Colorectal Primary Care guidance (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

SCI gateway referral categories

Referrals to Colorectal Surgery should be made in line with the NHS Highland Local Patient Access Policy and should be submitted electronically whenever possible via the SCI-Gateway. Most referrals should be “open” referrals (Dear Dr) unless there is a clear requirement for referral to a named clinician or sub-specialty service e.g. the pelvic floor service. There are currently three referral categories available to primary care:

Category E-vetting frequency Target time
(For outpatient clinic appointment or straight-to-test)
USC Daily 14 days
Urgent  Daily < 8 weeks
Routine Every 3 days < 3 months

National FIT guidance for primary care

In 2022, guidance around the use of faecal immunohistochemical testing (FIT) for faecal haemoglobin (f-Hb) was developed through a collaboration of over 120 primary and secondary care clinicians and service teams from across all Health Boards. This also included representation from patient bodies and Scottish Government.

This guidance was produced so that referral and investigation of patients with colorectal symptoms can be targeted to those with the highest risk of significant colorectal pathology. Individual symptoms are poor predictors of colorectal cancer and the predictive value can be improved using FIT. Referral and management triage applying FIT in symptomatic patients, shortens time to diagnosis, is cost effective and there is emerging data that its application may result in a migration to an earlier cancer stage at diagnosis. FIT will also prevent harm through the avoidance of investigations in patients who are not likely to have significant pathology. For example, the risk of bowel cancer in a patient with a normal Hb level and negative FIT is in the region of 0.3% while up to 95% (84-95%) of patients referred who are then diagnosed with colorectal cancer will have a f-Hb ³ 10ug Hb/g faeces.

As an adjunct to clinical acumen, a numerical FIT result should be available whenever possible before a patient is referred to secondary care for investigation or management of lower GI symptoms. Where a primary care referral does not include a FIT test result, secondary care will triage the referral according to the information available at the time and may downgrade patients to an urgent or routine pathway.

Indications for FIT

Any of the following:

  • A persistent (>4week) change in bowel habit especially to looser stool (not simple constipation)
  • Repeated anorectal bleeding without an obvious anal cause
  • Any blood mixed with the stool
  • Abdominal pain associated with weight loss
  • Iron deficiency anaemia (symptomatic or asymptomatic)
  • Other colorectal symptoms or family history of colorectal cancer when referral to secondary care is being considered
FIT is NOT required when referring patients with
  • A palpable abdominal mass
  • A palpable rectal mass
  • An incapacity that prevents the completion of the qFIT test
  • Patient declined to complete qFIT (this information should be provided in the referral)

 

Summary of Primary Care FIT guidance
  1. Patients with colorectal symptoms and a f-Hb > 10ugHb/g faeces should be referred through the USC pathway. Secondary Care will triage assessment and investigation priority dependent on the f-Hb value (see Secondary Care Guidance).
  2. Where a patient has persistent symptoms and a f-Hb < 10ugHb/g faeces, a second f-Hb within 6 weeks should be considered. There is growing evidence that requesting a second FIT, in patients where the first f-Hb was negative, increases the sensitivity for detecting colorectal pathology. However, this “double FIT” approach is not required for all patients and should be reserved for those with persistent symptoms or ongoing clinical concern. A secondary care referral is recommended if the second f-Hb is > 10ugHb/g faeces.
  3. Patients with a f-Hb < 10ugHb/g faeces should only be referred in certain circumstances (please specify in the referral):
    1. There is ongoing clinical concerns that the patient has significant colorectal pathology, despite 2 x f-Hb < 10ugHb/g faeces e.g. severe persistent diarrhoea.
    2. Symptom management support from secondary care is required eg persistent diarrhoea, faecal incontinence or anorectal bleeding.
    3. There is a significant family history of colorectal cancer requiring screening outwith the bowel screening programme (see Family History guidance).
  4. Colorectal referrals without a FIT or with a f-Hb < 10ugHb/g faeces are likely to be triaged by secondary care to Urgent or Routine pathways. This may delay investigations for some. To minimise the impact of this, primary care are asked to encourage FIT completion by patients and have a result prior to referral. Where a Primary Care clinician has an expectation that a FIT was not or may not be completed due to socioeconomic, ethnic or other reasons, providing this information in the referral is encouraged.

