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