Management Of Rectal Bleeding In The Community: How A Shared Care Approach Can Benefit Dr. Daniel Lee

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Hugo Goodwin
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1 Management Of Rectal Bleeding In The Community: How A Shared Care Approach Can Benefit Dr. Daniel Lee MD, MMed (S'pore), FRCS (Edin) Associate Consultant Department of Surgery 9 January 2016 Incidence Rectal bleeding is a common symptom encountered by primary care physicians Young and old Non specific symptom, transient and trivial Majority due to self-limiting benign anorectal conditions 1

Potential causes Hemorrhoids Anal fissure Colorectal cancer Diverticular disease Colorectal polyps Infectious colitis Ischaemic colitis Radiation proctitis

2 Potential causes Hemorrhoids Anal fissure Colorectal cancer Diverticular disease Colorectal polyps Infectious colitis Ischaemic colitis Radiation proctitis Solitary rectal ulcer Angiodysplasia Problems in primary care Who to investigate/ colorectal referral Missed a cancer Fear of patients being not adequately treated 2

3 Problems in colorectal unit Symptoms subsided upon assessment Lack of important information in referral letters Difficult to triage Long waiting time expectations: Immediate definitive treatment Same day colonoscopy Collaborative effort with primary care Will improve the quality of coloproctology care in the community Will ensure proper specialist referral Will provide better resources to augment workflow 3

4 Primary Care Primary care assessment Identify patients at high risk that require additional investigation History Presence or absence of perianal symptoms Age of patient: <40 or Family history of colorectal malignancy Red flag symptoms Red Flag Symptoms Altered blood mixed with mucous and stool Change in bowel habit ( loose stool) Constitutional symptoms, i.e weight loss, anemia Patients with known history of rectal bleeding, who develop new constitutional symptoms or a change in bowel habit. Significant family history 4

5 Physical Examination DIGITAL RECTAL EXAM Abdomen: palpable abdominal mass DRE: rectal mass Proctoscopy: anal fissure, piles Low rectal tumour 5

6 Hemorrhoids 6

7 Anal Fissure Chronic anal fissure 7

8 Blood Investigation Only for selected patients, e.g anemia, unexplained weight loss FBC, U&Es,Albumin No evidence for tumour markers, e.g CEA to aid diagnosis No role for FOBT in patients with frank rectal bleeding Proposed Management Flow Chart Primary care: Rectal bleeding History & Physical Exam High Risk Features No High Risk features Colorectal Clinic - Within 2 weeks Age <40 Age Further Investigation e.g colonoscopy Surgical treatment Colorectal review 6 weeks Non surg Tx Surgery 8

NICE Referral Guidelines for Suspected Cancer Two week wait criteria for suspected cancer: Age bowel habit towards looser and /or more frequent stools for 6 weeks or more Age weeks or more

9 NICE Referral Guidelines for Suspected Cancer Two week wait criteria for suspected cancer: Age bowel habit towards looser and /or more frequent stools for 6 weeks or more Age weeks or more without change in bowel habit and with anal symptoms Rectal bleeding and a palpable rectal mass Manage expectantly Old, frail, and unfit CT colonography maybe better tolerated than colonoscopy 9

10 Direct access screening colonoscopy service Admiralty Medical Centre One stop clinics by family medicine specialists Evaluation and treatment for patients with hemorrhoids and fissure Office treatment: injection therapy, rubber band ligation Shared care partnership with primary care physicians After colorectal pathology has been excluded, patients will continue to be cared for by the primary care physicians Tertiary care provider (KTPH) will support: Exclusion of colorectal malignancies by endoscopy Training of primary care physicians on non surgical management of benign anorectal conditions Provide surgical treatment for patients failing nonsurgical treatment 10

Rubber band ligation. 80% of patients satisfied with short term outcome.

11 Treatment of Hemorrhoids Treatment depends on degree of prolapse. Medications Stool softerner Daflon Topical agent, Proctosedyl Outpatient treatment Rubber band ligation. 80% of patients satisfied with short term outcome. 20% of patients require second banding procedure withint 6 months. Injection therapy, e.g sclerotheray, but not as effective 11

12 Treatment of Anal Fissure Acute fissure Dietary advice Stool softerner Topical glyceryl trinitrate (GTN) 0.4% ointment Topical analgesia lignocaine gel Chronic fissure Duration of symptoms > 6 weeks or clinical appearnce of chronicity Injection of botulinum toxin Surgical treatment lateral sphincterotomy Other conditions Diverticular bleeding Painless hematochezia Mx: Resuscitation, blood transfusion, colonoscopy, angioembolization. Surgery Solitary rectal ulcers Elderly, associated with obstructed defecation Direct trauma from digitation, seen in chronic constipation Check for presence of rectal prolapse Conservative: stool laxatives Endoscopic evaluation. Surgery: local excision, rectopexy, fecal diversion 12

13 Other conditions Inflammatory bowel disease Follow up with specialist Mild proctitis to be managed in primary care with topical anti-inflammatory Radiation proctitis Topical treatments: rectal sucralfate enemas bd Bleeding control with argon plasma coagulation 13

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Referral Criteria for Direct Access Outpatient Colonoscopy or Computed Tomography Colonography

Referral Criteria for Direct Access Outpatient Colonoscopy or Computed Tomography Colonography 2019 Released 2019 health.govt.nz Citation: Ministry of Health. 2019. Referral Criteria for Direct Access