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Rectal Bleeding

General points

  • Patients with persistent low-risk symptoms which do not respond to treatment, or which recur after stopping treatment, should be referred
  • Please consider the most likely diagnoses and tailor referral urgency accordingly i.e. 2 week wait or urgent or routine thus:

2 week wait criteria

 

Urgent referral – any of:

  • age > 50 at onset, in the absence of anal symptoms
  • blood mixed with stool
  • passage of altered blood or clots
  • associated change to looser stools
  • bleeding in the absence of anal symptoms
  • weight loss
  • strong family history of colorectal cancer - one first degree relative age < 45 or 2 first degree relatives
  • abdominal pain suggestive of partial bowel obstruction
  • iron deficiency anaemia

Routine referral for low risk symptoms

  • Persistent symptoms and absence of 2 week wait or urgent criteria above

NB: the risk of having bowel cancer is never zero, even in patients without symptoms. Some cancers will be found incidentally in patients presenting with symptoms from benign disease, and symptomatic cancers can develop in patients who already have symptoms from functional bowel disease or piles. This means that patients with persistent low-risk symptoms which do not respond to treatment, or which recur after stopping treatment, should be referred to routine clinics.

 

Investigations prior to referral

  • FBC
  • if anaemic ferritin and CRP

Top tips for primary care (once diagnosis confirmed)

Haemarrhoids

  • topical treatments with steroid e.g. scheriproct / proctosedyl for a week maximum - see BNF for details

Anal fissure

  • rectogesic ointment

Diverticular disease

  • milder disease in the younger patients - treat as IBS
  • more severe disease in older patients - low fibre diet and avoid NSAIDs
  • diverticulitis - antibiotics e.g. augmentin and admit if systemically unwell

Last updated 24th Nov 2011

References

[1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007

[2] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer - A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003. 

Personal communication Mr Widdison, Mr Arumugam RCHT 2011