One stop rectal bleeding clinic: The Coventry experience
Department of Colorectal Surgery, Walsgrave Hospital, Coventry, United Kingdom. International surgery
(Impact Factor: 0.47).
Among most patients attending a rectal clinic, rectal bleeding is a common presenting feature. In most patients, the cause is attributed to a benign lesion. In a small percentage, the cause is neoplastic, and for this reason, rectal bleeding merits further study. Left-sided tumors account for the majority of these tumors and are within the reach of a flexible sigmoidoscopy. This study aimed at examining the diagnostic performance of the one stop rectal clinic in Coventry. Between November 2001 and May 2002, 250 consecutive patients were seen in the one stop rectal bleeding clinic of a tertiary referral hospital. Patients were asked of the nature of rectal bleed and altered bowel habits and were examined by digital rectal examination, with a proctoscopy and rigid sigmoidoscopy before either a full colonoscopic examination or flexible sigmoidoscopy with a completion Barium enema. During the study period, colorectal cancer was detected in 4 patients (1.6%), adenomatous polyps in 36 patients (14.4%), and ulcerative colitis in 8 patients (3.2%). In 98 patients (39.2%), no abnormality was present, and in the remaining patients, diverticulosis (n = 60; 24%) and hemorrhoids were present (n = 44; 17.6%).
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ABSTRACT: Waiting time and costs from referral to day case outpatient surgery are at an unacceptably high level. The waiting time in Norway averages 240 days for common surgical conditions. Furthermore, in North Norway the population is scattered throughout a large geographic area, making the cost of travel to a specialist examination before surgery considerable. Electronic standardised referrals and booking of day case outpatient surgery by GPs are possible through the National Health Network, which links all health care providers in an electronic network. New ways of using this network might reduce the waiting time and cost of outpatient day case surgery.
In a randomised controlled trial, selected patients (inguinal hernia, gallstone disease and pilonidal sinus) referred to the university hospital are either randomised to direct electronic referral and booking for outpatient surgery (one stop), or to the traditional patient pathway where all patients are seen at the outpatient clinic several weeks ahead of surgery. Consultants in gastrointestinal surgery designed standardised referral forms and guidelines. New software has been designed making it possible to implement referral forms, guidelines and patient information in the GP's electronic health record. For "one-stop" referral, GPs must provide mandatory information about the specific condition. Referrals were linked to a booking system, enabling the GPs to book the hospital, day and time for outpatient surgery. The primary endpoints are waiting time and costs. The sample size calculation was based on waiting time. A reduction in waiting time of 60 days (effect size), 25%, is significant, resulting in a sample size of 120 patients in total.
Poor communication between primary and secondary care often results in inefficiencies and unsatisfactory outcomes. We hypothesised that standardised referrals would improve the quality of information, making it feasible to use a one-stop approach for all patients undergoing surgery on an outpatient basis for inguinal hernia, pilonidal sinus and gallstones. In this study we wanted to investigate the waiting time and cost-effectiveness of direct electronic referral and booking of outpatient surgery compared to the traditional patient pathway, where the patient is seen at the outpatient clinic prior to surgery.
This trial has been registered at ClinicalTrials.gov. The trial registration number is: NCT00692497.
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ABSTRACT: Rectal bleeding is considered an important sign of colonic disease, particularly colorectal cancer. The epidemiology of rectal bleeding in the community is poorly understood. Moreover, there is little information as to whether individuals seek health care for this problem. This study aimed to determine the prevalence of rectal bleeding and levels of healthcare seeking amongst an Australian population.
A community sample of adults aged above 18 years of Penrith (a Sydney suburb representative of the Australian population) selected randomly from the electoral roll. The survey consisted of a self-administered questionnaire sent out to 440 residents stratified for equal numbers of men and women.
The response rate was 77% (n = 338; mean age 46 years; SD: 16; range: 18-90; 55% women). Blood in the stools in the previous 12 months was reported by 18% (95% CI: 14-23). Colour of the blood in bowel movements was reported as bright (72%), dark (7%), bright and dark (10%), 11% did not know. Only 31% (n = 21/68) of respondents with rectal bleeding had visited a physician primarily about the presence of blood in the bowel movement within the previous 12 months. The majority (90%) who consulted about the presence of blood were aged between 30 and 60 years. Blood in the stools was independently associated with younger age (OR = 0.97, 95% CI: 0.95-0.99, P = 0.01), feelings of incomplete rectal evacuation (OR = 3.42, 95% CI: 1.66-7.08, P = 0.001), self-reported injury or tear (OR = 3.45, 95% CI: 1.53-7.69, P = 0.002), and surgery (OR = 2.70, 95% CI: 1.03-7.14, P = 0.04) to the perianal region.
Rectal bleeding is common in the general population. Only one-third of those with rectal bleeding consults a physician about their condition. Rectal bleeding occurs in younger individuals, those who suffer from incomplete evacuation and among individuals who have had an injury, tear or surgery to the anus.
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ABSTRACT: Rectal bleeding is a very common symptom, with the majority of cases being caused by benign conditions. However, a small but significant percentage of those over 40 will have an underlying colorectal cancer. A careful clinical history is important in making a diagnosis and aiding in the choice of further investigations. These investigations range from flexible sigmoidoscopy, barium enema and colonoscopy to the more recent introduction of virtual colonoscopy and CT colonography. Presentations have been altered by NICE referral guidelines and the introduction of the NHS Bowel Cancer Screening Programme. Management depends on the cause and varies from the conservative through clinic-based procedures to formal surgical interventions.
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