When should I refer a patient with chronic abdominal pain to a specialist for further evaluation?

You should refer a patient with chronic abdominal pain to a specialist for further evaluation in several circumstances, particularly when there are features suggestive of malignancy or serious underlying conditions.

• Urgent Suspected Cancer Pathway Referral:
  • Refer women using a suspected cancer pathway if an abdominal or pelvic mass is identified by physical examination (which is not obviously uterine fibroids) [1. 5. 1].
  • Consider a suspected cancer pathway referral for a rectal mass [1. 3. 5].
  • Consider a suspected cancer pathway referral for unexplained splenomegaly in adults, especially if associated with fever, night sweats, shortness of breath, pruritus, or weight loss [1. 10. 7].
  • Consider a suspected cancer pathway referral for an upper abdominal mass consistent with stomach cancer [1. 2. 6].
  • Refer using a suspected cancer pathway if a patient aged 55 and over presents with upper abdominal pain and weight loss [1. 2. 1, 1. 2. 7].
  • Refer using a suspected cancer pathway if a patient aged 55 and over presents with dyspepsia and weight loss [1. 2. 1, 1. 2. 7].
  • Refer adults using a suspected cancer pathway for colorectal cancer if they have a positive quantitative faecal immunochemical test (FIT) requested due to being aged 40 and over with unexplained weight loss and abdominal pain ⁴.
  • Consider a suspected cancer pathway referral for adults under 50 with rectal bleeding and any unexplained symptoms such as abdominal pain, change in bowel habits, weight loss, or iron-deficiency anaemia ⁴.
  • For dyspepsia, an urgent referral to a gastroenterologist is recommended if there are alarm features suggestive of malignancy ².
• Urgent Direct Access Investigations (within 2 weeks):
  • Consider an urgent direct access ultrasound scan (to be done within 2 weeks) for an upper abdominal mass consistent with an enlarged gall bladder [1. 2. 10].
  • Consider an urgent direct access ultrasound scan (to be done within 2 weeks) for an upper abdominal mass consistent with an enlarged liver [1. 2. 11].
  • Consider an urgent, direct access CT scan (to be done within 2 weeks), or an urgent ultrasound scan if CT is not available, for abdominal pain with weight loss in patients aged 60 and over (suspected pancreatic cancer) [1. 2. 5].
  • Consider a very urgent full blood count (within 48 hours) for hepatosplenomegaly (suspected leukaemia) [1. 10. 1].
• Routine/Non-Urgent Specialist Referral:
  • Arrange a routine referral to gastroenterology or a regional specialist pancreatic centre for all other people with suspected chronic pancreatitis, for confirmation of diagnosis and an ongoing management plan [Lohr, 2017; Conwell, 2014; Kleeff, 2017; Lew, 2017; Gupte, 2018; Singh, 2019; Levy, 2014] ³.
  • Consider non-urgent, direct access upper gastrointestinal endoscopy for upper abdominal pain with low haemoglobin levels or raised platelet count or nausea or vomiting in patients aged 55 and over [1. 2. 3, 1. 2. 9].
  • Consider non-urgent, direct access upper gastrointestinal endoscopy for treatment-resistant dyspepsia in patients aged 55 and over [1. 2. 3, 1. 2. 9].
  • Refer non-urgently to a gastroenterologist if dyspepsia symptoms do not adequately respond to antacids, alginates, or other treatment given in primary care, or if gastro-oesophageal symptoms are non-responsive or unexplained [NICE, 2019] ².
  • Refer if the diagnosis remains uncertain after a primary care assessment for acute diarrhoea, and it is suspected that an episode is due to a chronic cause [Farthing, 1996; BMJ Best Practice, 2023a; NICE, 2023] ⁴.
• Other Urgent Referrals:
  • Consider arranging an urgent referral if a person presents with a suspected serious complication of chronic pancreatitis, depending on clinical judgement ³.