeding
• Bleeding associated with constipation
• Bleeding associated with growth failure or weight loss
• Family history of inflammatory bowel disease
• Family history of colon polyps or colon cancer

Suggested pre-referral workup

• Complete blood count (CBC)
• Comprehensive metabolic panel
• Sedimentation rate (ESR) and C-reactive protein (CRP)
• Stool guaiac (occult blood)
• Stool culture including Yersinia and Campylobacter
• Stool C. difficile toxin assay

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes

Inflammatory bowel disease, Crohn’s disease, ulcerative colitis – ICD-10: K50.9*

When to refer

• Anemia, low albumin, elevated ESR or CRP
• Unexplained: growth failure or weight loss, diarrhea/rectal bleeding, vomiting, abdominal pain
• Family history of Crohn’s disease or ulcerative colitis
• Second opinion evaluation of IBD/Crohn’s disease/ulcerative colitis
• Known diagnosis of IBD/Crohn’s disease/ulcerative colitis, establishing care

Suggested pre-referral workup

• Stool C. difficile toxin assay
• Stool calprotectin, if available
• Stool O&P and Giardia antigen
• Stool guaiac (occult blood)
• Complete blood count (CBC)
• Comprehensive metabolic panel
• Sedimentation rate (ESR) and C-reactive protein (CRP)

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes
• Endoscopy and pathology reports, if available

Suspected eosinophilic esophagitis (EoE) – ICD-10: K20.0

When to refer

• Feeding problems
• Dysphagia
• History of food impaction
• Persistent vomiting
• Persistent reflux symptoms despite medical therapy
• Poor appetite
• Failure to thrive

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes

Feeding difficulties, oral aversion – ICD-10: R63.3 and Gastrostomy status – ICD-10: Z93.1

When to refer

• Feeding problems
• Abnormal feeding behaviors
• Poor appetite
• Failure to thrive
• Need for nutritional support, formula selection
• Gastrostomy tube status
• Consideration for placement of a feeding tube (nasogastric tube, PEG tube)

Suggested pre-referral workup

• Complete blood count (CBC)
• Comprehensive metabolic panel
• Upper GI study

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes

Additional diagnoses

When to refer

• Hirschsprung’s disease
• Megacolon
• Non-alcoholic fatty liver disease
• Chronic pancreatitis

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes

Urgent diagnoses

When to refer

• Melena/hematochezia/hematemesis
• Hyperbilirubinemia or jaundice
• Rule-out biliary atresia, complaints of white or gray stool
• Hepatitis
• Elevated liver enzymes
• Ingestion of a foreign body

Referral documentation requirements

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes