Rectal Bleeding pathway Dr Rob Palmer - GPwSI Gastroenterology - C&H Gastro CCG lead Miss Tamzin Cuming - Consultant Colorectal Surgeon, Homerton This is a revision of a pathway written in 2008. As you’ll know we launched DAFS just over a year ago, and in that most of these patients are discharged back to GP, the purpose is to revise how to manage these conditions in primary care, and also update mx particularly of anal fissure, where the . Also, as part of the early detection of cancer, we hope that thr DAFS service will improve access to diagnostic testing

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

Causes Common Rarer Benign anorectal disease: Haemorrhoids Anal fissure Fistula-in-ano Diverticular disease Inflammatory bowel disease: Crohn’s disease Ulcerative colitis Polyps Malignancy 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 Rectal varices GI tract invasion of non-GI tract malignancy Henoch-Schonlein purpura Trauma (possible sexual abuse).

Rectal Bleeding pathway The pathway – I’m afriad this will change again next year when we plan to launch direct access colonoscopy

History & Examination History: important to try to ascertain whether the history is suggestive of anorectal pathology or colonic – is the blood on the tissue on wiping or mixed in with the stool, is there perianal itch or discomfort. Is there altered bowel habit?

Urgent 2ww Referral All ages Definite, palpable, right sided, abdominal mass Definite, palpable, rectal (not pelvic) mass Unexplained iron deficiency anaemia AND: [ ] Male with a Hb of < 110g/l [ ] Non menstruating female with a Hb of < 100g/l Over 40 years Rectal bleeding WITH a change of bowel habit towards looser stools &/or increased frequency  6 wks (soon to change to  3 wks)   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 (both due to change to age >50yrs with duration >3 weeks) ###change to g/l Rectal bleeding with change of bowel habit* of ≥ 3 weeks duration (age 40 and over) Rectal bleeding without change in bowel habit with no obvious cause ≥ 3 weeks duration (age 50 years and over) Change of bowel habit* persisting for 3 weeks or more without bleeding (age 50 years and over) Abdominal mass thought to be large bowel cancer (any age) Palpable rectal mass (any age) Males of any age with Hb ≤ 11g/100ml; Ferritin ≤30 mg/dL; MCV ≤ 79 iron deficiency picture Non menstruating female with Hb ≤ 10g/100ml; Ferritin ≤30 mg/dL; MCV ≤ 79 iron deficiency picture Other high clinical suspicion of colorectal cancer

Routine Referral to Secondary Care No red flag sx, 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 1 First Degree Relative (FDRs) <50 2 FDR of any age Age >55yrs (not meeting 2ww criteria) These patients may need investigation with colonoscopy (rather than flexi sig) to exclude other pathology These patients likely to need a colonoscopy rather than flexi sig, so suggest referral [FH criteria: 1 FDR <50, 2 FDR of any age (HNPCC: 3 or more relatives with CRC, 2 FDR of one another, 1 aged <50 or other related malignancies]

Referral for Direct Access Flexible Sigmoidoscopy (DAFS) If no other GI symptoms and aged <55: Conservative management Refer for direct access flexible sigmoidoscopy if: Symptoms not settling within 4 weeks (or recurring) High level of patient anxiety

Results of DAFS 174 patients attended so far Colonic pathology found in 39/174 22% 16 hyperplastic polyps Significant pathology in 23/174 13% 3 cancers 10 adenomatous polyps 10 new diagnoses of IBD proctitis

DAFS Patient Satisfaction Procedure done quickly enough: 78% yes, 22% no Helpful to have test on one visit to hospital: 87% - yes, prefer one visit 4% - no, prefer to see dr in OPD first (9% don’t mind) Overall satisafaction: Very satisfied 61%, Satisfied 13%, Neutral 9%, Dissatisfied 9%, Very dissatisfied 9% We sent out a satisfaction questionnaire after the first 100 pts – only 23 returned

Referral for DAFS Choose and Book Under Diagnostic Endoscopy – Flexible Sigmoidoscopy – Homerton (only available if <55yrs) Directly bookable appointment Appointments available on Tuesday mornings Complete referral form and send electronically with CAB Give patient information leaflet to patient Referral form and patient info leaflet will be sent to your practices

Information for patients - medications Aspirin & Clopidogrel: Continue No contraindication to diagnostic procedure +/- biopsies on aspirin or clopidogrel Warfarin: GP to check INR 1 week before endoscopy date If INR within therapeutic range, continue usual daily dose If INR above therapeutic range but <5, reduce daily dose until INR returns to therapeutic range Iron tablets: Stop 1 week before procedure ###BSG guidelines – check re INR>5

Information for patients – the procedure Bowel prep Consent Procedure ##Clarify interpreters and transport Risks (perforation or serious bleeding: 1 in 15,000 – can require blood transfusion, surgery, stoma)

Unsuitable Patients Acute anal pain suggestive of anal fissure (procedure unlikely to be tolerated) Recent MI or CVA within 6w Obesity (overall weight >135kg) Dementia Poor mobility (need to be able to transfer from chair to bed)

Follow-up All patients will be discharged back to primary care following this procedure unless diagnosis of serious pathology found: malignancy IBD adenomatous polyps The report will include detailed advice on management ###The rest sent back to primary care – some may need referral back to colorectal cl if problematic piles etc, but may be possible to have one-stop service then###

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 of anal fissure suggested in not in midline, if multiple or irreg outline – causes include cancer, IBD, fistula, abuse

Anal Fissure

Anal Fissure - Management Acute: <6 weeks - conservative management: Increase fluid intake High fibre diet to achieve soft stools ?Bulk forming laxatives (fybogel) Topical creams –1w course of lignocaine gel Sitz baths pain relief Oral Analgesia Conservative mx: treat constipation and pain relief Sitz baths - bathe in hot water for 2-5minutes followed by cold water for 1 minute, after bowel movement

Anal Fissure - Management Chronic: >6 weeks Continue conservative measures Combination of bulk forming laxative (Fybogel BD) and softening laxative (Lactulose BD) for the full 8 weeks Prescribe topical 0.4% Glyceryl Trinitrate (GTN) BD for 8 weeks course N.B. 40% develop headaches as side effect 2 tubes of 30g should be sufficient to cover the 8 week course. 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®) Applied topically BD for 8 weeks. Cost of Anoheal® is approx £45 per tube If not settling – refer to secondary care Secondary care: Botox, anoplasty or sphincterotomy

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

Internal Haemorrhoids

Internal Haemorrhoids 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

Internal Haemorrhoids- Management Increase oral fluid intake Dietary advice Consider laxatives Bulk forming (ispaghula husk) 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: fail to respond to conservative management persistent bleeding, severe prolapse, affecting daily living fourth degree haemorrhoids Urgent referral if: thrombosis with severe pain, incarceration, gangrene or sepsis

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 Nerve fibres start at the dentate line and below, so these tend to be painful

External Haemorrhoids (Perianal haematoma)

Internal piles: Management Analgesia Topical anaesthetics and corticosteroids Cold compresses (If pt not tolerating pain in first 72hrs, consider referral for I&D)

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

Skin tags

Skin tags - Management Anal hygiene Management of constipation Wash after defaecation Thorough attention to anal washing in bath or shower Avoid perfumed soaps, biological washing powders, fabric conditioners Use cotton underwear, avoid tight fitting trousers Management of constipation Refer for removal if large and troublesome

Thank you!