{"id":627,"date":"2017-08-07T09:54:44","date_gmt":"2017-08-07T09:54:44","guid":{"rendered":"https:\/\/www.nhslref.scot.nhs.uk\/?p=627"},"modified":"2017-08-07T09:54:44","modified_gmt":"2017-08-07T09:54:44","slug":"colorectal-general-referral","status":"publish","type":"post","link":"https:\/\/www.nhslref.scot.nhs.uk\/?p=627","title":{"rendered":"Colorectal General Referral"},"content":{"rendered":"

This protocol should only be used where there is no suspicion of malignancy<\/span><\/p>\n

If there is a degree of suspicion please see the guidelines below and refer through the Lanarkshire Cancer Referral Centre<\/span><\/p>\n

Colorectal Cancer Referral Guideline<\/h2>\n

Risk-Based guidelines for Investigating Patients with Colorectal Symptoms<\/p>\n

Patients with any of the following symptoms and associated symptoms should be referred urgently through the Lanarkshire SCI Gateway Cancer Referral Services. This will ensure that a patient pathway co-ordinator tracks the referral from the day it is sent..<\/p>\n

Patients over 75 will be seen at the clinic first and will not be appointed straight to test.<\/p>\n\n\n\n\n\t\n\n\t\n\t\n\t\n\t
Main Symptom<\/th>Associated Symptom<\/th>Age<\/th>Patient will be booked for<\/th>\n<\/tr>\n<\/thead>\n
Rectal bleeding for > 6 week<\/td>
\nFrequent and\/or loose stools for 6 weeks
\nConstipation
\n
\nConstipation
\n
\nin isolation
\nin isolation<\/td>		>75
\n<75
\n
\n>50-74
\n
\n<50
\n
\n>50-74
\n<50<\/td>		Outpatient clinic
\nColonoscopy
\n
\nFlexible Sigmoidoscopy and Barium Enema
\nPlease refer using Routine Colorectal Guideline (below)
\nFlexible Sigmoidoscopy and Barium Enema
\nPlease refer using Routine Colorectal Guideline (below)<\/td>\n<\/tr>\n
Diarrhoea 3 or more loose or liquid stools\/day for > 4 weeks<\/td><\/td>>75
\n>50-74
\n<50<\/td>		Outpatient clinic
\nColonoscopy
\nPlease refer using Routine Colorectal Guideline (below)<\/td>\n<\/tr>\n
Palpable mass, right sided Abdominal mass or Rectal mass<\/td><\/td>Any<\/td>Outpatient clinic appointment<\/td>\n<\/tr>\n
Iron deficiency Anaemia. Unexplained<\/td>Upper GI symptoms
\n
\nin isolation male or postmenopausal female
\nin isolation male or postmenopausal female
\nPre-menopausal female<\/td>
\n
\n<75
\n
\n>75
\n<\/td>		Please refer using the Upper GI Suspected Cancer Guidelines
\nColonoscopy and gastroscopy
\n
\nOutpatient clinic
\n
\nPlease refer using Routine Colorectal Guideline (below) or to Gastroenterology<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n

Routine Colorectal Referral Guideline<\/h3>\n

Patients with any of the following symptoms and associated symptoms should be referred routinely through the Lanarkshire SCI Gateway to the colorectal specialty in the appropriate hospital.<\/p>\n

Patients over 75 will be seen at the clinic first and will not be appointed straight to test<\/span><\/p>\n\n\n\n\n\t\n\n\t\n\t\n\t\n\t
Main Symptoms<\/th>Associated symptom<\/th>Age<\/th>Patient will be booked for:<\/th>\n<\/tr>\n<\/thead>\n
Rectal bleeding for > 6 weeks<\/td>Constipation
\nin isolation<\/td>		<50
\n<50<\/td>		Flexible Sigmoidoscopy
\nFlexible Sigmoidoscopy<\/td>\n<\/tr>\n
Diarrhoea 3 or more loose or liquid stools\/day for > 4 weeks<\/td><\/td><50<\/td>Outpatient clinic<\/td>\n<\/tr>\n
Constipation recent change of bowel habit<\/td><\/td>>75
\n>50-74
\n
\n<50<\/td>		Outpatient clinic
\nFlexible Sigmoidoscopy and Barium Enema
\nOutpatient clinic<\/td>\n<\/tr>\n
Iron deficiency Anaemia. Unexplained<\/td>In isolation<\/td>Premenopausal female<\/td>Gastroenterology or Colorectal Outpatient Clinic<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n

