Advice

This intervention is NOT routinely commissioned.

Criteria

Patients are confirmed to have FAP on predictive genetic testing and so colonoscopic surveillance is to be carried out from 12-14 years (or every 1-3 years, personalised according to colonic phenotype )

OR

Patient has a first degree relative with a clinical diagnosis of FAP (i.e. “at risk”) and in whom a APC mutation has not been identified (so colorectal surveillance is to be carried out from 12-14 years or every 5 years until either a clinical diagnosis is made and they are managed as FAP or the national screening age is reached)

Criteria

Patient has MUTYH-associated Polyposis (MAP) and so colorectal surveillance to be carried out from 18-20 years, and, if surgery has not been undertaken, is to be repeated annually

Criteria

Patient is asymptomatic with PSJ then colorectal surveillance is to be carried out from 8 years

OR

Patient is asymptomatic with PSJ if baseline colonoscopy is normal, repeat colonoscopy deferred until 18 years, however if polyps are found at baseline examination, repeat every 3 years

Criteria

Patient has Serrated Polyposis Syndrome (SPS) and colonoscopic surveillance is every year from diagnosis once the colon has been cleared of all lesions >5mm in size

OR

Patient has Serrated Polyposis Syndrome (SPS) and no polyps ≥ 10mm in size are identified at subsequent surveillance examinations, so colonoscopic surveillance interval is every 2 years

OR

First degree relatives of patients with SPS undergoing an index colonoscopic screening examination at age 40 or ten years prior to the diagnosis of the index case will be carried out

OR

Patient is a first degree relative of a patient with SPS who is undergoing surveillance colonoscopy every 5 years until age 75 years, unless polyp burden indicates an examination is required earlier according to post-polypectomy surveillance guidelines

Criteria

For individuals with moderate familial CRC risk a one-off colonoscopy at age 55 years

OR

Subsequent colonoscopic surveillance should be performed as determined by post-polypectomy surveillance guidelines

OR

One colonoscopy every 5 years from age 40 years to age 75 years for individuals that have high familial CRC risk (a cluster of 3x FDRs with CRC across >1 generation)

Criteria

The patient has Lynch Syndrome and is a MLH1 and MSH2 mutation carrier and therefore colonoscopic surveillance is inline with every 2 years from age 25 years to age 75 years

OR

Patient has Lynch Syndrome and is a MSH6 and PMS2 mutation carrier and therefore colonoscopic surveillance is inline with every two years from age 35 years to age 75 years

OR

Patient has Lynch-like Syndrome with deficient MMR tumours without hypermethylation/BRAF pathogenic variant and no pathogenic constitutional pathogenic variant in MMR genes (and their unaffected FDRs), and no evidence of biallelic somatic MMR gene inactivation, and therefore has colonoscopic surveillance every 2 years from age 25 years to age 75 years

Criteria

Patient is diagnosed with CRC, under the age of 50 years and hereditary CRC symptoms have been excluded, colonoscopy surveillance to be carried out as standard post-CRC after 3 years

OR

Patient is diagnosed with CRC, under the age of 50 years and hereditary CRC symptoms have been excluded and they have had their previous 3 year interval colonoscopy and is now having colonoscopic surveillance every 5 years until eligible for national screening

Not routinely commissioned

Criteria

Patient has MCRA (defined as having 10 or more metachronous adenomas) and so is having annual colonoscopic surveillance from diagnosis to age 75 years after the colon has been cleared of all lesions >5mm in size

OR

Patient has MCRA (defined as having 10 or more metachronous adenomas) and no polyps 10mm or greater in size are identified at subsequent surveillance examinations, colonoscopic surveillance will be carried out every two years

Criteria

Pure subacromial impingement is not caused by associated diagnoses such as rotator cuff tears, acromio-clavicular joint pain or calcific tendinopathy

AND

Physiotherapy and exercise programmes have been actively undertaken and found to be ineffective in resolving the shoulder pain

AND

There is evidence that the risks and benefits of treatment options have been clearly discussed with the patient / carer and are documented in the patient notes.

