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Five weeks have passed and Simon has returned as he is experiencing further discomfort. 

Simon’s symptoms are persistent and worsening which is concerning. Dr Hamley carries out an abdominal examination, however he believes Simon’s symptoms are most likely due to IBS and treats accordingly. 

Discussion

Dr Sarah Taylor, GatewayC GP Lead, discusses the consultation scenario with Mr Malcolm Wilson, Consultant Colorectal and Peritoneal Oncology Surgeon.

Key points:

  • Simon has worsening diarrhoea and should have a FIT test
  • A positive FIT test (≥10µg/g) would necessitate referral
  • Faecal calprotectin tests would also be useful to exclude inflammatory bowel disease
  • Simon now has significant symptoms of abnormal bowel habit which need a suspected cancer referral
  • Bowel cancer is less common in younger patients but there is a significant incidence.

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See the table below for NICE NG12 Guidance on how to investigate persistent bowel changes.

Symptom and specific features Recommendation
Change in bowel habit (unexplained), in adults aged 60 and over Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.1]
Change in bowel habit (unexplained), with rectal bleeding, in adults under 50 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.3]
Change in bowel habit without rectal bleeding, in adults under 60 Offer testing with quantitative faecal immunochemical tests (see the NICE diagnostics guidance on quantitative faecal immunochemical tests to guide referral for colorectal cancer in primary care)
[1.3.4]
Abdominal pain and weight loss

Many, but not all, patients with bowel cancer have symptoms of abdominal pain. They may also complain of bloating which can lead to confusion with IBS symptoms. Worrying symptoms include visceral pain on defecation: patients will report severe pain on defecation, and as things get worse, they will report “dreading” going as it is painful to defecate.

Unexplained weight loss can be a sign of colorectal cancer, but is not always present, especially at early stages.

  • Absence of weight loss or abdominal pain is not uncommon; weight loss is a late stage symptom
  • Significant weight loss with changes in bowel habit is more likely to be explained by acute inflammatory process, Crohn’s disease or coeliac disease.

 

Simon describes his pain as bloating, but it is useful to clarify exactly what he means by this, to check for other red flag symptoms and ask about his family history. Whilst he doesn’t directly fit the referral guidelines, it is important to remember
the incidence of bowel cancer is rising in younger patients and consider a suspected cancer referral.

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See the table below for NICE NG12 Guidance on how to investigate persistent abdominal pain and/or weight loss.

Symptom and specific features Recommendation
Unexplained abdominal pain and weight loss in adults aged 40 and over Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.1]
Unexplained abdominal pain or weight loss with rectal bleeding in adults under 50 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.3]
Unexplained abdominal pain or weight loss without rectal bleeding, in adults aged 50 and over Offer testing with quantitative faecal immunochemical tests (see the NICE diagnostics guidance on quantitative faecal immunochemical tests to guide referral for colorectal cancer in primary care)
[1.3.4]

Additional resources

Link: Symptoms of bowel cancer, Bowel Cancer UK
Link: New research suggests increase in younger people diagnosed with bowel cancer, Bowel Cancer UK
Link: Abdominal pain – Suspected cancer: recognition and referral, NICE (2021)
Link: Weight loss – Suspected cancer: recognition and referral, NICE (2021)

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