Colorectal Service

The Colorectal Service (Pathway) is a common referral pathway for assessment of bowel symptoms, and is administered via the Referral Management System. It can be used by all Primary Care Practices across NHS Tayside and ensures equity of access.

• Referrals are vetted by Consultant Gastroenterologists within 4 working days.
• Patients may be triaged direct to test, or may be seen in the out-patient clinic first.
• Occasionally, some advice may be all that is required.
• Once a referral is accepted, the responsibility for the investigation, interpretation of results and management lies with Gastroenterology.
• Patients are usually offered appointments at their nearest hospital (Ninewells / PRI / Stracathro)

Scottish Cancer Referral Guideline - Lower Gastrointestinal Cancer

Before you consider referring a patient for secondary care assessment, please consider the above guidance and further guidance available in the NICE Clinical Knowledge Summaries. From peri-anal problems to IBS, there is helpful information to cover a multitude of scenarios. We are happy to provide ‘advice only’ via SCI Gateway advice template.

• If you think further investigation may be required, please perform the Colorectal Bundle of tests available via ICE.
• An anaemia screen, Creatinine & Electrolytes and Faecal Haemoglobin stool test (FIT) are all recommended.
• Test results will be available on ICE within 2 - 4 working days.
• If the FIT test reveals that faecal haemoglobin is undetectable, then significant underlying bowel disease is extremely rare.
• Please include the results of blood and FIT tests in your referral letter because this will facilitate speedy Consultant triage.

Why are the Colorectal Bundle tests necessary?

• The elements of the Colorectal Bundle are all important as they ensure we adhere to NICE guidance and avoid patient harm.
• Anaemia screen will identify those patients with iron deficient anaemia who require rapid investigation.
• Creatinine & Electrolytes identify those patients with CKD 4 and 5 for whom standard bowel prep may be harmful.
• FIT test for faecal haemoglobin will detect occult blood within the stool, and identify those patients with undetectable faecal haemoglobin who are extremely unlikely to harbour significant bowel pathology.

Faecal haemoglobin (1)
Trying to determine whether a patient's symptoms reflect significant underlying bowel disease (namely cancer, inflammatory bowel disease or adenomatous polyps) is almost impossible in the absence of other clues. Faecal haemoglobin (FHb) concentrations rise in proportion to the size of any underlying neoplastic lesion. Patients with detectable FHb have a 20% chance of underlying significant bowel disease, rising to almost 60% if levels are >400, and in the context of new bowel symptoms should be referred to the Colorectal Service. On the other hand, we have shown that patients with bowel symptoms and undetectable faecal haemoglobin have an extremely low risk of harbouring significant bowel disease.

(1) Faecal haemoglobin and faecal calprotectin as indicators of bowel disease in patients presenting to primary care with bowel symptoms . Mowat C et al. GUT 2015

Managing my patient's symptoms

• Bowel symptoms are often transient; a clear history may identify the trigger.
• Patients with undetectable faecal haemoglobin may not require immediate invasive investigations; however, those with rectal bleeding, iron deficient anaemia or a palpable mass should be referred.
• Helpful information on how to manage symptoms is available on the NICE Clinical Knowledge Summaries pages.

I think my patient should see a Colorectal Surgeon

• The Colorectal Service (Pathway) is managed by the Gastroenterologists.
• When referrals are vetted, we may choose to re-direct to our surgical colleagues.
• We may choose to bring patients with an abdominal mass or rectal mass direct to test before they see a surgeon.

When to refer to Colorectal Surgery

• Cases best seen by surgery include chronic problems such as haemorrhoids, anal fissure, difficulty with defaecation or faecal incontinence

How can the practice order more FIT kits?
Further FIT kits and patient instruction leaflets can be obtained from: Blood Sciences- lynne.taylor4@nhs.net

If you are unsure about referral then we are happy to provide advice through the SCI Gateway advice template.

You can organise initial tests by requesting the 'colorectal bundle' on ICE.
Referral is by SCI Gateway - Tayside Colorectal Service.

Scottish Cancer Referral Guidelines - Lower GI Cancer

How can the practice order more FIT kits?
Further FIT kits and patient instruction leaflets can be obtained from: Blood Sciences- lynne.taylor4@nhs.net