Rectal bleeding

Occurs in 12-15% of middle ages population but only 1/3 seek advice.

Change in bowel habit
- Change in bowel habit implies a structural narrowing and barium enema is a sensitive investigation except for the rectosigmoid and areas of severe diverticular disease
- If age >40 and persisting for >1 month needs investigation
- Refer for surgical opinion.
Rectal bleeding
- All patients with rectal bleeding aged over 40 should be investigated
- Possible investigation strategies
  - Rectal examination - if palpable tumour - urgent surgical clinic referral
  - Open access flexible sigmoidoscopy
- Barium enema is not an adequate investigation of rectal bleeding since it does not reliably identify significant polyps

See colorectal problems for urgency classification

Type of Blood	Associated Features	Possible Causes	Suggest Referral to
Bright red	on toilet paper painful throbs for hours	fissure in ano	surgical OPD
	before motion or with motion	polyp or cancer	Open Access Flexible Sigmoidoscopy
	after motion drips into toilet	haemorrhoids	Open Access Flexible Sigmoidoscopy
Dark red		cancer or polyp	Open Access Flexible Sigmoidoscopy
Any colour	passed alone	cancer or polyp	Open Access Flexible Sigmoidoscopy

Anaemia
- If hypochromic microcytic, gastric or colonic malignancy should be excluded
- Faecal Occult Bloods are not useful since they have a 20% false negative for colorectal cancer and a 70% false negative rate for colomc polyps
- Possible investigation strategies are
  - surgical or medical referral
  - open access gastroscopy, if negative surgical/medical referral for colonoscopy
Abdominal pain
- surgical referral if clinically concerned
Family history of colorectal cancer
- If symptomatic, refer
- If asymptomatic screening can be offered on the basis of assessed risk
- High risk groups are 1st degree relatives of patients aged <45 with colorectal cancer and those families with multiple cancers.
Squamous carcinoma of the anus
- A non healing ulcer of the anal verge should be urgently referred