When should I consider referring a patient with suspected exocrine pancreatic insufficiency to a specialist?

Consider referring a patient with suspected exocrine pancreatic insufficiency (EPI) to a specialist when:

• There is diagnostic uncertainty after initial investigations such as imaging (CT, ultrasound, or endoscopy) have been performed to exclude other causes of symptoms like chronic pancreatitis or cystic fibrosis-related complications.
• The patient has chronic pancreatitis with symptoms of malabsorption, malnutrition, or ongoing pancreatic exocrine insufficiency requiring specialist assessment and management, including pancreatic enzyme replacement therapy (PERT) dose adjustment and nutritional support.
• There is a need for specialist dietitian input to optimise nutrition and enzyme therapy, especially in complex cases or when symptoms persist despite treatment.
• There are complications related to pancreatic disease such as pseudocysts, pancreatic duct obstruction, or suspicion of pancreatic cancer, which require specialist pancreatic centre involvement.
• In cystic fibrosis patients, management of EPI and related complications should be coordinated with specialist cystic fibrosis centres, particularly if symptoms persist despite optimal enzyme replacement therapy.

Referral is also appropriate if there is a need for advanced interventions such as endoscopic or surgical drainage of pseudocysts or management of distal intestinal obstruction syndrome in cystic fibrosis.

Regular monitoring and follow-up for pancreatic exocrine function and nutritional status should be agreed with a specialist centre, especially in chronic pancreatitis, with at least annual clinical and biochemical assessment.

In summary, refer patients with suspected EPI when diagnosis is unclear, symptoms persist despite initial management, or complications arise that require specialist input for optimal treatment and monitoring.

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