Endoscopy Direct Access

Referral Form
The referral form appearing on this page is for all Leeds referrals, (not just those made at SJUH, LGI or Wharfedale).

Upper GI – Symptoms and Management Options

Indication

Urgent (two week wait)
Referral

Non urgent referral for direct access upper GI endoscopy

How to refer

Dysphagia

 

2week wait proforma – Suspected Upper GI cancer

Aged 55 or over with weight loss and any of the following:

  • Upper abdominal pain
  • Reflux
  • Dyspepsia

 

2week wait proforma – Suspected Upper GI cancer

 

Aged 55 or over with any of the following:

  • Treatment resistant dyspepsia
  • Upper abdominal pain with low haemoglobin levels
  • Raised platelet count with any of the following :-
    • Nausea
    • Vomiting
    • Weight Loss
    • Reflux
    • Dyspepsia
    • Upper Abdominal Pain
  • Nausea or vomiting with any of the following :-
    • Weight loss
    • Reflux
    • Dyspepsia
    • Upper Abdominal Pain

 


Providers will make a judgement on whether patient is fit for procedure, based on medical history detailed in referral.

If patient unfit, provider will organise appointment with gastroenterologist

Non-Urgent Direct Access Upper GI Endoscopy referral form

 

Aged less than 55 years with treatment resistant dyspepsia, patient requests endoscopy despite reassurance.

 

Non-Urgent Direct Access Upper GI Endoscopy referral form