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Rectal Bleeding Care Pathway Overview

Loss of blood from the back passage or anus is a very common symptom in adults of all ages and in most people is usually intermittent and often self-limiting.  Most patients present because of anxiety about serious underlying pathology, and following reassurance are content to live with minor symptoms.

This pathway has been published to clarify best practice in primary care for ano-rectal bleeding.

Please click the relevant flowchart box to be taken directly to textual information

Red Flags
  • Associated change in bowel habit, especially diarrhoea or increased frequency
  • Passing of dark red blood / altered blood / clots
  • Weight loss
  • Abdominal or rectal mass
  • Anaemia

Ano-rectal bleeding is the passing of bright red blood from the back passage or anus.  

It is very common and has an annual prevalence of about 10% in the UK.  It has a positive predictive value (PPV) for colorectal malignancy of 8% in patients aged over 50 years presenting to primary care.  Most perianal causes will be improved with application of topical treatment, increased high fibre diet and/or oral fibre supplement with increased oral fluid intake.

Best practice in primary care includes careful attention to the history, including:

  • The presence or absence of perianal symptoms
  • Age - in view of likely differential diagnosis with each age group
  • Family history of colorectal malignancy
Differential Diagnosis
  • Benign anal conditions account for the vast majority of patients with rectal bleeding, including over the age of 50:
    • Haemorrhoids
    • Anal fissure
    • Perianal dermatological disorders
  • Inflammatory bowel disease (IBD)
    • Patients with existing IBD should contact the IBD helpline.
  • Colorectal cancer
  • Other potential causes of rectal bleeding include, but are not limited to:
    • Infectious gastroenteritis
    • Diverticular disease
    • Colonic polyps
    • Radiation proctitis (e.g. post prostatic tumour irradiation)
    • Angiodysplasia
    • Ischaemic colitis
    • Solitary rectal ulcer
    • Anal cancer
    • Sexually transmitted diseases
    • Ano-rectal trauma
Initial Primary Care Assessment

Particular care must be taken in the following situations:

  1. Older patients with new symptoms.
  2. Patients in whom symptoms and/or clinical cause do not follow common patterns suggestive of benign disease.
  3. Persistent or unexplained symptoms.
  4. Intractable pain which prevents proper clinical assessment. 

Abdomen - to exclude abdominal mass

Visualisation and digital rectal examination (DRE) - to examine for fissure and exclude a rectal mass cancer.

Key Points

  1. If the patient is staying in primary care, good practice requires DRE prior to definitively attributing rectal bleeding symptoms to benign causes.  If onward referral is planned then DRE is desirable but may not be necessary.
  2. Anoscopy/proctoscopy may be used by some primary care clinicians as a screening tool in patients with rectal bleeding, but should not be used as a substitute for flexible sigmoidoscopy to rule out serious pathology.

Blood tests - Baseline blood tests may be useful in selected cases, including:

  • Full blood count (FBC).
  • Other blood tests will only be necessary if there are other features in the history, e.g. unexplained weight loss.
  • Inflammatory markers such as plasma viscosity and C-reactive protien test (CRP) in a younger, lower risk patient with suspected inflammatory bowel disease.

Practice Points

  • There is no evidence for tumour markers, e.g. Carcinoembryonic antigen (CEA), as a tool to aid diagnosis in patients with rectal bleeding. Likewise, faecal occult blood testing (as used in the Bowel Cancer Screening Programme (BCSP) to detect asymptomatic disease) has no place in investigating patients with frank bleeding.
  • Faecal calprotectin has a high positive predictive value (PPV) for finding inflammatory bowel disease and can be a useful screening tool but is not currently funded in Gloucestershire for this indication.
Initial Primary Care Management

In low risk patients who are not overly anxious it is 'reasonable to treat for up to 8 weeks conservatively' in the first instance.

Those who are particularly concerned about colorectal malignancy or who have been managed conservatively for 8 weeks without success should be considered for direct access (direct to test) flexible sigmoidoscopy.

Minimally symptomatic haemorrhoids may be safely observed.

Patients with symptomatic haemorrhoids should be given advice about self-management with over the counter remedies including topical treatment, oral fluid intake, high fibre diet and fibre supplementation.

An acute anal fissure is a tear in the skin of the anal canal, and may be treated with:

  • Dietary advice and a faeces bulking agent.
  • 1st Line: For chronic fissures (duration of symptoms more than 6 weeks or clinical appearances of chronicity) consider topical glyceryltrinitrate (GTN) 0.4% ointment twice daily for 2 weeks and review. If successful, continue for 6 weeks and then stop.
  • 2nd Line: Diltiazem 2% ointment twice daily for 2 weeks and review. If successful, continue for 6 weeks and then stop.

Practice Point

  • When advising on topical treatments, advise the patient carefully on application technique and duration, as above. If successful  continue for 4 more weeks and then stop. If not successful progress to next step. 
When to Refer

Two week wait criteria for suspected cancer

Any patient with rectal bleeding who meets the following criteria should be referred urgently under the two week wait guidelines for suspected colorectal cancer as recommended by NICE Referral Guidelines for Suspected Cancer (NICE NG12):

  • Aged  50 years or over with unexplained rectal bleeding or

  • Aged under 50 years with rectal bleeding and any of the following unexplained symptoms or findings:

    • abdominal pain

    • change in bowel habit

    • weight loss

    • iron-deficiency anaemia

Patients referred on the two week wait pathway usually require investigation, including FBC, U&E and LFT.