All patients who require direct referral to test should be:<\/p>\n

    \n
  • Physically fit for bowel preparation<\/li>\n
  • No Anal symptoms (pain, discomfort, itching, lump and prolapse)<\/li>\n
  • No Large bowel investigations carried out in the last 2 years<\/li>\n<\/ul>\n

    Investigations<\/h3>\n

    No examinations or investigations (other than abdominal and rectal examination ,Uamp;E (for patient safety with bowel prep) and FBC are recommended).<\/p>\n

    Chronic diarrhoea – recommended investigations are Uamp;E, FBC, CRP, TFT and faeces culture<\/p>\n

    FOB or CEA is not indicated and should not influence decision making in symptomatic patients.<\/p>\n

    Key Points:<\/h3>\n

    Patients with the following symptoms are at very low risk of cancer and could be managed initially within Primary Care or referred non-urgently for assessment:<\/p>\n

      \n
    • Rectal bleeding with anal symptoms<\/li>\n
    • Change in bowel habit to decreased frequency of defaecation and harder stools.<\/li>\n
    • Abdominal pain without clear evidence of intestinal obstruction.<\/li>\n<\/ul>\n

      Colorectal Cancer and Family History<\/h3>\n

      Individuals who have a family history of colorectal cancer but who are asymptomatic may warrant investigations if their history meets the criteria outlined in the following table. If any of the criteria are fulfilled patients should be referred for risk assessment to:<\/p>\n

      Regional Genetics Service<\/p>\n

      Management of High Risk Groups<\/h3>\n\n\n\n\n\t\n\n\t\n\t\n\t
      Risk<\/th>Criteria for Screening<\/th>Screening<\/th>Age of Screening<\/th>\n<\/tr>\n<\/thead>\n
      High<\/td>At least three family members affected by CRC and one with endometrial cancer in at least two generations; one affected relative must be age ?50 years at diagnosis; one of the relatives must be a first degree relative of the other two
      \n
      \nGene carriers (HNPCC genes)
      \n
      \nUntested primary relatives of gene carriers<\/td>      		Colonoscopy every 2 years
      \n
      \nDiscuss gynaecological screening for endometrial and ovarian cancer
      \n
      \nOffer 2 yearly upper GI endoscopy for gastric cancer
      \n
      \nConsideration needs to be given to other screening for other cancers which may occur in specific families and are part of the HNPCC spectrum<\/td>      		From 30 to 70 years (or 5 years younger than the youngest affected relative)
      \n
      \nFor stomach cancer from 50 to 70 years or 5 years younger than the youngest stomach cancer<\/td>\n<\/tr>\n
      Medium<\/td>One first degree relative affected by colorectal cancer when aged < 45 years;
      \n
      \nor
      \n
      \nTwo affected first degree relatives (one less than 55 years);
      \n
      \nor
      \n
      \nTwo (one CRC less than 55 years) or three affected individuals with colorectal or endometrial cancer who are first degree relatives of each other and one a first degree relative of consultand.<\/td>      		Single colonoscopy if normal findings
      \n
      \nSingle repeat colonoscopy<\/td>      		At 30-35 years and again at 55 years<\/td>\n<\/tr>\n
      Low<\/td>Anyone not fulfilling medium or high risk criteria<\/td>Reassure and encourage healthy lifestyle
      \n
      \nGP to monitor<\/td>      		N\/A<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n

