Clinical

Diagnosis

Rectal bleeding

Background

  • Loss of blood from the anus is a very common and usually intermittent and self-limiting symptom in people of all ages.
  • Sudden heavy blood loss, requiring emergency hospital admission and intervention, can occur, but is uncommon.
  • Most cases are due to benign anal conditions (eg haemorrhoids or anal fissure).
  • Bleeding is also an important symptom of colorectal cancer, and of other conditions including inflammatory bowel disease.
  • Only a small minority has significant pathology, and the risk of such pathology (particularly cancer) is dependent of the presence of other symptoms and age.

Patient View

  • Most patients present because of anxiety about serious underlying pathology.
  • Many seek reassurance only, are content to live with minor symptoms.
  • In some, bleeding from benign anal pathology has sufficient impact (staining of clothes, causing anaemia) that treatment is required.

Current Best Practice

  • Those with a very low risk of significant pathology (young, no other concerning symptoms, obvious anal cause of bleeding) are usually simply reassured and managed conservatively (dietary advice, topical medication).
  • This group are referred for treatment (eg injection sclerotherapy of haemorrhoids) if the symptoms continue to be troublesome.
  • Where the risk of other pathology (particularly cancer) is higher (eg aged over 50, absence of anal source of bleeding, change in bowel habit) investigation is needed (flexible sigmoidoscopy, colonoscopy or virtual colonoscopy, depending on symptoms).

Recommended Practice and Opportunities for Integrated Working

  • Rapid access to investigation (flexible sigmoidoscopy, colonoscopy or virtual colonoscopy) for high risk groups (over 50 years of age, associated red flag symptoms) via structured pathways.
  • Development of algorithms for conservative management of benign anal conditions, which could be linked to investigation in integrated ‘one stop’ clinic
  • Access to appropriate secondary care for management of benign anal conditions not responsive to conservative management in primary care.

Opportunities for Savings

  • Currently too many patients are referred to secondary care for management of benign anal conditions – many could be successfully treated using primary care based algorithms.
  • Over-investigation of this common and frequently trivial symptom should be avoided in low risk groups.
  • There is currently direct access to investigation in some regions, but not others. Where this exists there are issues regarding inappropriate investigation (eg flexible sigmoidoscopy when symptoms mandate colonoscopy, resulting in repeat investigation; colonoscopy when bowel preparation inappropriate). Where this is not available delay to investigation is longer.
  • Clear and robust diagnostic and referral algorithms are required defining high risk features (age over 50, accompanying persistent change in bowel habit to looseness, anaemia) and appropriate investigations (colonoscopy when diarrhoea or anaemia present, flexible sigmoidoscopy for isolated bleeding)

Quality Indicators (Outcomes)

  • Waiting time for urgent investigation.
  • Rate of cancer diagnosis with previous inappropriately uninvestigated symptoms.
  • Rate of further referral for benign anal conditions (ie not adequately managed initially)

Social Policy and Understanding

  • Public health education by approved sources (government/charities) focusing on:
    • Healthy lifestyle (high fibre diet, exercise)
    • Risk factors for bowel cancer
    • Symptoms look out for – when to see the doctor

References

NB: Quality standards for colorectal cancer

Rectal bleeding is a common presenting feature of colorectal cancer, along with altered bowel habits, the feeling of complete evacuation, weight loss, abdominal mass and ammonia. Unfortunately some of these symptoms are also associated with more trivial conditions (such as piles but also other serious ones such as ulcerative colitis. The UK lags behind other countries in the early diagnosis of Colorectal cancer. As with dyspepsia there is a case for local agreement on pathways and algorithm, and feedback on referral rates and mis-diagnosis. In addition, in keeping with the Department of Health Outcomes Framework, healthcare professionals in primary and secondary care should consider meeting annually to discuss the following measures in relation to their own patients;

  • Proportion of symptomatic cases (bowel cancer screening programmes excluded) presenting at Duke’s stage A or B.
  • Colorectal cancer deaths; number of years lost (75-date of death)
  • Proportion of 2WW referrals that result in a trivial diagnosis (e.g. piles).

These reviews should have an educational impact that improves local practice.