Rectal Bleeding
General points
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Patients with persistent low-risk symptoms which do not respond to
treatment, or which recur after stopping treatment, should be referred
Please consider the most likely diagnoses and tailor referral urgency accordingly
i.e. 2 week wait or urgent or routine thus:
2 week wait criteria
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Definite palpable right sided abdominal mass probably involving large bowel
Definite intraluminal (not pelvic) rectal mass
Unexplained iron deficiency anaemia with
o Hb < 11g/dl in men
o Hb < 10g/dl in non-menstruating women
40-60 yrs old with persistent (>6 weeks) rectal bleeding and a change to looser /
more frequent stools
60 yrs or over with persistent (> 6 weeks) rectal bleeding (in absence of anal
symptoms) and / or change to looser / more frequent stools
Urgent referral – any of:
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age > 50 at onset, in the absence of anal symptoms
blood mixed with stool
passage of altered blood or clots
associated change to looser stools
bleeding in the absence of anal symptoms
weight loss
strong family history of colorectal cancer - one first degree relative age < 45 or 2
first degree relatives
abdominal pain suggestive of partial bowel obstruction
iron deficiency anaemia
Routine referral for low risk symptoms
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Persistent symptoms and absence of 2 week wait or urgent criteria above
NB: the risk of having bowel cancer is never zero, even in patients without symptoms.
Some cancers will be found incidentally in patients presenting with symptoms from
benign disease, and symptomatic cancers can develop in patients who already have
symptoms from functional bowel disease or piles. This means that patients with
persistent low-risk symptoms which do not respond to treatment, or which recur after
stopping treatment, should be referred to routine clinics.
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Investigations prior to referral
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FBC
if anaemic ferritin and CRP
Top tips for primary care (once diagnosis confirmed)
Haemarrhoids
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topical treatments with steroid e.g. scheriproct / proctosedyl for a week maximum
- see BNF for details
Anal fissure
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rectogesic ointment
Diverticular disease
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milder disease in the younger patients - treat as IBS
more severe disease in older patients - low fibre diet and avoid NSAIDs
diverticulitis - antibiotics e.g. augmentin and admit if systemically unwell
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