Advice

Meniscal tears in the knee are a common finding and in many cases are not related to any significant symptoms.

Criteria

Non-operative treatments (including paracetamol and topical NSAIDS) have not settled symptoms after 3 months/persistent symptoms ongoing and an MRI has revealed an unstable meniscal tear

OR

The patient has had an acute injury and an MRI scan reveals a potentially reparable meniscus tear

OR

Patient has a locked knee and required an urgent assessment, which showed a bucket handle tear of the meniscus to be present.

AND

The patient has gone through a shared decision making process and understands the risks of surgery.

Advice

The woman has received a full package of supportive care from their GP such as advice on weight loss and managing pain

AND

In cases of thoracic/ shoulder girdle discomfort, a physiotherapy assessment has been provided

AND

Breast size results in functional symptoms that require other treatments/interventions (e.g. intractable candidal intertrigo; thoracic backache/kyphosis where a professionally fitted bra has not helped with backache, soft tissue indentations at site of bra straps)

AND

Breast reduction planned to be 500gms or more per breast or at least 4 cup sizes

AND

Body mass index (BMI) is <27 and stable for at least twelve months

AND

The woman must be provided with written information to allow her to balance the risks and benefits of breast surgery

AND

Women should be informed that smoking increases complications following breast reduction surgery and should be advised to stop smoking

AND

Women should be informed that breast surgery for hypermastia can cause permanent loss of lactation

Criteria

The symptoms significantly interfere with daily activities and sleep symptoms and have not settled to a manageable level with either one local corticosteroid injection and/or nocturnal splinting for a minimum of 8 weeks

OR

There is a permanent (ever-present) reduction in sensation in the median nerve distribution

OR

Muscle wasting or weakness of thenar abduction (moving the thumb away from the hand).

Criteria

Has been present for more than 6 months and has been managed conservatively with warm compresses, lid cleaning and massage for 4 weeks

OR

Interferes significantly with vision, demonstrated by visual fields test

OR

Interferes with the protection of the eye by the eyelid due to altered lid closure or lid anatomy

OR

Is a source of infection that has required medical attention twice or more within a 6 month time frame

OR

Is a source of infection causing an abscess which requires drainage

OR

Suspicion of malignancy to remove and send for histology

Criteria

Patient is asymptomatic with JPS offer colorectal surveillance from 15 years

OR

Patient is asymptomatic with JPS then offer a surveillance colonoscopy every 1-3 years, personalised according to colorectal phenotype

Advice

This guidance applies to adults aged 19 years and over. Further details are outlined in NICE guidance and ECS guidance for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk.

Creatine kinase should not be routinely monitored in asymptomatic people who are taking lipid modification therapy

Criteria

Prior to lipid modification therapy initiation in patients who have experienced generalised, unexplained muscle pains or weakness (whether or not associated with previous lipid-monitoring therapy)

OR

If a patient develops muscle pains or weakness whilst on lipid modification therapy.

Advice

Cystoscopy should only be offered when clinically indicated and the patient has LUTS symptoms

Criteria

The patient has lower urinary tract symptoms (LUTS) and suffers recurrent urinary tract infections

OR

The patient has lower urinary tract symptoms (LUTS) and has sterile pyuria (urine dip positive for leukocytes without bacterial growth)

OR

The patient has lower urinary tract symptoms (LUTS) and haematuria

OR

The patient has very significant/profound lower urinary tract symptoms (LUTS)

OR

The patient has lower urinary tract symptoms (LUTS) with pain around urinary tract

OR

The patient has lower urinary tract symptoms (LUTS) and risk factors such as long smoking history, travel or occupational history suggesting a high risk of malignancy, or previous urogenital surgery

This intervention is NOT routinely commissioned.

