Case 1
Follow-up for rectal bleeding and altered bowel habit. Previously referred under 2WW pathway but did not attend. Resistant to colonoscopy.
Long-standing history of intermittent haemorrhoids, previously managed conservatively. No previous colonoscopy. Brother had colonic polyps at age 65. No known inflammatory bowel disease. No anticoagulant use.
Examination performed 1 week ago by Nurse Caroline Edwards, Practice Nurse. Observations: BP 140/86 mmHg, pulse 78 regular. Weight 4 kg lower than recorded 3 months ago. Abdominal examination: soft, mild left lower quadrant tenderness, no palpable masses, no hepatosplenomegaly. Digital rectal examination not performed at that appointment. FBC result available: haemoglobin 104 g/L (previously 132 g/L one year ago), MCV low.
You are a 61-year-old man attending a follow-up appointment regarding ongoing rectal bleeding and change in bowel habit. You were seen three weeks ago with intermittent bright red bleeding per rectum and looser stools. At that time, you were advised to undergo urgent referral under the suspected colorectal cancer pathway and to have blood tests performed. You are returning today because you are unhappy with the plan and have not yet attended the arranged hospital appointment.
The rectal bleeding has been occurring for approximately three months. Initially, it was occasional streaks of bright red blood on the toilet paper, but over the past month, you have noticed blood mixed within the stool. Your bowel habit has changed from once daily formed stools to 3–4 looser motions per day. There is occasional urgency and a sensation of incomplete emptying. You deny severe abdominal pain but describe intermittent lower abdominal cramping. Over the past two months, you have unintentionally lost around 4 kg. You feel more tired than usual.
You have a history of haemorrhoids and believe this is the cause. You are frustrated that the GP “jumped straight to cancer referral.” You did not attend the hospital appointment because you felt it was unnecessary and were worried about invasive procedures. You state, “It’s probably piles — I don’t want cameras put inside me.”
You deny black tarry stools. No vomiting. No family history of bowel cancer under age 50, though your older brother had polyps removed at age 65. You have not had a colonoscopy before. You appear defensive and somewhat irritated during the consultation.
You are retired but active. You avoid long outings due to fear of urgency. You feel embarrassed about the bleeding and have not told many people. Your partner is worried and urging you to attend hospital, causing tension at home. You are sleeping poorly due to anxiety but are unwilling to admit this directly unless asked sensitively.
You believe the bleeding is due to haemorrhoids and think cancer referral was an overreaction.
You are concerned about complications from colonoscopy and fear bad news. If the GP insists again on urgent investigation, you initially resist and question whether it is truly necessary. If given a clear explanation about red flag features (age, weight loss, altered bowel habit, blood mixed with stool), you may reluctantly agree but remain anxious.
You expect reassurance and possibly topical treatment for piles.
Red flags present: age over 60, rectal bleeding mixed with stool, altered bowel habit to looser stools, unintentional weight loss, fatigue. You deny severe persistent abdominal pain, vomiting, melaena, or known inflammatory bowel disease. No occupational chemical exposure. No recent travel.
Positive indicators
Negative indicators
Positive indicators
Negative indicators
Positive indicators
Negative indicators
Recognising colorectal cancer red flags including rectal bleeding, altered bowel habit, weight loss and iron deficiency anaemia requiring urgent referral.
Care of People with Gastrointestinal Problems; Cancer Recognition and Referral.
Exploring fears around colonoscopy and using shared decision-making to encourage attendance for urgent cancer investigation.
Person-Centred Care; Consultation and Communication Skills.
Interpreting microcytic anaemia with GI symptoms and ensuring appropriate safety-netting and follow-up of suspected malignancy.
Haematology in Primary Care; Managing Medical Complexity and Promoting Patient Safety.
