BMJ  2006;333:201 (22 July), doi:10.1136/bmj.333.7560.201-b

Letter

Colorectal cancer and rectal bleeding in primary care

Rectal bleeding needs attention in primary care

EDITOR—Du Toit et al emphasise the importance of rectal bleeding in primary care and try to address this important management dilemma.¹ One potential weakness of the study, however, was its assumption that bleeding was caused by any neoplasia found, rather than more common causes. The character of rectal bleeding (bright red v dark) was not mentioned, nor was the coexistence of piles, probably because rigid sigmoidoscopy rather than proctoscopy was carried out. In addition, the presence of anal symptoms, usually due to piles, which is a protective factor to the finding of neoplasia, was not said to be recorded.

As Weller's editorial in the same issue says,² the specific characteristics of the bleeding are important to record; if the colour of the blood was recorded it may help plan investigations. Bright red bleeding is well investigated by flexible sigmoidoscopy, but it is generally agreed that darker bleeding usually requires colonoscopy. The paper did not report why three different modes of investigation were used, nor the rationale for choosing between the three. The location of the cancers was not stated but should have been; caecal cancer would be unlikely to cause bright rectal bleeding. Finally the size and number of adenomas are necessary information to estimate whether these lesions are important in a study population largely older than 65.

Credit: CUSTOM MEDICAL STOCK/SPL

 

If the nature of the bleeding and presence of bleeding piles is to be ignored and a one-off bleed results in booking an endoscopy, then up to 20% of the adult population (the widely accepted incidence in a population, not those presenting) would need an endoscopy every year. In practice most patients, rather than having new rectal bleeding, have chronic bleeding, and neoplastic causes persist whereas benign causes abate, which allows some sorting into who to investigate with what urgency.

chrisnewman{at}doctors.org.uk, Poole General Hospital, Poole BH15 2JB

Poole General Hospital, Poole BH15 2JB

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Competing interests: None declared.

References

1. Du Toit J, Hamilton W, Barraclough K. Risk in primary care of colorectal cancer from new onset rectal bleeding: 10 year prospective study. BMJ 2006;333: 69-70. (8 July.)[Abstract/Free Full Text]
2. Weller D. Colorectal cancer in primary care. BMJ 2006;333: 54-5. (8 July.)[Free Full Text]

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