Buying health services for local people

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Change in Bowel Habit – Information for GPs

Referral Criteria / Commissioning position

2 Week Wait referral for:

  1. definite palpable right-sided abdominal mass (to exclude caecal tumour)
  2. definite rectal mass of PR exam
  3. unexplained iron deficiency anaemia with: Hb<11g/dl in men / Hb<10g/dl in non-menstruating women
  4. 40-60 yrs old with persistent (> 6 weeks) rectal bleeding and a change to looser/more frequent stools
  5. 60 yrs or over with persistent (>6 weeks) rectal bleeding (in the absence of anal symptoms) and/or change to looser/more frequent stools

Urgent referral to secondary care if:

  • rectal bleeding in the absence of anal symptoms/haemorrhoids
  • blood mixed with stool and or clots
  • rectal bleeding and associated change to looser stool
  • unexplained weight loss
  • strong family history of colorectal cancer (1st degree with colorectal cancer <50 yrs or 2 1st degree relatives with colorectal cancer at any age)
  • iron deficiency anemia (see separate guideline)

Routine referral for:

  • patients with persistent low-risk symptoms which do not respond to treatment or which recur after stopping treatment

Red flag symptoms in anyone with a history of ABC

  1. Abdominal pain that is either eased by defecation or associated with altered stool frequency or stool form
  2. And at least 2 out of:
  • Bloating, distension, tension or firm abdomen
  • Change in stool passage- straining, urgency, incomplete evacuation
  • Symptoms worse with eating
  • Passage of mucus
  1. Plus normal FBC, CRP and coeliac screen (NICE soon to recommend a negative faecal calprotectin to differentiate from IBD)
  2. No need for scoping, imaging, breath tests, stool testing or TFTs
  3. IBS rarely presents for the first time in women >50 years of age and NICE suggests considering the possibility of ovarian cancer. Offer appropriate tests e.g. CA125 +/- USS

Investigations prior to referral

Dependent on most likely diagnosis in the differential but will include FBC, U&E, CRP, coeliac screen, CA125, USS

Information to include in referral letter

  • Treatments and interventions tried including the results
  • Relevant past medical/surgical history
  • Drug history (prescribed and non-prescribed)
  • Current regular medication
  • BMI
  • Smoking status
  • Alcohol consumption

Patient information leaflets

To view the diverticula including diverticulosis, diverticular, disease and diverticulitis Patient Information Leaflet, please click here

To view the irritable bowel syndrome Patient Information Leaflet, please click here

To view the anal fissure Patient Information Leaflet, please click here

To view the haemorrhoids Patient Information Leaflet, please click here

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