PPwT form – Double Balloon Enteroscopy at St Mark’s Hospital, LNWH NHS Trust

This form is provided for secondary and specialist clinicians to register when a patient meets the North West London CCGs PPwT criteria

This form confirms that the patient meets the North West London CCGs PPwT criteria. A completed form submitted to the email address below supports funding. All completed forms are subject to validation. Any additional information or queries will be notified within 5 working days.Where the criteria are not met, funding may be considered via the IFR route if there are any exceptional reasons.

TO REGISTER THIS REFERRALemail it to: nly using your nhs.netemail account.

Applicant Details
Designation (Please mark one):Trust Clinician GP Other, please specify
Name of Referrer / GP Practice Name
Speciality / CCG Name
Name of Trust / GMC number
NHS.net email
Telephone / Date of decision to treat / (dd/mm/yyyy)
Patient Details
NHS NUMBER: / D.O.B. : (dd/mm/yyyy)

THRESHOLDS FOR TREATMENT: Please provide supporting evidence as this form is subject to clinical triage

  1. Clinical Indications:

-To obtain small bowel biopsies for a histological diagnosis e.g. suspected 

Crohn’s Disease, where standard endoscopy* and small bowel imaging has

proved inconclusive and/or is unable to reach the diseased location

-To treat gastro-intestinal bleeding from a small bowel lesion(s) identified at  imaging or video capsule endoscopy

-To obtain histology/remove/tattoo a suspected small bowel polyp or tumour that has been identified at small bowel imaging, where standard

endoscopy* has failed and/or is unable to reach the lesion

-Dilatation of a small bowel stricture(s) identified at small bowel imaging

in patients who are symptomatic and where standard endoscopy* has failed

and/or is unable to reach the site of the stricture

-To insert or replace a percutaneous endoscopic jejunal feeding tube in 

patients who have failed or are unable to tolerate PEG** feeding and need

long-term nutritional support

* standard endoscopy = OGD/push enteroscopy and ileo-colonoscopy

** PEG = percutaneous endoscopic gastrostomy

  1. Any other relevant clinical information: