Download LOWER GI Suspected Cancer Referral

City & Hackney CCG: Rectal Bleeding Pathway
Rectal bleeding:
- up to 38% of people will experience rectal bleeding at some point in their
lives
- only 13-40% of these will consult a doctor about it
- the majority of cases are benign and caused by minor problems that can
be managed in primary care
Common causes of rectal bleeding
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Benign anorectal disease:
o Haemorrhoids
o Anal fissure
o Fistula-in-ano
Diverticular disease
Inflammatory bowel disease:
o Crohn's disease
o Ulcerative colitis
Polyps
Malignancy
Less common causes of rectal bleeding
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Coagulopathies
Arteriovenous malformation
Massive upper GI bleeding.
Radiation proctitis.
Ischaemic colitis (mesenteric vascular insufficiency).
Solitary rectal ulcer syndrome.
Dieulafoy's lesion of small or large bowel.
Endometriosis.
Meckel's diverticulum (in adults less often than children).
Rectal varices.
GI tract invasion of non-GI tract malignancy.
Henoch-Schönlein purpura (children).
Trauma (possible sexual abuse).
Rectal Bleeding Pathway
Patient presents with rectal bleeding
History
- Age of onset
- Weight loss, altered bowel habit, abdominal pain
- FH of cancer, polyps or IBD
Examination
- Abdominal
- Rectal examination (+/- proctoscopy)
Investigations (if indicated)
- FBC
- Stool culture (if increased frequency)
Red flag
symptoms or
signs
Refer under 2
week rule
No other GI sx
No red flag sx, but other
GI symptoms
- Abdominal pain
- Change in bowel habit
- Weight loss
- Previous colonic polyps
- Past history IBD
- Strong FH CRC
- Conservative measures
(treat pathology: see below)
Age <55
Age >55
Consider routine referral
to secondary care – to
consider colonoscopy
and other Ix
Symptoms
settle
Symptoms
persist >4w or
recur (or patient
anxiety)
Reassure
Referral for
Direct Access
Flexible
Sigmoidoscopy
(DAFS)
Refer routinely to
colorectal clinic
(if no red flags)
LOWER GI Suspected Cancer Referral
(2 Week Wait Referral)
To support NICE guidance 2005
Section 1 PATIENT INFORMATION (Please complete in BLOCK CAPITALS)
Date of Referral
Date of Birth
NHS number
UBRN
SURNAME
FIRST NAME
Miss Mrs Ms Mr
/
/
/
/
-
-
Mobile/Daytime Tel.
Home Tel.
Other: __________
Transport
Address
Y
N
Interpreter Y
N
Language
Post Code
Has the patient consented to be contacted for
the appointment?
Y N
Section 2 PRACTICE INFORMATION (Please use practice stamp if available)
Referring GP
Locum
Practice Address
Y
N
Telephone
Fax
Post Code
Section 3 CLINICAL INFORMATION (please TICK all applicable entries)
Please enclose print outs of CURRENT medications and PAST MEDICAL HISTORY
All ages
[ ] Definite, palpable, right sided, abdominal
mass
[ ] Definite, palpable, rectal (not pelvic) mass
[ ] Unexplained iron deficiency anaemia
AND:
[ ] Male with a Hb of < 11g/dl
[ ] Non menstruating female with a Hb
of < 10g/dl
Over 40 years
[ ] Rectal bleeding WITH a change of bowel habit towards
looser stools &/or increased frequency  6 wks
Medical History, Known Allergies
All Medication
DIABETIC: YES/NO
WARFARIN:
YES/NO
CLOPIDROGREL: YES/NO
Over 60 years
[ ] Rectal bleeding persisting  6wks WITHOUT a change in bowel
habit or anal symptoms (e.g. soreness, discomfort, itching, prolapse, pain)
[ ] Change in bowel habit to looser stools &/or more frequent stools
persisting  6 wks WITHOUT rectal bleeding
Mandatory Investigations
[ ] PR examination
[ ] Abdo examination
Findings:
[ ] FBC: Hb:____ MCV ___ Date: __ /__/__
Family History incl. relative and age at diagnosis
Fitness Rating (ECOG) Please circle approp. no.:
0 Fully active
3 Able to carry out limited self-care,
1 Unable to do strenuous activities
mainly confined to bed or chair
2 Able to walk and self-care
4 Completely confined to bed or chair
Discussed urgent suspected cancer referral with patient
Y
N
Your patient may go straight to a diagnostic test, for example, Colonscopy, Ba enema, CT abdo pelvis, Flexi sigmoidoscopy.
In your opinion would this patient be suitable to go straight to a diagnostic test? Yes / No
Have you told the patient they may go straight to a diagnostic test?
Yes / No
Comments/other reasons for urgent referral:
Hospital use only: (Tick where appropriate)
Date Appointment Booked:
Target Dates
2ww
62/7
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Date of Referral receipt:
Database:
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Patient confirmed:
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Urgent Referral under 2 week wait
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Abdominal mass (esp R sided)
Rectal mass
Iron deficiency anaemia (<11g/dl in males, <10g/dl in non-menstruating
females)
Rectal bleeding and altered bowel habit for >6w in patients aged >40 yrs
Rectal bleeding for >6w in patients aged >60 yrs with no change in bowel
habit or anal symptoms
Change in bowel habit for >6w in patients aged >60 yrs with no rectal
bleeding
Routine Referral to Secondary care
Don't meet criteria for 2ww referral but other GI symptoms
- Abdominal pain
- Change in bowel habit
- Weight loss
- Previous colonic adenomatous polyps or malignancy
- Past history IBD
- Strong family history colorectal cancer
o 1 First Degree Relative (FDRs) <50
o 2 FDR of any age
- Aged >55
These patients may need investigation with colonoscopy (rather than flexi sig) to
exclude other pathology.
