Indications for Symptomatic Patients & Surveillance
of Groups at Increased Risk
Southern District Health Board (District)
Acute
Indications and Priorities for Colonoscopy and CTC
Continuous, > 4U of blood, normal
gastroscopy
Acute lower
GI haemorrhage
Emergency
(If unstable consider CTA)
Stable, requiring blood transfusion
Next available list
2 week
category
A
Suspected and severe IBD to establish diagnosis
Known or suspected CRC
(on imaging, or palpable, or visible on rectal examination for preoperative procedure to rule out
synchronous pathology)
Unexplained rectal bleeding with iron deficiency anaemia
(benign anal causes treated – haemoglobin below local reference range)
Altered bowel habit AND rectal bleeding
(more frequent and/or looser stools; benign anal causes treated
If > age 50 & > 6weeks duration
or excluded)
Altered bowel habit
(more frequent and/or looser stools)
Altered bowel habit AND rectal bleeding
(more frequent and/or looser stools; benign anal causes treated
If > age 50 & > 6weeks duration
If age 40 - 50 &
> 6weeks duration
or excluded)
Six week category
B
Unexplained rectal bleeding
(benign anal causes treated)
Iron deficient anaemia
(haemoglobin below local reference range with low ferritin level)
NZGG Cat. 2 plus one or more of altered bowel habit AND
rectal bleeding
looser
stools; benign
analhabit
causesAND
treated
NZGG Cat. 3(more
plusfrequent
one orand/or
more
of altered
bowel
or
excluded)
rectal
bleeding
If > age 50
For woman < 55 menstruation
history should be obtained
coeliac disease and urinary loss to
be excluded
If age > 40
If age > 25
(more frequent and/or looser stools; benign anal causes treated
Imaging
or excluded)reveals polyp > 5mm
Suspected and moderately severe IBD for diagnosis / mapping
Acute diarrhoea (likely infectious aetiology and self limited)
Rectal bleeding
(normal Hb – consider FSA or flexible sigmoidoscopy if
no anal cause)
Not accepted
Irritable bowel syndrome
Constipation
< 6 weeks duration
< age 50
May require FSA
(as a single symptom)
Uncomplicated CT proven diverticulitis without suspicious radiological features
Abdominal pain
(without any “six week category” features)
Decreased ferritin (normal Hb)
< age 50
Abdominal mass
Refer for appropriate imaging
Comments
Metastatic adenocarcinoma of unknown primary
(6% due to CRC – in absence of radiological or tumour marker evidence colonoscopy is not indicated)
The indication of iron deficiency anaemia requires a haemoglobin level below the local reference range in association with
a low ferritin level.
Menstruation is the commonest cause of iron deficiency anaemia in women. Coeliac disease and urinary loss should be
excluded.
Use of faecal occult blood tests collected in asymptomatic individuals is not currently recommended in New Zealand and
should not be encouraged.
CT colonography is an acceptable alternative investigation to colonoscopy for many indications in the ‘six week category’
where direct mucosal visualisation is not required.
CT colonography may also be the most appropriate investigation for patients with significant co-morbidities but who meet
the criteria for investigation.
Southern DHB 71404 V1 Issued 21/01/2013
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Surveillance
CRC
Pre- or within 12 months post- operation
1st
rescope
Subsequent
rescope
3 years
5 years
Surveillance intervals apply after complete removal and polyp clearance
Serrated adenomas should be treated as adenomatous polyps
Polyps
Low risk
1 or 2 adenomas <10mm
5 years
Intermediate
risk
3-4 adenomas <10mm
1 or 2 adenomas if one is ≥10mm
Histological polyps with villous features
Polyps with high grade dysplasia
3 years
High risk
≥5 adenomas <10mm
≥3adenomas if one is ≥10mm
Consider to stop
3 years
then stop
3 years
1 year
if low or intermediate
risk
1 year
If high risk
Piecemal polypectomy
Not part of NZGG recommendations
3 months*
According to risk
level
* check of polypectomy site,
only
Offer baseline colonoscopy 8-10 years after diagnosis for UC and colonic Crohn’s colitis (CC)
Risk similar for UC and Crohn’s colitis with same extent
Low risk
Extensive but quiescent UC / CC; or
Left sided UC/ CC (but not proctitis)
Extensive UC or CC
with mild active inflammation confirmed histologically;
or
Post-inflammatory polyps; or
FH CRC in 1st degree relative≥50
Intermediate
risk
IBD
High risk
Extensive UC or CC with moderate or severe active
inflammation confirmed histologically; or
PSC (including after LT); or
Colonic stricture in the past 5 years; or
Any degree of dysplasia* within last 5 years; or
FH of CRC in 1st degree relative <50
5 years
5 years
3 years
3 years^
1 year
1 year^
^ High or intermediate risk patients: consider extending the interval to 5 years after two consecutive colonoscopies with low
risk findings
* Interpreting dysplasia and visualising DALMs/adenomas is more difficult when there is active inflammation
Dysplasia should be confirmed by a second pathologist before commencing treatment
1st colo
Family History
Cat 1
Cat 2
One FDR > age 55
No recommendation made
One FDR < age 55
Starting at age 50 or at an age 10 years
younger than earliest cancer in the family
Two FDR of any
ageA family history of FAP, HNPCC or other familial cancer
syndromes
 One FDR plus ≥ 2 FDR or SDR
C
same side of the family,
Cat 3
Two FDR
Or One FDR plus ≥ 1SDR
same side of the
family
o
o
o
C
And one such relative had CRC < 55
Or developed multiple CRC’s
Or developed extra colonic tumour - ?HNPCC
(endometrial, ovarian, stomach, small bowel,
upper renal tract, pancreas, brain)
polyps
Index
A personal
history
CRC age
Or40One
FDR with
< age
colonoscopy
around
– if normal
noCRC
further
o
- a genetic
specialist /
family cancer
clinic or registry
for further
assessment and
possible genetic
testing
- to a bowel
cancer specialist
to plan
appropriate
surveillance
 ≥ one FDR or SDR CRC in association with multiple
Acromegaly 50
surveillance
5 years
Refer to:
at any age

Subsequent
rescope
C
where tumour has shown loss of mismatch repair
gene
Southern DHB 71404 V1 Issued 21/01/2013
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Indications for CTC
High risk patients
AND
High risk for
colonoscopy
On warfarin – high risk to
stop
Frail /old
Change in bowel habit (more frequent/looser stools)
Appropriate
Moderate risk patients
Iron deficiency non responsive / relapsing to
treatment
High risk symptoms of long-term duration
Indications
Diverticulitis with thickened bowel on CT scan
Moderate risk symptoms but <age 60 / long-term
Low risk patients
Inappropriate
Indications
Abnormal appendicitis
presentation
> age 60 and unusual
High risk patients
Unless colonoscopy carries high risks
Known / strongly suspected polyp /
tumour
Where polypectomy and / or biopsy may be
required
Inflammatory bowel disease
Initial diagnosis / mapping OR surveillance
Polyp surveillance
First surveillance examination
Southern DHB 71404 V1 Issued 21/01/2013
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