Undiagnosed Rectal Bleeding

In scope                   

Undiagnosed rectal bleeding not requiring emergency, same or next day treatment.

 

Out of scope            

Undiagnosed rectal bleeding requiring emergency, same day or next day treatment, including rapid transit upper GI bleeding.

 

General points

• Patients with persistent low-risk symptoms which do not respond to treatment, or which recur after stopping treatment, should be referred
   
• Please consider the most likely diagnoses and tailor referral urgency accordingly.

 

See as needed

• Anal fissures guideline
  
  
• Haemorrhoids/piles
  
  
• Iron deficiency anaemia
  
  
• Fast Track Suspected Cancer

 

Prior to referral

• Rectal examination
   
• qFIT – a measure of ‘colonic health’ – it is reassuring if negative in a patient with rectal bleeding, as is a pointer that the bleeding is of anal verge origin.  Sample should be taken from the centre of the stool and not as part of DRE examination.
  See qFIT guideline 

• FBC, eGFR, CRP and ferritin

 

Colorectal Fast Track criteria

qFIT Positive (10 or more) with one or more:

• Unexplained weight loss and abdominal pain
• Change in bowels for more than 3 weeks
• Abdominal pain
• Weight loss
• Unexplained rectal bleeding
• Any anaemia (with or without iron deficiency) with a positive qFIT
• Any other GP concern with a positive qFIT.

 

Concerning clinical finding irrespective of qFIT

• Rectal mass
• Abdominal mass
• Unexplained anal mass or anal ulceration
• Referred following investigation that suggests or confirms colorectal cancer.

Nb. If anal fissure only, follow anal fissure guideline

qFIT Negative (qFIT less than 10) Patients can be referred on Fast Track with the following and will have subsequent tests within 6-8 weeks under the colorectal team.

• Change in bowels for more than 3 weeks
• Unexplained rectal bleeding
• Anaemia (with or without iron deficiency) with a negative qFIT in a patient with bowel symptoms, if bowel is the only concern (otherwise consider alternative causes or non-site-specific pathway)
• Abdominal pain
• Weight loss, if bowel is the only concern (otherwise consider alternative causes or non-site-specific pathway).

 

Nb: the risk of having bowel cancer is never zero, even in patients without symptoms. Some cancers will be found incidentally in patients presenting with symptoms from benign disease, and symptomatic cancers can develop in patients who already have symptoms from functional bowel disease or piles. This means that patients with persistent low-risk symptoms which do not respond to treatment, or which recur after stopping treatment, should be referred to routine clinics.

 

Page Review Information

Review Date            05 September 2025           

Next Review Date    05 September 2027           

Author                     Dr Melanie Schick, RMS, Cornwall and Isles of Scilly ICB