Other referrals

If symptoms persist/alter or are particularly troublesome such as persistent or highly symptomatic haemorrhoids or fissures despite treatment, direct access flexible sigmoidoscopy is the investigation of choice for patients under the age of 45 and should be offered if at all possible.

Patients over the age of 45 with persistent rectal bleeding should be offered either colonoscopy (this may be the more cost effective investigation) or flexible sigmoidoscopy.

In elderly, frail or unfit patients, CT colonography with flexible sigmoidoscopy may be better tolerated than colonoscopy (Royal College of Radiologists 2012, Colon cancer: diagnosis guideline).

Barium enema has a significant miss rate for colorectal cancer and other pathologies, and does not have a role in investigation of rectal bleeding.

Direct access flexible sigmoidoscopy provides the best reassurance for patients with rectal bleeding who are primarily concerned about malignancy but who do not meet the two week wait criteria.

Referral for screening colonoscopy or genetics assessment may be appropriate when rectal bleeding has triggered access to medical care if the patient does not meet the two week wait criteria and the primary concern is strong family history of colorectal malignancy.

If there is a family history of colorectal malignancy, colonoscopy may be a better investigation for rectal bleeding than flexible sigmoidoscopy as these patients have a higher risk of right colon cancers.

Practice Point

Current British Society of Gastroenterology (BSG) guidelines recommend one-off screening colonoscopy at 55 years or over in asymptomatic individuals with one first-degree relative diagnosed with colorectal cancer under 50 years old, or two (or more) first degree relatives diagnosed at any age.

Radiation proctitis is common. If it is failing to settle it may be best investigated with direct access flexible sigmoidoscopy.

Gastroenterology Advice & Guidance

The above pathway aims to provide the necessary guidance required to support the management of your patient, however if you would like to discuss a specific patient's case further please seek Advice & Guidance, via the NHS e-Referral Service, from GHNHSFT's Consultant Gastroenterologists as an alternative to making a referral. Advice & Guidance can be helpful in the following circumstances:

  • For their advice on a treatment plan and/or the ongoing management of a patient
  • For clarification (or advice) regarding a patient's test results
  • For advice on the appropriateness of a referral for a patient (e.g. whether to refer, or what the most appropriate alternative care pathway might be)
  • To identify the most clinically appropriate service to refer a patient into

Please view the resource for further information on using the Advice & Guidance service.

Secondary Care Management

Referral for secondary care treatment of haemorrhoids is subject to Criteria Based Access.  Please see the relevant Individual Funding Request policy.  If haemorrhoids are found incidentally during direct access endoscopy, banding may be performed as part of the procedure.

Treatment of bleeding haemorrhoids depends on the degree of prolapse and the severity of symptoms.

  • Suction rubber band ligation is currently the best available outpatient treatment for haemorrhoids with up to 80% of patients satisfied with short term outcomes. About 20% of patients require a second banding procedure within six months for symptom control.
  • Injection sclerotherapy with oily phenol, but this is not as effective as suction banding.
  • Surgery is reserved for bleeding or prolapsing haemorrhoids that have not responded to outpatient treatment (see ASCRS Practice Parameters for the Management of Hemorrhoids).
    • Haemarrhoidectomy.
    • Doppler-guided haemorrhoidal artery ligation and stapled haemorrhoidopexy are alternatives to formal haemorrhoidectomy. These are associated with lower pain scores but neither procedure has long term outcomes data available yet.

  • If a patient with a chronic anal fissure has previously used Glyceryl Trinitrate (GTN) ointment, the first line options in secondary care are topical diltiazem 2% (NICE ESUOM3 as currently an unlicensed indication) or injection of botulinum toxin (botox).
  • Surgery
    • Fissurectomy with injection of botulinum toxin (botox)
    • Lateral internal anal sphincterotomy

Decision making is a balance between efficacy for fissure healing and risk of long term faecal incontinence.

Patients with significant inflammatory bowel disease should be referred to specialist gastroenterology services for long term management. Mild proctitis may be safely managed in primary care with topical anti-inflammatory agents, where local guidelines or integrated care exist.

Radiation proctopathy responds poorly to topical treatments although rectal sucralfate enemas 2g in 20ml tap water twice a day may be of some benefit.  Argon plasma coagulation (APC) should be used with considerable caution in this patient group.

As listed in the background section, there are a number of other pathological conditions causing rectal bleeding. Management of these conditions falls outside the remit of this guide, which assumes that they will be treated appropriately.
Ongoing Care

Secondary Care Follow Up

Ongoing care will vary as appropriate according to the cause of the rectal bleeding and the response observed to treatment.

Community Aftercare

After any treatment for haemorrhoids or fissures, patients should be advised to remain on a high fibre diet with good oral fluid intake to prevent recurrence. Patients with new or recurring symptoms should be reassessed. 

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