Gastroenterology, Hepatology and Nutrition Referral Guidelines

Age: Infancy and preschool to adolescence

Suggestions For Initial Work-Up:

• Stool studies: guaiac; culture; and C. difficile toxin titer for child older than 3 months old
• Assess stool frequency and consistency
• CBC with differential
• PT and PTT

Possible Pre-Referral Therapy:

• Anal/rectal tear is most likely cause.

Referral When:

• If symptoms persist, referral should be made. Colonoscopy may be required in preschool to adolescent children.

Age: Infancy and preschool to adolescence

Suggestions For Initial Work-Up:

• Stool studies: guaiac; culture; consider stool O and P; and C. difficile toxin titer for child older than 3 months old
• CBC with differential
• PT and PTT
• Albumin
• Urinalysis (for preschool to adolescence)

Possible Pre-Referral Therapy:

• If evaluation is negative, food protein allergy is likely in infants; inflammatory bowel disease is likely in preschool to adolescent.

Referral When:

• If symptoms persist, referral should be made. Preschool to adolescent children will require EGD and colonoscopy. 

Age: Toddler to adolescence

Suggestions For Initial Work-Up:

• Weight and height percentiles
• Urinalysis
• CBC with diff ESR or CRP
• Stool studies: Guaiac and consider EIA antigen for giardia
• Careful evaluation of stooling pattern
• Diary to look for possible triggers such as foods, activities or stressors

Possible Pre-Referral Therapy:

• Treatment of constipation, if present
• Acid suppression - H2 receptor
• Antagonist or proton pump
• Inhibitor
• Trial off lactose

Referral When:

If symptoms persist after improvement of stooling pattern, trial of a lactose-free diet and lack of response to acid suppression, referral should be made. The child may require endoscopy (EGD) and/or colonoscopy.

Age: Preschool to adolescence

Suggestions For Initial Work-Up:

• Weight and height percentiles
• Stool studies: Guaiac; consider leukocytes culture; EIA antigen for giardia; C. difficile toxin titer; reducing substances, pH; and Sudan stain (spot test for fecal fat)
• CBC with differential, ESR or CRP
• Albumin
• Quantitative IgA and anti-tTG Antibody (screen for celiac)
• Consider sweat test
• Consider upper GI with small bowel follow through
• Consider laxative abuse, especially in adolescent females

Possible Pre-Referral Therapy:

• Treat any dietary abnormality (e.g. high fructose and/or low fat)
• Try increased fiber in diet
• Diary of dairy and other food intake in relation to symptoms

Referral When:

If symptoms persist, referral should be made. The child may require EGD and/or colonoscopy.

Age: Infancy to adolescence

Suggestions For Initial Work-Up:

• Caloric intake
• 3-day diet diary
• Trial of concentrated calories
• Stool Studies: Guaiac, pH, reducing substances, pH, Sudan stain
• Urinalysis
• CBC with differential
• Serum electrolytes
• BUN, creatinine
• Albumin
• Consider sweat test, quantitative IgA, anti-tTG antibody
• Can consider ESR or CRP in a child or adolescent

Possible Pre-Referral Therapy:

• Increase caloric content of diet.
• If breastfed infant, consider fortifying pumped breast milk or supplementation with formula.

Referral When:

• If problems persist, referral should be made. The child may require an EGD and/or colonoscopy.

Age: Infancy to adolescence

Suggestions For Initial Work-Up:

• Use history and physical to evaluate for triggers, GERD or neurologic causes
• Weight and height percentiles
• CBC with differential
• Serum electrolytes
• Amylase and lipase
• Consider ESR or CRP
• Urinalysis

• Consider upper GI series to rule out anatomic abnormality

Possible Pre-Referral Therapy: 

• Consider trial of acid suppression (H2 receptor antagonist or proton pump inhibitor).

Referral When:

• If problems persist, referral should be made. The child may require an EGD.

Constipation can present with infrequent and/or painful stools, fecal incontinence and abdominal pain. It causes significant distress to the child and family. In most children no disease is found to be responsible for the constipation. Early treatment may improve outcome. Please refer to the evidence based guidelines on the evaluation and treatment of constipation in infants and children provided below.

Initial Evaluation

A thorough history and physical exam often is sufficient to make the diagnosis of functional constipation. The aims of the initial evaluation are to:

• Assess for fecal impaction
• Look for ‘red flags’ that may indicate an underlying disease (eg. delayed passage of meconium)

Initial Management

Conservative:

• Increase fiber and fluid in the diet
• Avoid excessive consumption of dairy
• Establish a toilet routine
• Proper position when having a bowel movement

Medication:

• Disimpaction with oral or rectal medication when patient has a large stool burden or encopresis with constipation.
• Maintenance of a laxative for 2 months and then gradually decrease the dose if the patient is doing well.

When to Refer

• Red flags on initial evaluation like passage of meconium beyond 24 hrs of birth, significant abdominal distention with vomiting or poor weight gain, anatomical abnormality-increased rectal tone, abnormally located anus, abnormality in distal spinal region like a dimple/tuft of hair/mass.
• Lack of improvement despite 2 months of adequate therapy.

How to Refer

• Administration fax: 202-476-3032
• Evenings and weekends: GI doctor on call (for urgent referrals)
• Nurse triage line: Not applicable
• Appointment line: Call center
• If you have a question about referral criteria please contact: x4880 covered by a pediatric gastroenterologist

What to Expect from a Visit to Children's

• An office encounter with a pediatric gastroenterologist lasting approximately 30 minutes
• Detailed history
• General examination with focus on growth, abdomen, perianal and a digital rectal examination
• Assessment and plan outlining specific treatment, any future testing as warranted and follow up  

Age: Preschool to adolescence

Suggestions For Initial Work-Up:

• Refer to “Constipation in Infants and Children: Evaluation and Treatment” Journal of Pediatric Gastroenterology and Nutrition. 1999:29:612-26.
• Also available at www.naspghan.org (under “Medical Professionals” – Position Papers

Possible Pre-Referral Therapy:

Successful treatment usually involves 3 components:

• Treatment of constipation (see above)
• A regular pattern of sitting on the toilet after each meal to invoke the gastro-colic reflex
• Psychological counseling. Successful treatment usually takes months.

Referral When:

• If problems persist, referral should be made.