Altered bowel habit

Borders Ref Help Toolkit (in development)
NHS Borders

If you are concerned about Colorectal Cancer in the context of Altered Bowel Habit please see the  page on the pathway to follow.

The most common cause of altered bowel habit in those under 50 years is Irritable Bowel Syndrome (IBS). Coeliac and Inflammatory Bowel Disease should also be considered. Please see separate Diagnostic & Management pathways.

 

Factors more likely to indicate the presence of serious pathology (e.g. colorectal cancer):

  • Age over 40 years (risk rises aged 50 and rises sharply over 60 years)
  • A change in bowel habit to looser or more frequent stools
    • An isolated change to firmer or less frequents stools seldom indicates serious pathology
  • Presence of unexplained weight loss accompanied by any of:
    • Rectal bleeding
    • Abnormal FBC
      • Iron deficiency anaemia
      • Anaemia (in the presence of other symptoms)
      • High platelet count
  • Elevated Faecal calprotectin
    • NB calprotectin is NOT a test for cancer and its use is currently unproven in those over the age of 50 years

 

Who to refer:

If any of the following High-risk features are present, consider an urgent referral to the Borders Colon Service

  • Bleeding
    • Repeated rectal bleeding without an obvious anal cause
    • Any blood mixed with the stool
  • Bowel habit
    • Persistent change in bowel habit especially to looser stools (more than 4 weeks)
  • Mass
    • Right-sided abdominal mass
    • Palpable rectal mass
  • Iron deficiency anaemia
    • Unexplained iron deficiency anaemia (i.e. not menstrual blood loss)
  • Other
    • Past history of lower gastrointestinal cancer with any of the symptoms above

 

How to refer:

Patients should be referred via the separate diagnostic pathways for the possible diagnosis depending on the initial investigations.

These pages would include:

Borders colon service

Irritable bowel syndrome

Coeliac

Inflammatory bowel disease

 

 

Basic investigations in Primary Care

  • FBC, Ferritin (+/- Iron and transferrin)
  • LFTs, TFTs, Ca, Alb
  • Coeliac screen (anti tTG antibody)
  • Faecal calprotectin (those under 50 years old)

 

For patients with chronic diarrhoea please consider offering HIV testing for patients.

Primary care management

A 4-week Watch & Wait Policy is reasonable in those with Low-risk features such as:

  • Transient symptoms (less than 4 weeks)
  • Patients under 40 years in absence of high-risk features

Watch and wait Policy (4 weeks)

  • Assessment and review
  • Consider bowel diary
  • Appropriate information, counselling and agreed plan for review with GP
  • Refer if symptoms persist or recur

Cancer referral Guidelines - lower gastrointestinal cancer

Editorial Information

Author(s): Jonathan Fletcher, Angus Wallace.

Author email(s): bor.gastroenterology@borders.scot.nhs.uk.