Criteria

Participants in the ongoing clinical trial (HTA-15/102/04)

OR

Adult patients with a palpable cord if there is evidence of moderate disease (functional problems and MCP joint contracture of 30° to 60° and PIP joint contracture of less than 30° or first web contracture)

AND

Up to two affected joints

AND

Needle fasciotomy is not considered appropriate, but limited fasciectomy is considered appropriate by the treating hand surgeon

Criteria

Finger contractures causing loss of finger extension of 30° or more at the MCP joint or 20° at the PIP joint

OR

Severe thumb contractures which interfere with function

OR

Rapidly progressive disease

Advice

In patients with recurrent acute sinusitis, nasal examination is likely to be relatively normal. Ideally, the diagnosis should be confirmed during an acute attack if possible, by nasal endoscopy and/or a CT sinus scan.

Criteria

A diagnosis of CRS has been confirmed from clinical history and nasal endoscopy and / or CT scan

AND

Disease-specific symptom patient reported outcome measure confirms moderate to severe symptoms e.g. Sinonasal Outcome Test (SNOT-22) after trial of appropriate medical therapy (including counselling on technique and compliance) as outlined in RCS/ENT-UK commissioning guidance ‘Recommended secondary care pathway’

AND

Pre-operative CT sinus scan has been performed and confirms presence of CRS. Note: a CT sinus scan does not necessarily need to be repeated if performed sooner in the patient’s pathway

AND

Patient and clinician have undertaken appropriate shared decision-making consultation regarding undergoing surgery including discussion of risks and benefits of surgical intervention

OR

Any suspected or confirmed neoplasia

OR

Emergency presentations with complications of sinusitis (e.g. orbital abscess, subdural or intracranial abscess)

OR

Patients with immunodeficiency

OR

Fungal Sinusitis

OR

Patients with conditions such as Primary Ciliary Dyskinesia, Cystic Fibrosis or NSAID-Eosinophilic Respiratory Disease (NSAID-ERD, Samter’sTriad Aspirin Sensitivity, Asthma, CRS)

OR

Treatment with topical and / or oral steroids contra-indicated

OR

As part of surgical access or dissection to treat non-sinus disease (e.g. pituitary surgery, orbital decompression for eye disease, nasolacrimal surgery)

Category 1 – Not routinely commissioned

Advice

Spinal fusion is not indicated for the treatment of non-specific, mechanical back pain.

Criteria

Patient has a symptomatic spinal deformity (e.g. scoliosis)

OR

Patient has instability (e.g. spondylolisthesis; trauma).

OR

Spinal fusion is to be used as an adjunct during spinal decompression surgery, where a more extensive exposure of the affected neurological structures is required and would otherwise render the spine unstable.

Criteria

Aspiration fails to resolve pain or tingling/numbness, and there is restricted hand function.

OR

The ganglion persists or recurs after puncture/aspiration

OR

There is recurrent spontaneous discharge of fluid or significant nail deformity.

Criteria

All children must have had specialist audiology and ENT assessment and demonstrate:

Persistent bilateral otitis media with effusion over a period of 3 months

OR

Hearing level in the better ear of 25-30dbHL or worse averaged at 0.5, 1, 2, & 4kHz

OR

Exceptionally where persistent bilateral OME with a hearing loss less than 25-30dbHL where the impact of the hearing loss on a child’s developmental, social or educational status is judged to be significant

OR

Where there is clinical and tympanographic evidence of persistent glue ear and where the impact of the hearing loss on a child’s developmental, social or educational status is judged to be significant

OR

The child has Down’s syndrome or has a cleft palate

Advice

Image guided subacromial injections are not recommended in primary, intermediate or secondary care.

Criteria

Subacromial injections for the treatment of subacromial shoulder pain (which should not be image guided)

OR

Image guided shoulder injections for other causes of shoulder pain (not subacromial) should only be offered under the guidance of a secondary care shoulder service.

Not routinely commissioned

Criteria

Recommendations for the medical treatment of heavy menstrual bleeding (and/or symptomatic large or multiple fibroids) set out in NICE Clinical Guideline NG88 for Heavy Menstrual Bleeding have failed, or are contraindicated, or has been declined by the woman

AND

There is a wish for amenorrhoea (no periods)

AND

The woman has been fully informed of the implications of surgery, and does not wish to retain her uterus and fertility

This intervention is NOT routinerly commissioned

Advice

Invasive coronary angiography should only be offered for low risk, stable chest pain as third-line investigation when the results of non-invasive functional imaging are inconclusive.

Criteria

Patient has significant findings on CT coronary angiogram (Significant coronary artery disease (CAD) found during CT coronary angiography is ≥ 70% diameter stenosis of at least one major epicardial artery segment or ≥ 50% diameter stenosis in the left main coronary artery)

OR

CT coronary angiography is inconclusive and further non-invasive functional imaging (either Stress echocardiography OR first-pass contrast-enhanced magnetic resonance (MR) stress perfusion OR MR imaging for stress-induced wall motion abnormalities OR Fractional flow reserve CT (FFR-CT) OR Myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) is inconclusive

This intervention is NOT routinely commissioned.

Advice

Degenerate meniscal tears and OA are extremely common in the general population. MRI is not usually recommended for a suspected degenerative meniscal tear

Criteria

Clear history of a significant acute knee injury

AND

Mechanical symptoms

OR

Have a locked knee

Advice

An MRI of the knee is not usually needed for the diagnosis of Osteoarthritis.

Criteria

Patient has severe symptoms but relatively mild osteoarthritis on standard X-rays.

OR

Patient is working up for possible HTO (High Tibial Osteotomy) or partial knee replacement (to focus on the state of the anterior cruciate ligament and retained compartments).

Advice

This guidance applies to adults aged 19 years and over. Further details on are outlined in NICE guidance and ECS guidance for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk.

Criteria

Measure full lipid profile by taking at least one lipid sample before starting lipid modification therapy. This should include measurement of total cholesterol, HDL cholesterol, non‑HDL cholesterol and triglyceride concentrations. A fasting sample is not needed.

OR

Total cholesterol, HDL cholesterol and non‑HDL cholesterol should be measured in all people who have been started on high-intensity statin treatment (both primary and secondary prevention, including atorvastatin 20 mg for primary prevention) at 3 months of treatment and aim for a greater than 40% reduction in non‑HDL cholesterol.

OR

Consider an annual non‑fasting blood test for non‑HDL cholesterol to inform discussion at annual medication reviews.

Advice

This guidance applies to adults aged 19 years and over.

Further details are outlined in NICE guidance and ECS guidance for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk.

Criteria

Baseline liver function to be carried out before starting lipid modification therapy

OR

Liver function is being measured (once) within 3 months of starting treatment

OR

Liver function is being measured (once) at 12 months following treatment

Criteria

Serious underlying pathology is suspected – this may include, but is not limited to, cancer, infection, trauma, spinal cord injury (full or partial loss of sensation and/or movement of part(s) of the body) or inflammatory disease. Please see the relevant NICE guideline for further information around these conditions.

AND

A full history and medical examination of the patient has been carried out.

Advice

Some patients may benefit from a discectomy – a shared decision making framework has been used with the patient to determine the appropriateness of the discectomy

Criteria

Patient has compressive nerve root signs and symptoms have lasted at least three months (or are severe cases)

AND

Non-operative management has failed to resolve symptoms

AND

Concordant MRI changes are present

Advice

Radiofrequency denervation will be prescribed in accordance with NICE Guideline NG59, which recommends it as an adjunct in the management of chronic low back pain

Criteria

Patient has had a one-off medial branch block that has improved symptoms

AND

Non-operative treatment (such as weight loss, exercise programmes, physiotherapy, pain killers) has failed

Advice

Do not request a hip MRI when the clinical presentation (history and examination) and X-rays demonstrate typical features of OA.

Criteria

The patient is under 45

AND

The patient does not have activity-related joint pain

AND

The patient has morning stiffness lasting more than 30 minutes

OR

Suggestions of infection, e.g. pyrexia, swollen and red joint, significant irritability, other risk factors of septic arthritis

OR

Patient has suffered trauma

OR

Patient has history or family history of an inflammatory arthropathy

OR

Mechanical, impingement type symptoms

OR

Prolonged and morning stiffness

OR

History of cancer or corresponding risk factors

OR

Suspected Osteonecrosis / Avascular necrosis of the hip

OR

Suspected transient osteoporosis

OR

Suspected periarticular soft tissue pathology e.g. abductor tendinopathy

Advice

NICE recommend that chest radiographs should not be routinely offered before elective surgery.