      Hereditary Nonpolyposis Colorectal Cancer (HNPCC)
      \nSign revised edition – in press<\/h4>\n

      HNPCC is an autosomal dominant condition caused by a mismatch repair gene mutation. Individuals carrying a mismatch repair gene mutation or fulfilling high risk criteria for HNPCC should be offered endoscopic screening starting in the twenties if possible and repeated every 2-3 years taking into account the patient’s general condition and uptake. Diagnosis requires:<\/p>\n

      At least three relatives with a HNPCC-associated cancer (colorectal, endometrial, small bowel, ureter or renal pelvis) (one of whom should be a first degree relative of the other two)<\/p>\n

      At least two consecutive generations should be affected<\/p>\n

      At least one should be diagnosed before age fifty years<\/p>\n

      Referral should be made to the Regional Genetics Service for consideration of Mismatch Repair Gene mutation analysis<\/p>\n

      Familial adenomatous polyposis (FAP)
      \nSign Revised edition – in press<\/h4>\n

      FAP is an autosomal dominant condition caused by an APC gene mutation and characterised by the development of multiple adenomatous colorectal polyps and the subsequent development of one or more colorectal cancers. In patients with FAP, referral should be made to the Regional Genetics Service for consideration of APC Gene mutation analysis. For those at risk of FAP, determined either by a positive family history or on the basis of mutation analysis should be offered:<\/p>\n

      At least three relatives with a HNPCC-associated cancer (colorectal, endometrial, small bowel, ureter or renal pelvis) (one of whom should be a first degree relative of the other two)<\/p>\n

      Colonoscopy every 2-3 years and yearly sigmoidoscopy<\/p>\n

      Patients should be offered proctocolectomy with or without ileoanal reconstruction or total colectomy with ileorectal anaastomsis once adenomas have developed. Subsequent management should include lifelong survey<\/p>\n

      Other High Risk Groups<\/h4>\n

      A number of chronic conditions require structured surveillance. These include:<\/p>\n

      Chronic Inflammatory Bowel Disease<\/p>\n

      Acromegaly<\/p>\n

      Peutz-Jeghers Syndromme<\/p>\n

      Juvenile Polyposis Coli<\/p>\n

      \n

      Reference: Scottish Referral Guidelines for Suspected Cancer. Scottish Executive 2007<\/em>
      \nSIGN Guideline 67 -Management of Colorectal Cancer<\/em>
      \nLead Clinician Mr Alistair Brown, NHS Lanarkshire <\/em>
      \nReview Date Dec 2010<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

      This protocol should only be used where there is no suspicion of malignancy If there is a degree of suspicion please see the guidelines below and refer through the Lanarkshire Cancer Referral Centre Colorectal Cancer Referral Guideline Risk-Based guidelines for Investigating Patients with Colorectal Symptoms Patients with any of the following symptoms and associated symptoms […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[12,11],"tags":[38,36],"class_list":["post-627","post","type-post","status-publish","format-standard","hentry","category-all-referrals","category-gp-referrals","tag-bowel","tag-colorectal"],"_links":{"self":[{"href":"https:\/\/www.nhslref.scot.nhs.uk\/index.php?rest_route=\/wp\/v2\/posts\/627","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.nhslref.scot.nhs.uk\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.nhslref.scot.nhs.uk\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.nhslref.scot.nhs.uk\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.nhslref.scot.nhs.uk\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=627"}],"version-history":[{"count":1,"href":"https:\/\/www.nhslref.scot.nhs.uk\/index.php?rest_route=\/wp\/v2\/posts\/627\/revisions"}],"predecessor-version":[{"id":628,"href":"https:\/\/www.nhslref.scot.nhs.uk\/index.php?rest_route=\/wp\/v2\/posts\/627\/revisions\/628"}],"wp:attachment":[{"href":"https:\/\/www.nhslref.scot.nhs.uk\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=627"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.nhslref.scot.nhs.uk\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=627"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.nhslref.scot.nhs.uk\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=627"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}