When should a patient be referred to a Gastrointestinal (GI) specialist?

When to Refer Patients to a Gastroenterology Specialist

Patients should be referred to a gastroenterologist when they have alarm symptoms, abnormal laboratory findings, or symptoms that persist despite appropriate primary care management.

Indications for Urgent Referral

Alarm Symptoms

• Rectal bleeding
• Unexplained weight loss
• Iron deficiency anemia
• Persistent nocturnal symptoms
• Abdominal mass or unexplained anal ulceration
• Fever
• Family history of colorectal cancer or inflammatory bowel disease (IBD)
• New onset symptoms in patients over 45 years of age 1

Laboratory Findings

• Elevated fecal calprotectin >250 μg/g (requires urgent referral) 1, 2
• Abnormal blood tests (anemia, elevated inflammatory markers)
• Positive celiac serology

Indications for Routine Referral

Persistent Symptoms Despite Primary Care Management

• Chronic diarrhoea (>4 weeks) not responding to first-line treatments 1
• Symptoms interfering with quality of life despite appropriate management
• Intermediate fecal calprotectin (100-250 μg/g) 1, 2
• Patients with functional bowel disorders who develop worsening symptoms or anxiety 1

Special Populations

• Patients with suspected IBD
• Patients with post-cancer treatment GI symptoms 1
• Patients with IBS and significant psychological comorbidities that affect treatment response 1

Diagnostic Pathway for Chronic Diarrhoea

Initial Assessment in Primary Care

1. Detailed history and physical examination
2. Basic laboratory tests:
   • Full blood count
   • Renal function tests
   • C-reactive protein
   • Celiac serology
   • Stool cultures (if infectious etiology suspected)
   • Fecal calprotectin (not if NSAIDs used in past 6 weeks) 1

Fecal Calprotectin-Based Referral Algorithm for Patients 16-40 Years

• <100 μg/g: Likely IBS, treat in primary care
• 100-250 μg/g: Consider repeat testing or routine referral

• 250 μg/g: Refer urgently to gastroenterology 1

Management Algorithm for Suspected IBS vs. IBD

For patients aged 16-40 with chronic lower GI symptoms:

1. If presenting with rectal bleeding plus any of: abdominal pain, change in bowel habit, weight loss, or iron deficiency anemia

   • Refer for specialist evaluation

2. If no alarm features but IBD is suspected:

   • Measure fecal calprotectin
   • Refer based on results as per algorithm above 1

3. For patients with typical IBS symptoms (age <45 years, female, symptoms >2 years, no alarm features):

   • Manage in primary care
   • Consider referral if symptoms persist despite appropriate management 1

Pitfalls to Avoid

• Delaying referral for patients with alarm symptoms
• Overreliance on symptom criteria alone to distinguish IBS from IBD (symptoms alone have limited specificity) 1
• Failing to consider fecal calprotectin testing in younger patients with chronic diarrhea
• Missing post-cancer treatment GI complications that require specialist management 1
• Overlooking psychological comorbidities that may require multidisciplinary management 1

Remember that early referral to a gastroenterologist can facilitate timely diagnosis and treatment, potentially improving outcomes and quality of life for patients with significant GI disorders.