Gastroenterology, Hepatology, and Nutrition - Referral Guidelines

The Division of Gastroenterology, Hepatology, and Nutrition at Children’s National offers the largest and most experienced team in the region. The Division works closely with Children’s National's other specialty areas to ensure that patients receive comprehensive care to manage their conditions.

The dedicated and experienced team of physicians, nurse practitioners, nurses, physician assistants, nutritionists, social workers, and pharmacists offer a full spectrum of GI, hepatology, and nutrition consultations, procedures, and support for children who are in the hospital, as well as those who visit our clinics. Investigations include those of intestinal function and structure, employing biochemical, endoscopic, and manometric techniques.

The Division has many programs and clinics that offer children and families specialized care for their unique needs. Specialized programs include:

  • Celiac Disease Program
  • Feeding Disorders Program
  • Gastroesophageal Reflux Disease (GERD) Program
  • H. pylori Program
  • Hepatology Program
  • Home Parenteral and Enteral Nutrition Program
  • Inflammatory Bowel Disease (IBD) Program
  • Intestinal Rehabilitation Program
  • Motility Program
  • Nutrition Program
  • Poor Growth Program
  • Small Bowel and Liver Transplantation Program

Parents are welcome to call for appointments; however, referring physicians may wish to directly contact a GI attending through the Physician Access Line (201-476-4880) regarding emergency cases. Previous X-rays and growth charts are extremely helpful in completion of an initial consultation.

Chronic Abdominal Pain: 

ICD-9 code – 789.0 Age: toddler to adolescence

Suggestions For Initial Work-Up:

  • Weight and height percentiles
  • Urinanalysis
  • CBC with dif 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.

Chronic, Non-Bloody Diarrhea:

ICD-9 code – 787.91 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

Bloody Diarrhea (Colitis):

ICD-9 code – 558 Age: infancy

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

Possible Pre-Referral Therapy:

  • If evaluation is negative, food protein allergy is likely

Referral When:

  • If symptoms persist, referral should be made.

Bloody Diarrhea (Colitis):

ICD-9 code – 558 Age: preschool to adolescence

Suggestions For Initial Work-Up:

  • Stool studies: guaiac; culture; and C. difficile toxin titer
  • CBC with differential
  • PT and PTT
  • Albumin
  • Urinanalysis

Possible Pre-Referral Therapy:

  • If evaluation is negative, inflammatory bowel disease is likely

Referral When:

  • If symptoms persist, referral should be made. The child will require EGD and colonoscopy.

Blood in stool/ Rectal bleeding:

ICD-9 code – 569.3 Age: infancy

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.

Blood in stool/ Rectal bleeding:

ICD-9 code – 569.3 Age: preschool to adolescence

Suggestions For Initial Work-Up:

  • Stool studies: guaiac; culture; and C. difficile toxin titer
  • 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.

Gastroesophageal Esophageal Reflux Disease (GERD):

ICD-9 code – 530.11 Age: infancy to adolescence

Suggestions For Initial Work-Up:

  • Weight and height evaluation
  • Stool guaiac
  • CBC with differential
  • Consider Upper GI series
  • Refer to “Guidelines for Evaluation and Treatment of Gastroesophageal Reflux in Infants and Children” Journal of Pediatric Gastroenterology and Nutrition. (32)Suppl 2. 2001; S1-S31
  • Also available at www.naspghan.org (under “Medical Professionals” - Position Papers)

Possible Pre-Referral Therapy:

  • Acid suppression (H2 receptor antagonist or proton pump inhibitor)

Referral When:

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

Poor Growth (Failure to Thrive):

ICD-9 code – 783.1 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, Sudanstain
  • Urinanalysis
  • 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

Vomiting with or Without Abdominal Pain:

ICD-9 code – 787.03 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
  • Urinanalysis
  • 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:

ICD-9 code – 564.00 Age: infancy 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:

  • Treatment should include the AAP-recommended six servings of fruits and vegetables each day, adequate fluid intake, daily vigorous physical activity and the use of a safe, (preferably non-absorbed) stool softener like Lactulose or Miralax. Successful treatment should continue to ensure that improvement persists

Referral When:

  • If problems persist, referral should be made.

Encopresis:

ICD-9 code – 787.6 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: (1) treatment of constipation (see above), (2) a regular pattern of sitting on the toilet after each meal to invoke the gastro-colic reflex, and (3) psychological counseling. Successful treatment usually takes months.

Referral When:

  • If problems persist, referral should be made

Download a pdf of these guidelines or read additional information

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