Referral for Direct Access Flexible Sigmoidoscopy
If no other GI symptoms and aged <55:
- Conservative management (see below for treatment of common
conditions)
- Refer for direct access flexible sigmoidoscopy if:
o Symptoms not settling within 4 weeks (or recurring)
o High level of patient anxiety
Arrange Direct Access Flexible Sigmoidoscopy through Choose & Book (under
Diagnostic Endoscopy  Flexible Sigmoidoscopy), complete referral form and
give patients a patient information leaflet (both saved on ELIC or Homerton
websites). On arrival in the department, patients will be administered a
phosphate enema for bowel prep. Following completion of the procedure, one
copy of the report will be stored in the patient's notes, another given to the
patient, and one sent to the GP.
All patients will be discharged back to primary care following this procedure
unless diagnosis of serious pathology is found:
- malignancy
- IBD
- adenomatous polyps
If any of the above are found, appropriate follow-up arrangements will be made
(Lower GI cancer MDM discussion, follow-up in Gastroenterology clinic, or full
colonoscopy and polypectomy).
If Pathology Found:
Anal Fissure
A tear of the squamous lining of the distal anal canal.
Clinical Features:
- Sharp searing perianal pain, worse after defaecation.
- Bleeding is common, usually bright red on tissue paper.
- Pruritus and irritation.
- Examination (gently part buttocks) may reveal linear split, usually in
midline posteriorly (90%), or anterior midline 10%. Fissure may not be
seen, but may be palpated or be tender on palpation of the anal margin.
Secondary causes:
- Should be suspected if:
o Lateral
o Multiple
o Irregular outline
- Causes include malignancy, IBD, fistula, STI, sexual abuse
Management in Primary Care
ACUTE: <6 weeks
Manage conservatively by:
- Increase fluid intake
- Treating or preventing constipation
o Provide dietary advice – high fibre diet
o Consider bulk forming bowel regulator if constipation present.
o Fybogel® will reduce length of symptoms if prescribed BD with
increased water intake.
- Provide pain relief
o Topical creams –consider 1 week course of lignocaine gel
o Sitz baths – hip bath in hot water for 2-5minutes followed by cold
water for 1 minute, after bowel movement
o Offer paracetamol or ibuprofen for people with prolonged burning
pain following defecation.
CHRONIC: >6 weeks
- Increase fluid intake
- Continue conservative measures (as per acute management).
- Combination bulk forming laxative e.g.: Fybogel® BD and softening
laxative e.g. lactulose for the full 8 weeks
- Prescribe topical 0.4% Glyceryl Trinitrate (GTN) BD for 8 weeks course
o N.B. 40% develop headaches as side effect
o 2 tubes of 30g should be sufficient to cover the 8 week course.
o Cost £34.80 for 30g tube
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If fissure fails to heal (after 8 weeks of GTN) or if side-effects on GTN
ointment  switch to diltiazem 2% ointment (Anoheal®)
o Applied topically BD for 8 weeks.
o Cost of Anoheal® is approx £45 per tube
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If not settling – refer to secondary care
o To consider Botox© injection, sphincterotomy (in young males), or
anoplasty (in females)
Internal Haemorrhoids
Abnormally swollen vascular mucosal cushions that are present in the anal canal
originating from above the dentate line.
- first degree
- second degree
- third degree
- fourth degree
Project into lumen of anal canal but do not prolapse
Prolapse on straining then reduce spontaneously
Prolapse on straining but require manual reduction
Prolapsed and incarcerated; cannot be reduced
Clinical Features:
- rectal bleeding
- mucus discharge
- itching and irritation
- often painless (unless thrombosed or strangulated)
Causes:
- Straining
- Increasing age
- Raised intra-abdominal pressure
- Hereditary factors
Management:
- Increase oral fluid intake
- Dietary advice
- Consider laxatives
o Bulk forming (ispaghula husk)
o Lactulose (osmotic) or docusate (stimulant laxative with stool
softening properties, avoid in pregnancy)
- Topical anaesthetics with corticosteroids - use for up to 7 days
- Oral analgesics
- Referral if:
o fail to respond to conservative management
o persistent bleeding, severe prolapse, affecting daily living
o fourth degree haemorrhoids
- Urgent referral if:
o thrombosis with severe pain, incarceration, gangrene or sepsis
o suspected malignancy
External Haemorrhoids (Perianal Haematoma)
A thrombosis of the external haemorrhoid plexus, arising from below the dentate
line
Clinical Features:
- acute severe pain, peaks 48-72hrs after onset
- usually self-limiting to 7-10 days
- bleeding
- discomfort
- itch
Management:
Within first 72hrs:
- Consider referral to on-call surgeons for incision & drainage under local
anaesthetic if pain severe
- Conservative management if patient prefers
After 72hrs:
- Analgesia
- Topical anaesthetics and corticosteroids
- Cold compresses
Skin tags
Growths of excess skin in the anal region, which are often a remnant following
the resolution of a thrombosed external haemorrhoid or other perianal trauma or
inflammation, though they can be an isolated finding.
Clinical features:
- pruritus usually the biggest problem
- Usually skin-coloured lesions arising from the rim of the anal canal, which
don’t contain dilated blood vessels
Management:
- Anal hygiene
o Wash after defaecation
o Thorough attention to anal washing in bath or shower
o Avoid perfumed soaps, biological washing powders, fabric
conditioners
o Use cotton underwear, avoid tight fitting trousers
- Management of constipation
- Refer for removal if large and troublesome