Criteria

Patients undergoing cardiac or thoracic surgery

OR

Patients undergoing organ transplantation or live organ donation

OR

At the request of the anaesthetist in those with suspected or established cardio-respiratory disease, who have not had a chest radiograph in the previous 12 months, and who are likely to go to critical care after surgery

OR

At the request of the anaesthetist in those with a recent history of chest trauma

OR

At the request of the anaesthetist in patients with a significant smoking history who have not had a chest radiograph in the previous 12 months, or those with malignancy and possible lung metastases

OR

At the request of the anaesthetist in those undergoing a major abdominal operation, who are at high risk of respiratory complications

Advice

Pre-operative electrocardiograms should not be routinely performed in low risk, non-cardiac, adult elective surgical patients.

Criteria

Patients with an American Society of Anaesthesiologists (ASA) physical classification status of 3 or greater and no ECG results available for review in the last 12 months

OR

Patients with a history of cardiovascular or renal disease, or diabetes.

OR

Patients with any history of potential cardiac symptoms (e.g. cardiac chest pain, palpitations, unexplained syncope or breathlessness) or a new murmur, that has not previously been investigated.

OR

Patients over the age of 65 attending for major surgery.

Advice

Note: PSA testing for prostate cancer should be avoided if the man has:

• An active or recent urinary infection (PSA may remain raised for many months).
• Had a prostate biopsy in the previous 6 weeks.

Both of which are likely to raise PSA and give a false positive result.

Criteria

The man is asymptomatic and over age 40 and at higher risk of prostate cancer (e.g. they are Black and/or have a family history of prostate cancer)

OR

Symptomatic men with lower urinary tract symptoms (LUTS), such as nocturia, urinary frequency, hesitancy, urgency or retention, visible haematuria

OR

Erectile dysfunction

OR

Symptoms that could be due to advanced prostate cancer (for example lower back pain, bone pain, weight loss).

AND

A careful discussion about the potential risks and benefits of PSA testing has been held, allowing for shared decision

Advice

Adjuvant adenoidectomy should not be routinely performed in children undergoing grommet insertion for the treatment of otitis media with effusion

Criteria

The child has persistent and / or frequent nasal obstruction which is contributed to by adenoidal hypertrophy (enlargement)

OR

The child is undergoing surgery for re-insertion of grommets due to recurrence of previously surgically treated otitis media with effusion

OR

The child is undergoing grommet surgery for treatment of recurrent acute otitis media

OR

Adenoidectomy as part of treatment for obstructive sleep apnoea or sleep disordered breathing in children (e.g. as part of adenotonsillectomy)

OR

Adenoidectomy as part of the treatment of chronic rhinosinusitis in children

OR

Adenoidectomy for persistent nasal obstruction in children and adults with adenoidal hypertrophy

OR

Adenoidectomy in preparation for speech surgery in conjunction with the cleft surgery team

Criteria

History of incarceration, difficulty in reducing the hernia,

OR

Increased risk of strangulation (high risk in female patients)

OR

Inguino-scrotal hernia

OR

Progressive increase in size of hernia (month-on-month)

OR

Significant pain or discomfort sufficient to cause significant functional impairment

AND

There is evidence that the risks and benefits of treatment options have been clearly discussed with the patient / carer and are documented in the patient notes

Advice

This guidance applies to adults (or equivalent based on body weight for children or adults with low body weight) only. Blood transfusions should not be given to patients due to B12, folate or iron deficiency anaemia alone. Restrictive red blood cell transfusion should not be used for patients with major haemorrhage, acute coronary syndrome or who need regular transfusions for chronic anaemia.

Criteria

A single unit of blood is given to a patient with severe acute anaemia (Hb <70g/litre) that is symptomatic and prevents rehabilitation or mobilisation.

