Rectal bleeding in general practice: new guidance on commissioning

Rectal bleeding is a common symptom in adults of all ages. The 1-year prevalence in adults is about 10% in the UK. As many as one in five primary care patients will report rectal bleeding in the previous year. In most people it is intermittent and self-limiting. Only a minority will seek medical attention. The majority of those who seek advice do so either because the symptoms are truly troublesome or they are concerned about an underlying sinister cause. In the vast majority of patients in primary care the cause will be benign and most often a benign anorectal condition such as haemorrhoids and/or an anal fissure. However, rectal bleeding may be a symptom of colorectal cancer or ulcerative colitis. Therein lies the dilemma for primary and secondary care doctors alike.

The Association of Coloproctology of Great Britain and Ireland, along with the Royal College of Surgeons, have recently updated their guidance on commissioning for the elective management and onward referral for diagnosis, investigation, and management of patients who experience rectal bleeding.¹ It is not intended to guide commissioning relating to suspected cancer, and pathways already exist for: patients >50 years with unexplained rectal bleeding, who qualify for 2-week referral as per National Institute for Health and Care Excellence guidance;² asymptomatic patients in the NHS Bowel Cancer Screening Programme; investigation of occult gastrointestinal bleeding; or emergency management of major lower gastrointestinal haemorrhage. However, the issue for a GP is not only who to treat in general practice but also who to refer and which referral pathways to choose.

The 2-week referral pathway tends to be a colorectal cancer exclusion service, so does not always benefit the symptomatic patient with rectal bleeding. There may be little attention paid to …