Referral

Key points

It is important that patients are aware of the reasons for referral
It may be useful to direct patients to reliable sources of information such as Macmillan, Cancer Research UK or Bowel Cancer UK

Student Information

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Key points when explaining a colonoscopy

Before:

Gain consent
Laxatives to be taken beforehand to improve view of bowel

During:

Patients will be awake during the procedure, and are offered sedatives and pain relief
Long, thin tube with a small camera is inserted up the back side to visualise bowel.
Air is pumped into bowel to help see. This may make patient feel bloated o Biopsies or polyps can be removed and further investigated

After:

Bloated and cramping sensation is common for a few hours post procedure
Bleeding from bottom in small amounts is also common
Unable to drive home if intravenous sedative given

Risks:

Bleeding
Perforation
Infection – although this is uncommon

Red flags:

If severe pain, fever, heavy bleeding following colonoscopy seek urgent medical attention

Results:

Initial results are explained to patients following the procedure
If biopsied, results may take 2-3 weeks and depending on findings will be followed up with specialists

Reference:
What is a colonoscopy?, NHS (2019)

Management

Multidisciplinary team approach

Resection of the area of malignancy is the only curative option. The procedures include:

Site of cancer	Type of resection
Caecum, ascending and proximal transverse colon	Right hemicolectomy
Distal transverse and descending colon	Left hemicolectomy
Sigmoid colon	High anterior resection
Rectum	Anterior resection
Anal verge	Abdomino-perineal excision of rectum

In some cases, treatment may be endoscopic (for example, some sigmoid colectomies can be performed laparoscopically).

Chemotherapy, radiotherapy and palliative care are also options for treatment.

Patients are regularly followed up for CEA blood tests and CT scans.

Stomas

An abdominal stoma is an opening between the skin and bowel, this provides a diversion of faeces into a stoma bag to be removed. These are the following types:

	Colostomy	Ileostomy
Origin	Made from large intestine – colon	Made from the small intestine – ileum
Location	Left iliac fossa (most commonly)	Right iliac fossa
Contents	Formed stools as water Absorption has occurred	Faecal matter in a liquid consistency
Association to skin	Flushed to the skin	Sprouted – as enzymes and faecal contents are irritative to skin
Types	Permanent end – Post abdomino-perineal excision of rectum Temporary end – Post emergency surgery to provide bowel with rest (e.g. due to bowel obstruction) Loop – Has 2 openings, protects distal anastomosis following removal surgery	Permanent – Post removal of entire colon, rectum, and anal canal (panproctocolectomy). This can be done in Familial adenomatous polyposis patients Temporary end – e.g. post emergency surgery to provide bowel with rest (e.g. due to a bleed) Loop – Has 2 openings , protects distal anastomosis following removal surgery

Reference:
What is a stoma?, Bladder & Bowel Community [online]

Communication
SPIKES model used in breaking bad news

S – setting (location, time, place, rapport building)
P – perception (gain understanding of patients current knowledge)
I – invitation (confirm patient is ready to receive news)
K – knowledge (provide information in steps with pauses)
E – empathy (validate patients thoughts and feelings and provide support)
S – summary (ensure full understanding)

Reference:
Breaking bad news, Medical Defence Union (2019)
Dealing with angry patients – Tips

Listen to the patient and validate their feelings
Highlight to them what your role is and what your are able and not able to do
If you are unable to help, refer them to the correct person or pathway
Do not take the anger personally or reply in a similar manner
Discuss and reflect on the encounter with your supervisor/member of team/portfolio

Reference:
Managing angry patients, British Medical Association (2022)

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