Criteria for referral

Criteria for referral: Urgent suspected cancer

  • All lower GI Urgent Suspected Cancer (USC) referrals should be referred to Colorectal Surgery rather than Gastroenterology.
  • This category of referral should be reserved for patients at high risk of having colorectal cancer. An assessment of symptoms, abdominal and rectal examination, faecal immunohistochemical testing (FIT) and blood tests for Hb (including ferritin level and TTG if anaemic) are all required to ascertain the level of risk.
  • Colorectal symptoms should fit with those described in the Scottish Referral Guidelines for Suspected Lower GI Cancer. In addition, a numerical FIT result should be available whenever possible before the patient is referred. In line with national guidance, patients without a FIT result or a f-Hb <10mgHb/g can still be referred but may be downgraded to Urgent or Routine pathways.
  • To allow secondary care clinicians to triage appropriately, it is strongly encouraged that an assessment of co-morbidity is included for all patients e.g. Clinical Frailty Scale https://www.bgs.org.uk/sites/default/files/content/attachment/2018-07-05/rockwood_cfs.pdf
USC referral criteria Comments
Bleeding
  • Repeated rectal bleeding without an obvious anal cause
  • Any blood mixed with the stool

 
Bowel habit
  • Persistent change in bowel habit towards loose stool for more than 4 weeks
 consider alternative causes e.g. infective diarrhoea, changes of medication or hypothyroidism
Mass
  • Unexplained abdominal mass
  • Palpable anorectal mass
 FIT not required if there is an abdominal or rectal mass
Pain
  • Abdominal pain associated with weight loss
 also consider an UGI cancer
Iron deficiency anaemia
  • Unexplained iron deficiency anaemia
 defined as a low Hb by local lab criteria AND a ferritin <30

PLUS
FIT value
  • >10mgHb/g
 referrals without a FIT are likely to be downgraded to urgent or routine pathways (unless rectal or abdominal mass is present)

Criteria for referral: Urgent

  • This category of referral should be reserved for patients experiencing significant colorectal symptoms who are thought to need urgent assessment but who do not meet the criteria for a USC referral e.g. persistent diarrhoea but FIT negative.
  • Referrals in an Urgent category will be vetted by a secondary care clinician on a daily basis and, based on the information given, triaged to either an outpatient clinic appointment (F2F or virtual) or direct-to-test (e.g. flexible sigmoidoscopy or colon capsule endoscopy). However, the priority of any investigations will be ‘Urgent’ rather than ‘USC’.
  • Again, it is strongly encouraged that an assessment of co-morbidity is included for all patients e.g. Clinical Frailty Scale https://www.bgs.org.uk/sites/default/files/content/attachment/2018-07-05/rockwood_cfs.pdf

Criteria for referral: Routine

  • This category of referral should be reserved for patients with colorectal symptoms where the management is not time-critical. Examples would include low risk anorectal bleeding (FIT negative, no palpable mass), anal fissure, fistula-in-ano or pilonidal disease.
  • Patients with incontinence or bowel dysfunction should also be referred in a Routine category, assuming there is no primary care concern that the symptoms warrant more urgent assessment e.g. change in bowel habit.
  • For most patients in this category, ongoing attempts should be made to manage the pathology in primary care according to the Primary Care Management of Colorectal Conditions

Criteria for referral: Pelvic floor conditions

  • Please see separate Pelvic Floor referral guidelines

Colonic investigations

There are currently three main options available to clinicians in NHS Highland when considering the investigation of patients with lower GI symptoms. All of them have the ability to visualise the entire colon and rectum, exclude bowel cancer and diagnose alternative colorectal pathology but there are advantages and disadvantages to each. The following gives a summary of each test along with an estimate of the current capacity.

Colonoscopy

Logistics:

An optical colonoscopy is seen by many as the gold standard for the diagnosis of lower GI pathology. The test involves the patient physically attending the endoscopy department and having a flexible endoscope passed via the anus to the caecum or terminal ileum. A colonoscopy is termed ‘diagnostic’ if the nature of the pathology is unknown or ‘therapeutic’ if the pathology is known and a particular intervention is planned e.g. polypectomy or endomucosal resection (EMR). The preparation for the test is relatively intense and may involve stopping certain medications e.g. iron tablets or anticoagulants as well as following the specific dietary and bowel preparation advice provided by the endoscopy department. Detailed information on the current oral bowel cleansing protocols is provided via the NHSH endoscopy homepage (link below) but normally involves the patient following strict dietary advice as well as drinking 4 litres of ‘Vistaprep’ solution. The colonoscopy itself usually takes 30-45 minutes to complete and the patient is often asked to roll into different positions during the procedure. The procedure can be uncomfortable and each patient is offered the choice of IV sedation (usually a combination of fentanyl and midazolam) or inhaled nitrous oxide (Entonox). NHS Highland endoscopy intranet site

Advantages and disadvantages:

A colonoscopy (or flexible sigmoidoscopy) is the only colonic investigation that has the ability to provide histological confirmation of a cancer via biopsy and/or the option to remove colorectal polyps. For this reason, it is the preferred investigation for patients deemed at high risk of having colorectal cancer and is therefore the test of choice for most patients referred in a USC category.  The main disadvantage of the test is that it is an invasive procedure that carries a small but real risk of serious or even life-threatening complications such as perforation or bleeding. In addition, the invasive nature of the test, combined with the requirement for bowel preparation and medication alterations means it is not generally a good test for elderly, frail or co-morbid patients The other consideration from a service perspective is that colonoscopy has a limited capacity within NHS Highland and efforts should therefore be directed towards priority access for patients who are likely to benefit most.