Advice

X-rays should be used routinely as the first line of radiological investigation for the diagnosis of most routine shoulder pathology. This practice should be followed in primary, intermediate and secondary care.

Criteria

Ultrasound, MRI or CT scan has been requested by secondary care services that are responsible for the definitive treatment of the patient

OR

Investigations are outside secondary care and a referral pathway has been developed with the local secondary care specialist shoulder service

Advice

First-line treatment is with appropriate medical therapy, which should include intranasal steroids and nasal saline irrigation. In the case of CRSwNP a trial of a short course of oral steroids should also be considered.

This guidance applies to adults and children.

If there’s anything unclear/any doubt about the need for referral please use the local Advice and Guidance (A&G).

Criteria

A clinical diagnosis of CRS has been made (as set out in RCS/ENT-UK Commissioning guidance) in primary care and patient still has moderate / severe symptoms after a 3-month trial of intranasal steroids and nasal saline irrigation

AND

In addition, for patients with bilateral nasal polyps there has been no improvement in symptoms 4 weeks after a trial of 5-10 days of oral steroids (0.5mg/kg to a max of 60 mg)

OR

Patient has nasal symptoms with an unclear diagnosis in primary care

OR

Any patient with unilateral symptoms or clinical findings, orbital, or neurological features should be referred urgently / via 2-week wait depending on local pathways.

Advice

There are many different approaches to surgical intervention for benign prostatic hyperplasia.
Only men with severe voiding symptoms, or in whom conservative management options and drug treatment have been unsuccessful, should be offered surgical intervention. Surgery is indicated (in healthy men) in complicated BPH i.e. chronic retention with renal impairment as evidenced by hydronephrosis and impaired GFR, and in most cases of acute retention secondary to BPH.

Criteria

The person is healthy and has complicated benign prostatic hyperplasia (i.e. chronic retention with renal impairment) as evidenced by hydronephrosis and impaired GFR

OR

Other evidence of complicated BPH (e.g. urinary tract infections, bladder stones or acute urinary retention)

OR

Bothersome LUTS persist alongside high, or unchanged International Prostate Symptom Scores despite optimal conservative and drug treatment

AND

Shared Decision making process has been carried out and the person has been counselled thoroughly regarding alternatives

Criteria

The benign skin lesions, which are listed above, must meet at least ONE of the following criteria to be removed:

The lesion is unavoidably and significantly traumatised on a regular basis with evidence of this causing regular bleeding or resulting in infections such that the patient requires 2 or more courses of antibiotics (oral or intravenous) per year

OR

There is repeated infection requiring 2 or more antibiotics per year

OR

The lesion causes regular pain, bleeds in the course of normal everyday activity, or significantly impacts on function eg: restricts joint movement

OR

The lesion is obstructing an orifice or impairing field vision

OR

The lesion causes pressure symptoms e.g. on nerve or tissue

OR

If left untreated, more invasive intervention would be required for removal

OR

Facial viral warts

OR

Facial spider naevi in children causing significant psychological impact

OR

Lipomas on the body > 5cms, or in a sub-facial position, with rapid growth and/or pain

Criteria

Recurrent grade 3 or grade 4 combined internal/external haemorrhoids with persistent pain or bleeding

OR

Irreducible and large external haemorrhoids

Criteria

Seven or more, documented, clinically significant, adequately treated sore throats (due to acute Tonsilitis) in the preceding year and episodes are disabling and prevent normal functioning

OR

Five or more, documented, clinically significant, adequately treated sore throats (due to acute Tonsilitis) in each of the preceding 2 years and episodes are disabling and prevent normal functioning

OR

Three or more, documented, clinically significant, adequately treated sore throats (due to acute Tonsilitis) in each of the preceding 3 years and episodes are disabling and prevent normal functioning

Criteria

Renal stones are 5-10mm and not suitable for watchful waiting, shockwave lithotripsy is to be offered as first-line treatment (unless contra-indicated or not targetable)

OR

Renal Stones are 10-20mm shockwave lithotripsy can be considered as first-line treatment (if treatment can be given in a timely fashion)

OR

Renal stones are 10-20mm and shockwave lithotripsy is contraindicated or ineffective, then ureteroscopy can be considered.

