1. Direct Access Flexible Sigmoidoscopy
Mr Sanjay Wijeyekoon
– Consultant Colorectal Surgeon
Dr Rob Palmer
– GPwSI Gastroenterology

2. Direct Access Flexible Sigmoidoscopy
A diagnostic service for GPs to assist them with the management of patients under the age of 55yrs presenting to primary care with rectal bleeding.

3. So this is a protocol for the management of patients with rectal bleeding: 3 main strands – those with alarm sx: referred under 2ww; those of an older age group or those with other abdo sx but not 2ww criteria – routine referral; and younger patients: maybe managed if primary care +/- with a diagnostic flexible sigmoidoscopy
Red flags

4. History & Examination

5. 2 week wait referral criteria
All ages
Definite, palpable, right sided, abdominal mass
Definite, palpable, rectal (not pelvic) mass
Unexplained iron deficiency anaemia
AND: [ ] Male with a Hb of < 11g/dl
[ ] Non menstruating female with a Hb of < 10g/dl
Over 40 years
Rectal bleeding WITH a change of bowel habit towards looser stools &/or increased frequency  6 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
So the patients who should be referred under the 2ww, pts of any age with

6. Routine Referral to Secondary Care
No red flag sx, but other GI symptoms
- Abdominal pain
- Weight loss
- Normocytic anaemia
- Previous colonic polyps
- Past history IBD
- Strong FH CRC
Age >55yrs (not meeting 2ww criteria)
These patients likely to need a colonoscopy rather than flexi sig, so suggest referral
[FH criteria: 1 FDR <50, 2 FDR of any age (HNPCC: 3 or more relatives with CRC, 2 FDR of one another, 1 aged <50 or other related malignancies]

7. Direct Access Flexible Sigmoidoscopy
If age <55 and no colonic sx:
Treat pathology
Monitor
Consider referral if:
Symptoms persist >4w
Symptoms recur
?If no perianal pathology found
Patient anxious

8. Referral for DAFS Choose and Book
Under Diagnostic Endoscopy
Directly bookable appointment
Appointments available on Monday afternoons
Complete referral form and send electronically with CAB
Give patient information leaflet to patient
###Clarify where under CAB
###Send electronically
Referral form and patient info leaflet will be sent to your practices

10. Information for patients - medications
Aspirin & Clopidogrel:
Continue
No contraindication to diagnostic procedure +/- biopsies on aspirin or clopidogrel
Warfarin:
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
###BSG guidelines – check re INR>5

11. Information for patients – the procedure
Bowel prep
Consent
Procedure
Advocacy / Transport
##Clarify interpreters and transport
Risks (perforation: 1 in 10,000; serious bleeding 1 in 1000)

12. Unsuitable Patients
Acute anal pain suggestive of anal fissure (procedure 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)

13. 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
###The rest sent back to primary care – some may need referral back to colorectal cl if problematic piles etc, but may be possible to have one-stop service then###