RLUH Lower GI Investigation pathways in clinical practice
This guidance proposes to clarify the investigation algorithm for patients presenting with Lower GI symptoms. It essentially prescribes the demise
of the Barium Enema and devises a rational plan for the employment of CT-Colonography, Flexible Sigmoidoscopy and Colonoscopy.
Aims
Improve quality of care for patients with lower GI symptoms and provide an evidence-based and high quality service
Reduce the rate of missed colorectal cancers/advanced colorectal polyps by replacing double contrast barium enema with a more accurate
investigation (CT colonography).
Reorganise colonoscopy service to provide the best evidence-based service and improve the appropriateness of referral for colonoscopy
NOTES applying to ALL tests!

ALL patients referred for these investigations MUST be able to tolerate bowel prep and MUST be agile enough to climb on and
move on an examination couch – if in doubt please discuss with Endoscopist or Radiologist!. Special considerations for bowel
prep apply for patients with diabetes or renal failure.

Abdominal pain on its own is NOT an indication for any of these investigations

Irritible Bowel Syndrome does not require investigation except as new onset sypmptom >45 years (see NICE
http://guidance.nice.org.uk/CG61)

Please use other referral form to ensure patient gets onto database!

Please see NICE guidance

Patients who have had an MI should NOT have endoscopy for 3 months or CT-Colonography for 6 weeks. Exceptional
circumstances should be discussed with a Radiologist or Endoscopist whom you should name in your referral.
This document has been agreed October 2009 by:
Dr. Martin Lombard, Clinical Director Gastroenterology
Dr. Mark Hughes, Clinical Director Radiology
Mr. Paul Rooney, Lead Clinician Colorectal Cancer
In consultation with Drs. Keith Leiper, Sanchoy Sarkar & Paul O’Toole .
Indications for CT Colonography:
Group 1: Investigation of weight loss or any palpable mass thought to be related to colon – CT colonography may give additional information in
this group.
Group 2: Patients with a distal cancer identified on Flexible Sigmoidoscopy or Limited colonoscopy to exclude metachronous tumours
Group 3: Patients with incomplete colonosocopy for any reason (anticipate <10%, includes where indication for colonoscopy is diagnostic or
surveillance except in IBD) could have same day colonography without the need to re-prep and return – not always possible but worth discussing
with CT on the day!.
Group 4: Age >45, change in bowel habit and abdominal pain (IBS type symptoms). Please see NICE guidance on this issue at:
http://guidance.nice.org.uk/CG61
Group 5: Patients with a major aversion to endoscopy where serious colonic disease needs exclusion or some patients who are have multiple comorbidities or are anticoagulated but consider first whether they would be fit for any further intervention. Note patients in this category with iron
deficiency or a history of bleeding should be considered for colonoscopy rather than colonography.
Indications for CT Colonography:
A patient in whom a colonic tumour is suspected but they are not capable or agile enough for bowel prep. PLEASE consider first whether
investigation will add anything and what outcomes are possible if a positive diagnosis is made
If in doubt please discuss with a Radiologist!.
Indications for Colonoscopy:
Group 6: Diarrhoea which is persistent >6 weeks as predominant symptom (regardless of age) except if patients have elevated endoscopic risk or
aversion (see Group 5 above)
Group 7: Patients with confirmed iron deficiency anaemia (low HB and Low ferritin, except if patients have elevated endoscopic risk or aversion
(see Group 5 above)
Group 8: Polyps/other abnormality detected by CTC or flexible sigmoidoscopy
Group 9: patients who have had previous polyps or cancer who may be on the surveillance system but who present with interval symptoms
Group 9: Screening and surveillance as per BSG and local guidelines for colonoscopic surveillance should be registered on the databse
Note: Young patients (guide age <45yrs) who warrant lower bowel investigation for any reason should have colonoscopy in preference to
colonography because of the longer terms risks of radiation exposure
Indications for Flexible sigmoidoscopy:
All bright red rectal bleeding, in the absence of diarrhoea, change of bowel habit, weight loss or pain, or significant family history should go to
OAFs.
Patients presenting with symptoms who require exclusion or assessment of inflammatory bowel disease should have flexible sigmoidoscopy
unless a full bowel assessment is required
Patients with localised rectal symptoms (Proctalgia, tenesmus etc) should only require flexible sigmoidoscopy
Note that abdominal pain on its own is not an indication for endoscopic tests
References
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