Simon has returned to his GP four weeks later as he is experiencing progressive symptoms.

Simon’s symptoms are worsening as the rectal bleeding has returned and he is now experiencing pain when opening his bowels. Dr Hamley performed a rectal examination and did not find anything concerning. He also sent Simon for some blood tests to exclude
other conditions.

Discussion

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

Key points:

• Simon’s description of dreading going to the toilet due to pain is concerning
• Iron deficiency anaemia and/or raised platelets would increase index of concern, but normal blood tests do not exclude bowel cancer
• It is important to remember that patients may have visited other healthcare settings and you may not have full information
• Simon returned to the GP, but that may not be the case for all patients. Patients should be provided with safety-netting advice explaining when to return if symptoms persist, change or worsen.

Lethargy

Lethargy can also be a sign of colorectal cancer, but is not always present, especially in the early stages. Anaemia, particularly in men, is a concerning finding, but a normal full blood count does not exclude colorectal cancer. ​FIT is not indicated
as Simon has rectal bleeding.

Simon now has altered bowel habits, rectal bleeding and lethargy and needs a suspected cancer referral. Blood tests may be helpful and iron deficiency anaemia would increase the level of concern.

See the tables below for NICE NG12 Guidance on how to investigate persistent bowel changes and anaemia.

Investigating persistent bowel changes 

Investigating anaemia

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Student Information

Bloods:

• FBC (raised platelets, microcytic anaemia) – Thrombocytosis study reference
• U&E (Urea raised in GI bleed)
• LFT (metastatic spread)
• Calcium (often raised in malignancies)
• TFT (can cause change in bowel habits)
• Clotting, group and save (important when a patient is bleeding)
• Carcinoembryonic antigen (CEA) is used when colorectal cancer is confirmed and monitors progression and response to treatment
• Coeliac serology (TTG and IgA)
• Ferritin

Other tests:

• Stool cultures (rules out infections)
• Faecal calprotectin (used to identify bowel inflammation – IBD)
• Faecal immunochemical test (FIT) – measures micrograms of human haemoglobin per gram of faeces
  • Symptomatic patient – sensitivity threshold is 10 micrograms*

* FIT sensitivity thresholds differ across the UK. These are the ones adopted by NHS England.

Imaging:

• Colonoscopy + biopsy/CT colonography if unable to tolerate
• CT scan if malignancy confirmed for staging
• MRI scan if rectal cancer for staging

Additional resources

Link: Safety netting, Cancer Research UK (2020)
Link: Symptoms of bowel cancer, Bowel Cancer UK
Link: Change in bowel habit – Suspected cancer: recognition and referral, NICE (2021)
Link: Anaemia – Suspected cancer: recognition and referral, NICE (2021)