OR

Renals stones are over 20mm (including staghorn), percutaneous nephrolithotomy (PCNL) can be offered as first-line treatment

Criteria

Ureteric Stones are 5-10mm so Shockwave lithotripsy will be offered as first-line treatment where it can be given in a timely fashion (unless contra-indicated or not targetable)

OR

Ureteric Stones are 10-20mm ureteroscopy can be offered OR shockwave lithotripsy if local facilities allow stone clearance within 4 weeks

Criteria

The triggering persists or recurs after conservative measures including up to two steroid injections, or splinting of the affected finger for 3-12 weeks

OR

The finger is permanently locked in the palm

OR

The patient has previously had 2 other trigger digits unsuccessfully treated with appropriate non-operative methods

OR

The patient is diabetic

Criteria

A clinical diagnosis of acute coronary syndrome is suspected

OR

A clinical diagnosis of myocarditis is suspected or myocardial damage following chemotherapy

OR

Test is for prognostic purposes when pulmonary embolism is confirmed

Criteria

The patient has GORD (endoscopically determined oesphagitis or endoscopy – negative reflux disease) so endoscopy is to be carried out to diagnose Barrett’s oesphagus

OR

Endoscopy surveillance for patient’s diagnosed with Barrett’s Oesphagus

Patient is aged 55 and under with suspected coeliac disease and anti-TTG >10x reference range should be treated for coeliac disease on the basis of positive serology and without endoscopy or biopsy

Advice

There should be separate consideration for those with symptoms that qualify for a 2WW, for which ebichecker is not relevant and 2WW pathways should be followed.

Criteria

Gastro-oesophageal symptoms are non- responsive to treatment or unexplained

OR

Suspected GORD who are thinking about surgery

OR

H pylori that has not responded to second- line eradication (which can be confirmed with a urea breath test)

Criteria

If there is a coexisting peptic ulcer then repeat endoscopy should be considered 6-8 weeks after beginning treatment for H pylori and the associated peptic ulcer

Criteria

Following complete endoscopic excision of adenomas, gastroscopy is to be performed at 12 months or annually thereafter (when appropriate)

Criteria

Screening is to be performed in keeping with European expert guidelines (2015)

AND

Individual is aged 50 and over, with multiple risk factors for gastric cancer (e.g. H. Pylori infection, family history of gastric cancer – particularly in first degree relative -, pernicious anaemia, male, smokers)

Criteria

Patient is fit enough for subsequent endoscopic or surgical intervention, should neoplasia be found. Senior clinician input has been provided before embarking on long term endoscopic surveillance

OR

Patients diagnosed with extensive gastric atrophy (GA) or gastric intestinal metaplasia, (GIM) (defined as affecting the antrum and the body) should have endoscopy surveillance every three years

OR

Patients diagnosed with GA or GIM just in the antrum with additional risk factors – such as strong family history of gastric cancer of persistent H pylori infection, should undergo endoscopy every three years

Criteria

Bleeding varicose veins (an immediate referral is required)

OR

Symptomatic primary or recurrent varicose veins that are causing severe pain, aching, discomfort, swelling, heaviness or itching

OR

Lower-limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency

OR

Superficial vein thrombosis (characterised by the appearance of hard, painful veins) and suspected venous incompetence

OR

A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks)

OR

A healed venous leg ulcer

Advice

Older patients (>60 years old) with fractures at most 6 weeks old and severe pain despite optimal pain management that benefit most from the procedure.

Criteria

Patient has severe (7/10 or greater on VAS scale) ongoing pain after a recent, unhealed vertebral fracture despite optimal pain management

AND

The acute vertebral fracture has been proven on imaging and correlates with the site of maximal pain on clinical examination

AND

Multidisciplinary team discussions have taken place

AND

The procedure will take place at a facility with access to spinal surgery services

AND

Processes for audit and clinical governance are in place

AND

Vertebroplasty must be performed in conjunction with additional measures to improve bone health