Transcript Direct Access Flexible Signmoidoscopy

Dr Rob Palmer
- GPwSI Gastroenterology
- C&H Gastro CCG lead
Miss Tamzin Cuming
- Consultant Colorectal Surgeon, Homerton
Rectal Bleeding
 Up to 38% of people will experience rectal bleeding at
some point in their lives
 Only 13-40% of these will consult a doctor about it
 The majority of cases are benign and caused by minor
problems that can be managed in primary care
Causes
Common
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Benign anorectal disease:
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Haemorrhoids
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Anal fissure
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Fistula-in-ano
Diverticular disease
Inflammatory bowel disease:
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Crohn’s disease
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Ulcerative colitis
Polyps
Malignancy
Rarer
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Coagulopathies
Arteriovenous malformation
Massive upper GI bleeding
Radiation proctitis
Ischaemic colitis (mesenteric vascular
insufficiency)
Solitary rectal ulcer syndrome.
Dieulafoy's lesion of small or large
bowel.
Endometriosis
Meckel’s diverticulum
Rectal varices
GI tract invasion of non-GI tract
malignancy
Henoch-Schonlein purpura
Trauma (possible sexual abuse).
Rectal
Bleeding
pathway
History & Examination
Urgent 2ww Referral
 All ages
 Definite, palpable, right sided, abdominal mass
 Definite, palpable, rectal (not pelvic) mass
 Unexplained iron deficiency anaemia
 AND:
[ ] Male with a Hb of < 110g/l
[ ] Non menstruating female with a Hb of < 100g/l
 Over 40 years
 Rectal bleeding WITH a change of bowel habit towards looser stools
&/or increased frequency  6 wks (soon to change to  3 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
(both due to change to age >50yrs with duration >3 weeks)
Routine Referral to Secondary Care
 No red flag sx, but other GI symptoms
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Abdominal pain
Change in bowel habit
Weight loss
Previous colonic adenomatous polyps or
malignancy
Past history IBD
Strong family history colorectal cancer
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1 First Degree Relative (FDRs) <50
2 FDR of any age
 Age >55yrs (not meeting 2ww criteria)
These patients may need investigation with
colonoscopy (rather than flexi sig) to exclude other
pathology
Referral for Direct Access Flexible
Sigmoidoscopy (DAFS)
 If no other GI symptoms and
aged <55:
 Conservative management
 Refer for direct access
flexible sigmoidoscopy if:
 Symptoms not settling within
4 weeks (or recurring)
 High level of patient anxiety
Results of DAFS
 174 patients attended so far
 Colonic pathology found in 39/174
22%
 16 hyperplastic polyps
 Significant pathology in 23/174
 3 cancers
 10 adenomatous polyps
 10 new diagnoses of IBD proctitis
13%
DAFS Patient Satisfaction
 Procedure done quickly enough:
 78% yes, 22% no
 Helpful to have test on one visit to hospital:
 87% - yes, prefer one visit
 4% - no, prefer to see dr in OPD first (9% don’t mind)
 Overall satisafaction:
 Very satisfied 61%, Satisfied 13%, Neutral 9%,
Dissatisfied 9%, Very dissatisfied 9%
Referral for DAFS
 Choose and Book
 Under Diagnostic Endoscopy – Flexible Sigmoidoscopy
– Homerton (only available if <55yrs)
 Directly bookable appointment
 Appointments available on Tuesday mornings
 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
Unsuitable Patients
 Acute anal pain suggestive of anal fissure (procedure
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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
Anal Fissure
 A tear of the squamous lining of the distal anal canal.
Clinical Features:
 Sharp searing perianal pain, worse after defaecation.
 Bleeding is common, usually bright red on tissue paper.
 Pruritus and irritation.
 Examination (gently part buttocks) may reveal linear split,
usually in midline posteriorly (90%), or anterior midline
10%. Fissure may not be seen, but may be palpated or be
tender on palpation of the anal margin.
Anal Fissure
Anal Fissure - Management
Acute: <6 weeks - conservative management:
 Increase fluid intake
 High fibre diet
to achieve soft stools
 ?Bulk forming laxatives (fybogel)
 Topical creams –1w course of lignocaine gel
 Sitz baths
 Oral Analgesia
pain relief
Anal Fissure - Management
Chronic: >6 weeks
 Continue conservative measures
 Combination of bulk forming laxative (Fybogel BD) and softening
laxative (Lactulose BD) for the full 8 weeks
 Prescribe topical 0.4% Glyceryl Trinitrate (GTN) BD for 8 weeks course
 N.B. 40% develop headaches as side effect
 2 tubes of 30g should be sufficient to cover the 8 week course.
 Cost £34.80 for 30g tube
 If fissure fails to heal (after 8 weeks of GTN) or if side-effects on GTN
ointment  switch to diltiazem 2% ointment (Anoheal®)
 Applied topically BD for 8 weeks.
 Cost of Anoheal® is approx £45 per tube
 If not settling – refer to secondary care
Internal Haemorrhoids
 Abnormally swollen vascular mucosal cushions that
are present in the anal canal originating from above
the dentate line.
first degree
Project into lumen of anal canal but do not prolapse
second degree
Prolapse on straining then reduce spontaneously
third degree
Prolapse on straining but require manual reduction
fourth degree
Prolapsed and incarcerated; cannot be reduced
Internal Haemorrhoids
Internal Haemorrhoids
Clinical Features:
 rectal bleeding
 mucus discharge
 itching and irritation
 often painless (unless thrombosed or strangulated)
Causes:
 Straining
 Increasing age
 Raised intra-abdominal pressure
 Hereditary factors
Internal Haemorrhoids- Management
 Increase oral fluid intake
 Dietary advice
 Consider laxatives
 Bulk forming (ispaghula husk)
 Lactulose (osmotic) or docusate (stimulant laxative with stool
softening properties, avoid in pregnancy)
 Topical anaesthetics with corticosteroids - use for up to 7 days
 Oral analgesics
 Referral if:
 fail to respond to conservative management
 persistent bleeding, severe prolapse, affecting daily living
 fourth degree haemorrhoids
 Urgent referral if:
 thrombosis with severe pain, incarceration, gangrene or sepsis
External Haemorrhoids (Perianal haematoma)
 A thrombosis of the external haemorrhoid plexus,
arising from below the dentate line
Clinical Features:
 acute severe pain, peaks 48-72hrs after onset
 usually self-limiting to 7-10 days
 bleeding
 discomfort
 itch
External Haemorrhoids (Perianal haematoma)
Internal piles: Management
 Analgesia
 Topical anaesthetics and corticosteroids
 Cold compresses
 (If pt not tolerating pain in first 72hrs, consider
referral for I&D)
Skin tags
 Growths of excess skin in the anal region, which are
often a remnant following the resolution of a
thrombosed external haemorrhoid or other perianal
trauma or inflammation, though they can be an
isolated finding.
 Clinical features:
 pruritus usually the biggest problem
 usually skin-coloured lesions arising from the rim of the
anal canal, which don’t contain dilated blood vessels
Skin tags
Skin tags - Management
 Anal hygiene
 Wash after defaecation
 Thorough attention to anal washing in bath or shower
 Avoid perfumed soaps, biological washing powders,
fabric conditioners
 Use cotton underwear, avoid tight fitting trousers
 Management of constipation
 Refer for removal if large and troublesome
Thank you!