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

 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

 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)

No other GI sx Red flag No red flag sx, but other symptoms or GI symptoms signs - Abdominal pain - Change in bowel habit - Conservative measures - Weight loss (treat pathology: see below) - Previous colonic polyps Refer under 2 - Past history IBD week rule - Strong FH CRC

Age <55 Age >55 Consider routine referral to secondary care – to consider colonoscopy and other Ix

Symptoms Symptoms settle persist >4w or Refer routinely to recur (or patient colorectal clinic anxiety) (if no red flags)

Reassure Referral for Direct Access Flexible Sigmoidoscopy (DAFS) 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 / / SURNAME Date of Birth / /

NHS number FIRST NAME UBRN - -

Miss Mrs Ms Mr Home Tel. Mobile/Daytime Tel. Other: ______Address Transport 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 Y N Practice Address 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 Over 40 years [ ] Definite, palpable, right sided, abdominal [ ] Rectal bleeding WITH a change of bowel habit towards mass looser stools &/or increased frequency  6 wks [ ] Definite, palpable, rectal (not pelvic) mass [ ] Unexplained iron deficiency anaemia Over 60 years AND: [ ] Rectal bleeding persisting  6wks WITHOUT a change in bowel [ ] Male with a Hb of < 11g/dl habit or anal symptoms (e.g. soreness, discomfort, itching, prolapse, pain) [ ] Non menstruating female with a Hb [ ] Change in bowel habit to looser stools &/or more frequent stools of < 10g/dl persisting  6 wks WITHOUT rectal bleeding

Medical History, Known Allergies All Medication Mandatory Investigations DIABETIC: YES/NO WARFARIN: YES/NO [ ] PR examination CLOPIDROGREL: YES/NO [ ] 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: / / Date of Referral receipt: / / Target Dates 2ww / / Database:  Patient confirmed:  62/7 / / Urgent Referral under 2 week wait

- 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

- 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

- 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 Project into lumen of anal canal but do not prolapse - second degree Prolapse on straining then reduce spontaneously - third degree Prolapse on straining but require manual reduction - fourth degree 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