1. 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 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

2. 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

3. 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).

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

5. 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?

6. 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

7. 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]

8. 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

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

10. 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

11. 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

13. 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

14. 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)

15. 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)

16. 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###

17. 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

18. Anal Fissure

19. 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

20. 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

21. 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

22. Internal Haemorrhoids

23. 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

24. 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

25. 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

26. External Haemorrhoids (Perianal haematoma)

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

28. 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

29. Skin tags

30. 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

31. Thank you!