Investigating rectal bleeding

doi:10.1136/bmj.39379.598090.AD

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David Burling, consultant gastrointestinal radiologist 1,
James E East, research fellow in endoscopy 2,
Stuart A Taylor, senior lecturer3

¹Intestinal Imaging Centre, St Mark’s Hospital, Harrow HA1 3UJ
²Wolfson Unit for Endoscopy, St Mark’s Hospital
³Department of Specialist Radiology, University College Hospital, London NW1 2BU

Correspondence to: D Burling burlingdavid{at}yahoo.co.uk

Conventional colonoscopy is considered the optimal investigation for rectal bleeding; however, this article explores the use of virtual colonoscopy as a new investigative technique

Learning points

Conventional colonoscopy is considered the optimal procedure for investigating rectal bleeding and is the only investigation that allows tissue removal, is widely available, and does not involve radiation
For some patients, virtual colonoscopy may be preferable as it is minimally invasive and convenient for patients and may also provide additional extracolonic information
Diagnostic virtual colonoscopy and therapeutic endoscopy can be complementary techniques
Close collaboration between endoscopy and radiology staff enables same day (single visit) virtual colonoscopy and conventional colonoscopy

The patient

An 83 year old man was referred to a surgical outpatient clinic by his general practitioner via the “two week wait” bowel cancer pathway for patients with persistent rectal bleeding (painless dark red blood with clots per rectum for one month with blood mixed in the stool) but no anal symptoms. He had had no weight loss or change in bowel habit, and except for hypertension, he was a fit non-smoker with no family history of colorectal cancer. Abdominal examination showed no masses, and rigid sigmoidoscopy to 15 cm was unremarkable.

What is the next investigation?

The patient’s symptoms suggested a possible underlying colorectal cancer, which was therefore the primary target of investigation. Flexible sigmoidoscopy was deemed inappropriate in this patient as (regardless of whether the sigmoidoscopy result was negative or positive) the proximal colon would have required examination to detect a proximal cancer or to exclude a synchronous cancer (or advanced polyp), which could be included in the subsequent surgical resection.

Currently three options are available for whole colon investigation of rectal bleeding to look for colorectal cancer: conventional colonoscopy, barium enema, and virtual colonoscopy (or computed tomography colonography).