Transcript Dafs Pathway

Mr Sanjay Wijeyekoon
– Consultant Colorectal Surgeon
Dr Rob Palmer
– GPwSI Gastroenterology
Direct Access Flexible
Sigmoidoscopy
 A diagnostic service for GPs to assist them with the
management of patients under the age of 55yrs
presenting to primary care with rectal bleeding.
Patient presents with rectal bleeding
History
- Age of onset
- Nature of rectal bleeding
- Weight loss, altered bowel habit, abdominal pain
- FH of cancer, polyps or IBD
Examination
- Abdominal
- Rectal examination (+/- proctoscopy)
Investigations
- FBC, CRP, ESR
- Stool culture (if increased frequency)
Red flag
symptoms
or signs
Refer under 2
week rule
No red flag sx, but
other GI symptoms
- Abdominal pain
- Weight loss
- Normocytic anaemia
- Previous colonic polyps
- Past history IBD
- Strong FH CRC
Age >55yrs (not meeting
2ww criteria)
Consider routine
referral to secondary
care – to consider
colonoscopy and
other Ix
No other GI sx
Age <55yrs
Treat
pathology
found
If symptoms
settle <4wks
 reassure
If symptoms
persist >4w, if
symptoms recur
or if no perianal
pathology found
Referral for
Direct Access
Flexible
Sigmoidoscopy
History & Examination
2 week wait referral criteria
 All ages
 Definite, palpable, right sided, abdominal mass
 Definite, palpable, rectal (not pelvic) mass
 Unexplained iron deficiency anaemia
 AND:
[ ] Male with a Hb of < 11g/dl
[ ] Non menstruating female with a Hb of < 10g/dl
 Over 40 years
 Rectal bleeding WITH a change of bowel habit towards looser stools
&/or increased frequency  6 wks
 Over 60 years
 Rectal bleeding persisting  6wks WITHOUT a change in bowel
habit or anal symptoms (e.g. soreness, discomfort, itching, prolapse,
pain)
 Change in bowel habit to looser stools &/or more frequent stools
persisting  6 wks WITHOUT rectal bleeding
Routine Referral to Secondary Care
 No red flag sx, but other GI symptoms
- Abdominal pain
- Weight loss
- Normocytic anaemia
- Previous colonic polyps
- Past history IBD
- Strong FH CRC
 Age >55yrs (not meeting 2ww criteria)
Direct Access Flexible Sigmoidoscopy
If age <55 and no colonic sx:
- Treat pathology
- Monitor
Consider referral if:
- Symptoms persist >4w
- Symptoms recur
- ?If no perianal pathology found
- Patient anxious
Referral for DAFS
 Choose and Book
 Under Diagnostic Endoscopy
 Directly bookable appointment
 Appointments available on Monday afternoons
 Complete referral form and send electronically with
CAB
 Give patient information leaflet to patient
Information for patients medications
 Aspirin & Clopidogrel:
 Continue
 No contraindication to diagnostic procedure +/- biopsies on aspirin
or clopidogrel
 Warfarin:
 Continue
 GP to check INR 1 week before endoscopy date
 If INR within therapeutic range, continue usual daily dose
 If INR above therapeutic range but <5, reduce daily dose until INR
returns to therapeutic range
 Iron tablets:
 Stop 1 week before procedure
Information for patients – the
procedure
 Bowel prep
 Consent
 Procedure
 Advocacy / Transport
Unsuitable Patients
 Acute anal pain suggestive of anal fissure (procedure
unlikely to be tolerated)
 Recent MI or CVA within 6w
 Obesity (overall weight >135kg)
 Dementia
 Poor mobility (need to be able to transfer from chair to
bed)
Follow-up
 All patients will be discharged back to primary care
following this procedure unless diagnosis of serious
pathology found:
 malignancy
 IBD
 adenomatous polyps
 The report will include detailed advice on
management