Risks:

  • Caution required in elderly or frail patient who may struggle with oral bowel preparation.
  • Caution required in patients with diabetes, renal impairment or significant cardiorespiratory disease
  • Complications associated with IV sedation, opiod use or Entonox inhalation e.g. respiratory depression or hypotension.
  • Inability to complete the test due to pain, acute angulation, looping or other technical difficulty.
  • Bleeding from a biopsy or damage to the bowel from the scope (1 in 1000)
  • Bleeding from a polypectomy (1 in 100). Particular care must be taken if a patient takes blood-thinning medication.
  • Perforation of the bowel (1 in 1000). In some cases this can require emergency surgery.

Capacity

  • Screening colonoscopy: 550 per year
  • New colonoscopy: 1,000 per year
  • Return colonoscopy: 500 per year

CT colonogram (CTC)

Logistics:

A computed tomography pneumocolonogram (CTC) or ‘virtual’ colonoscopy is a specialised type of CT scan designed to detect pathology in the colon. The test involves the patient following specific instructions and can only be carried out in secondary care environments. Preparation involves following a low fibre diet for the 24 hour period before the test. On the day before the scan, patients are asked to drink 50ml of gastrograffin (diluted in 500ml of water) at 6pm. This has a slight laxative effect and the patient should be aware of the need to be near a toilet. On the day of the test, the patient attends the radiology department and has a cannula placed in order to receive Buscopan and x-ray contrast. Once on the scanning table, a small tube is inserted into the rectum and the colon is filled with carbon dioxide. During the scan sequence, the patient is asked to turn into different positions (supine, lateral, prone) to obtain complete views of the colon.

Advantages and disadvantages:

A CTC is less invasive than an optical colonoscopy and is often chosen to exclude significant bowel pathology, including colorectal cancer, in patients who are unable or unwilling to tolerate a colonoscopy. However, it still requires some bowel preparation and involves passing a rectal tube which some patients can find uncomfortable. In general, a CTC is the preferred test for elderly patients although in those who are particularly frail a plain CT or not investigating at all may be more appropriate.

Risks:

  • Involves ionising radiation, especially relevant to females of child bearing age.
  • Involves IV contrast, especially relevant to those with kidney impairment or known allergies.
  • Involves buscopan which can be associated with short-term side effects e.g. dry mouth or blurred vision
  • Caution is required in patients with diabetes
  • The test can miss low rectal pathology and should be supplemented with a careful rectal examination +/- rigid sigmoidoscopy if there is clinical concern.
  • 1 in 3000 risk of perforation

Capacity:

700 per annum

Colon Capsule Endoscopy (CCE)

Logistics:

Colon capsule endoscopy (CCE) is a non-invasive alternative to colonoscopy. It involves the patient swallowing a capsule which captures around 50,000 images of the gastrointestinal (GI) tract as it travels through. Bowel preparation is required (equivalent to colonoscopy) to cleanse the colon before the procedure. “Boosters” (additional laxatives) are consumed after the capsule is swallowed to help propel the capsule through the GI tract and ensure the whole colon and rectum is visualised. Tests are currently carried out by a managed service at 4 sites across NHS Highland – Inverness, Thurso, Skye and Fort William. CCE procedures are interpreted by a consultant gastroenterologist and a report produced which is returned to the referring consultant to decide if further management is required. A link to the electronic version of the NHS Scotland Colon Capsule Endoscopy ‘Playbook’ is provided here https://learn.nes.nhs.scot/61072

Advantages and disadvantages:

CCE is best suited for those patients with new lower GI symptoms with a low risk of harbouring colorectal pathology (based on their FIT result). Some patients who undergo CCE will require a further test such as colonoscopy or flexible sigmoidoscopy. For the majority, a further endoscopic procedure is required to treat or biopsy pathology found by the capsule, although some require a test because the colon and rectum have been inadequately visualised. The published accuracy of CCE for colorectal pathology is high and it can safely exclude colorectal cancer. CCE has been shown to be a safe test with a very low rate of adverse events. Overall, 37% of patients will not need any further investigation while 63% will require an additional or supplementary test (see below).

Risks:

  • Approximate 30% chance of an ‘incomplete’ test.
  • SCOTCAP data suggest 63% of patients will need an additional investigation or procedure, either because the test was incomplete or pathology (e.g. size significant polyps) was found.
  • capsule retention is a rare complication (rate 0.05%) but can cause obstruction requiring emergency management

Capacity:

500 to 600 per annum

Primary care management of colorectal conditions

Further information for Health Care Professionals

Editorial Information

Last reviewed: 01/08/2022

Next review date: 31/08/2025

Author(s): Colorectal department .

Version: 1

Approved By: Awaiting approval of TAM Subgroup of the ADTC

Reviewer name(s): Colin Richards, Kenneth Walker .

Document Id: TAM522