When to Refer to Gastroenterology
Knowing when to refer to gastro is a key clinical skill.
Over-referring overwhelms the service.
Under-referring delays care and can harm patients.
This guide focuses on safe, practical decision-making for junior doctors working on wards or on-call in the NHS.
✅ First principle
Always ask:
Is this patient unstable, high-risk, or needing a specialist procedure?
If yes → refer early.
If stable and straightforward → manage locally first.
🚨 Immediate / Same-Day Referral (Urgent)
These patients need gastro review NOW or within hours, not tomorrow.
🔴 Upper GI Bleeding
- Haematemesis
- Melaena with instability
- Hb dropping
- Suspected varices
Because:
- May need urgent endoscopy
- May need banding/therapy
👉 Refer immediately
🔴 Suspected Variceal Bleed
- Known cirrhosis + bleed
Because:
- Needs urgent scope
- Terlipressin/antibiotics
- High mortality
👉 Refer immediately
🔴 Cholangitis
- Fever + jaundice ± pain
- Sepsis with biliary obstruction
Because:
- Needs urgent ERCP
👉 Refer immediately
🔴 Acute Severe Colitis (IBD flare)
- ≥6 bloody stools/day
- Tachycardia/fever
- Raised CRP
- Systemically unwell
Because:
- May need IV steroids/biologics/surgery
👉 Same-day referral
🔴 Decompensated Cirrhosis with complications
- Encephalopathy
- SBP
- AKI/HRS
- Severe ascites
- Variceal bleed
Because:
- Complex management
- Rapid deterioration risk
👉 Early senior involvement
🔴 Acute Liver Failure
- Jaundice + INR ≥1.5 + confusion
Because:
- Time-critical
- May need transplant centre
👉 Urgent escalation
🔴 Severe Pancreatitis
- Hypotension
- Organ failure
- Rising lactate
- HDU/ICU level
👉 Early specialist input
⚠️ Early Inpatient Referral (within 24–48h)
These aren’t crashing, but still need specialist input.
🟡 New ascites
- Cause unclear
- First presentation
Needs:
- Workup
- FibroScan/long-term plan
🟡 Persistent abnormal LFTs (unclear cause)
- Negative initial screen
- No obvious alcohol/metabolic cause
Needs:
- Further liver workup
🟡 Suspected IBD (new diagnosis)
- Chronic diarrhoea
- Raised calprotectin
- Weight loss
Needs:
- Endoscopy
🟡 Suspected malignancy
- Weight loss
- Anaemia
- Dysphagia
- Obstructive jaundice
Needs:
- Urgent cancer pathway
🟡 Recurrent pancreatitis
Needs:
- MRCP/EUS
- Cause investigation
🟡 Complex nutrition/malabsorption
- Chronic pancreatitis
- Severe coeliac
- Weight loss
Needs MDT input
✅ Usually manage yourself first (no urgent referral)
These usually don’t need gastro unless persistent or complicated.
🟢 Simple dyspepsia
- No red flags
→ PPI trial first
🟢 Typical IBS
- Normal tests
- No red flags
🟢 Mild abnormal LFTs with clear MASLD
→ Lifestyle advice + primary care follow-up
🟢 Mild constipation
→ Laxatives first
🟢 Mild self-limiting gastroenteritis
Don’t refer everything — manage what is safe.
✅ On-call practical decision rule
Use this simple framework:
Ask:
- Is the patient unstable?
- Do they need urgent endoscopy/ERCP/procedure?
- Is there liver failure or severe complication?
- Am I unsure or out of my depth?
If YES → refer
If NO → manage + discuss later
📞 How to make a good gastro referral (important)
Consultants respond better to structured referrals.
Include:
- Clear reason for referral
- Observations/NEWS
- Blood results
- Imaging
- What you’ve already done
- What you’re worried about
Instead of:
“Can you review?”
Say:
“Known cirrhosis, hypotensive, melaena, Hb dropped 30, needs urgent endoscopy”
Much safer and faster.
❌ Common mistakes juniors make
- Waiting too long in unstable patients
- Referring mild problems without basic workup
- Not escalating variceal bleed early
- Not treating sepsis before referral
- Calling without key information
Refer early when sick, investigate first when stable.
✅ Take-home concept
Refer early for unstable, bleeding, septic, or decompensated patients.
Manage simple, stable problems yourself.
When in doubt and patient is sick — escalate.