Rectal Bleeding pathway Dr Rob Palmer - PowerPoint Presentation

Slide1

Rectal Bleeding pathway

Dr Rob Palmer

-

GPwSI

Gastroenterology

- C&H Gastro CCG lead

Miss

Tamzin

Cuming

- Consultant Colorectal Surgeon,

HomertonSlide2

Rectal Bleeding

U

p

to 38% of people will experience rectal bleeding at some point in their lives

O

nly

13-40% of these will consult a doctor about it

T

he

majority of cases are benign and caused by minor problems that can be managed in primary

careSlide3

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).Slide4

Rectal

Bleeding

pathwaySlide5

History & ExaminationSlide6

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 yearsRectal 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)Slide7

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

IBDStrong family history colorectal cancer1 First Degree Relative (FDRs) <502 FDR of any ageAge >55yrs (not meeting 2ww criteria) These patients may need investigation with colonoscopy (rather than flexi sig) to exclude other pathologySlide8

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 anxietySlide9

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

proctitisSlide10

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%Slide11

Referral for DAFS

Choose and Book

Under Diagnostic Endoscopy – Flexible

Sigmoidoscopy

–

Homerton

(only available if <55yrs)

Directly bookable appointment

Appointments

available on

Tuesday mornings

C

omplete

referral form and send electronically

with CABGive patient information leaflet to patientSlide12
Slide13

Information for patients - medications

Aspirin &

Clopidogrel

:

C

ontinue

No contraindication to diagnostic procedure +/- biopsies on aspirin or

clopidogrel

Warfarin:

Continue

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 procedureSlide14

Information for patients – the procedure

Bowel prep

Consent

ProcedureSlide15

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

)Slide16

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 managementSlide17

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.Slide18

Anal FissureSlide19

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 gelSitz baths pain reliefOral Analgesia Slide20

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 effect2 tubes of 30g should be sufficient to cover the 8 week course. Cost £34.80 for 30g tubeIf 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 Slide21

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 reducedSlide22

Internal HaemorrhoidsSlide23

Internal Haemorrhoids

Clinical Features:

rectal

bleeding

mucus

discharge

itching

and irritation

often

painless (unless

thrombosed

or strangulated)

Causes

:

StrainingIncreasing ageRaised intra-abdominal pressureHereditary factorsSlide24

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 livingfourth degree haemorrhoids Urgent referral if:thrombosis with severe pain, incarceration, gangrene or sepsisSlide25

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

itchSlide26

External Haemorrhoids (Perianal haematoma

)Slide27

Internal piles: Management

Analgesia

Topical

anaesthetics and corticosteroids

Cold

compresses

(If

pt

not tolerating pain in first 72hrs, consider referral for I&D)Slide28

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

u

sually

skin-coloured lesions arising from the rim of the anal canal, which don’t contain dilated blood vesselsSlide29

Skin tagsSlide30

Skin tags - Management

Anal

hygiene

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 troublesomeSlide31

Thank

you!