Mr Sanjay Wijeyekoon – Consultant Colorectal Surgeon Dr Rob Palmer – GPwSI Gastroenterology
Jan 27, 2016
Mr Sanjay Wijeyekoon – Consultant Colorectal Surgeon
Dr Rob Palmer – GPwSI Gastroenterology
Direct Access Flexible SigmoidoscopyA diagnostic service for GPs to assist them
with the management of patients under the age of 55yrs presenting to primary care with rectal bleeding.
Patient presents with rectal bleeding
No red flag sx, but other GI symptoms - Abdominal pain - Weight loss - Normocytic anaemia - Previous colonic polyps - Past history IBD - Strong FH CRC Age >55yrs (not meeting 2ww criteria)
Red flag symptoms or signs
No other GI sx Age <55yrs
History - Age of onset - Nature of rectal bleeding - Weight loss, altered bowel habit, abdominal pain - FH of cancer, polyps or IBD Examination - Abdominal - Rectal examination (+/- proctoscopy) Investigations - FBC, CRP, ESR - Stool culture (if increased frequency)
Refer under 2 week rule
Consider routine referral to secondary care – to consider colonoscopy and other Ix
Referral for Direct Access Flexible Sigmoidoscopy
If symptoms settle <4wks reassure
Treat pathology found
If symptoms persist >4w, if symptoms recur or if no perianal pathology found
History & Examination
2 week wait referral criteria All ages
Definite, palpable, right sided, abdominal mass Definite, palpable, rectal (not pelvic) mass Unexplained iron deficiency anaemia
AND: [ ] Male with a Hb of < 11g/dl [ ] Non menstruating female with a Hb of <
10g/dl Over 40 years
Rectal bleeding WITH a change of bowel habit towards looser stools &/or increased frequency 6 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
Routine Referral to Secondary CareNo red flag sx, but other GI
symptoms- Abdominal pain- Weight loss- Normocytic anaemia- Previous colonic polyps- Past history IBD- Strong FH CRC
Age >55yrs (not meeting 2ww criteria)
Direct Access Flexible Sigmoidoscopy
If age <55 and no colonic sx:-Treat pathology-Monitor
Consider referral if:-Symptoms persist >4w-Symptoms recur-?If no perianal pathology found-Patient anxious
Referral for DAFSChoose and Book
Under Diagnostic EndoscopyDirectly bookable appointment
Appointments available on Monday afternoons
Complete referral form and send electronically with CAB
Give patient information leaflet to patient
Information for patients - medicationsAspirin & Clopidogrel:
ContinueNo contraindication to diagnostic procedure +/- biopsies
on aspirin or clopidogrel
Warfarin: ContinueGP 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
Information for patients – the procedureBowel prepConsentProcedure
Advocacy / Transport
Unsuitable PatientsAcute anal pain suggestive of anal fissure
(procedure unlikely to be tolerated)Recent MI or CVA within 6wObesity (overall weight >135kg)DementiaPoor mobility (need to be able to transfer
from chair to bed)
Follow-upAll patients will be discharged back to
primary care following this procedure unless diagnosis of serious pathology found:malignancyIBDadenomatous polyps
The report will include detailed advice on management