LLR Policy for Rectal Bleeding

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Category

Threshold Criteria

Applicable OPCS Codes

This policy relates to the following indications

  • Changes to bowel habit in the last 6 weeks
  • Internal Haemorrhoids
  • Anal fissure

Eligibility

Presentation in Primary Care

Does the patient have higher risk of pathology?
– Review against the cancer exclusion pathway criteria
– Digital exam should always be included in patient assessment of per rectum bleeding
Changes in bowel habit in last 6 weeks?
– Consider FIT testing in the context of an adult with persistent change in bowel habit with or without rectal bleeding. reference ranges may vary depending on symptoms and blood results.

– Consider stool M+C+S and clostridium difficile toxin testing to exclude infection

– Consider blood tests (as per NICE) and faecal calprotectin in younger adults (under 50) or from whom IBD is likely to be a potential diagnosis
 
– Rectal bleeding with FIT < 10 mcg a proctoscopy or rigid sigi may suffice
 
– Direct access to flexi sigmoidoscopy for patients over 40 with rectal bleeding even if  FIT is < 10 mcg

– Consider onward referral to gastroenterology for patient with suspected IBD based on calprotectin result and associated clinical picture

– If IBD diagnosed follow IBD care plan

– If no IBD diagnose, treat for IBS or refer to cancer pathway if patient fits
Haemorrhoids
 
Patients with haemorrhoids usually present with isolated painless bleeding but also may present with complaints of a dull aching pain, pruritus or other symptoms due to prolapse. Bleeding haemorrhoids can be managed conservatively but prolapsing haemorrhoids that are troublesome should be referred to secondary care.
 
If patients are known to have a history of haemorrhoids and have been investigated in the last 2 years then they do not need to be referred again if there are NO new red flags (see NICE guidelines for red flags).
 
Acute

– Proctoscopy if available
– Reassure, advise
– Topical  treatments (no evidence base )
– Add high fibre diet or  fibre supplements if appropriate
– Add increased fluid intake or a macroglycol if stools are hard
– Follow up after 4 weeks

Chronic
 
A. Haemorrhoids that continue to bleed after 4 weeks of conservative treatment but do not prolapse on straining

Refer to one stop shop/ community services
– Diet
– Flexible sigmoidoscopy
– Banding
– Community refer on to secondary care where pathology indicates

B. Haemorrhoids that continue to bleed after banding or prolapse on straining or remain permanently out with visible mucosa

– GP to refer to secondary care for treatment
Anal Fissure

Acute

– GNT ointment/ Diltiazem ointment if side effects from GTN
– Dietary and lifestyle advice
– Follow up after 8 weeks

Chronic

– Refer to colorectal surgeon
– Anal stretch/ Botox
– Lateral anal sphincterotomy
Other anal pathology

– Refer to 2WW if patient fits the cancer pathway
– For perianal skin tags please comply with LLR policy for Benign Skin Lesions

Guidance

Recommendations organised by symptom and findings of primary care investigations | Suspected cancer: recognition and referral | Guidance | NICE
 
Overview | Crohn’s disease: management | Guidance | NICE
 
Overview | Ulcerative colitis: management | Guidance | NICE
https://leicesterleicestershireandrutland.icb.nhs.uk/llr-policy-for-benign-skin-lesions/
Ballal et al. Colorectal Disease Journal 2010 12(5):407-14

British Society of Gastroenterology. Commissioning report 2012

Hamilton, W (2009). Caper studies
 
Leung et al (2005). Management of rectal bleeding in the community
ARP 80 Review Date: 2027

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