Cases corner – 38 year old with change in bowel habit
30th July 2019
David, a 38 year old man, presents to you with a 4 week history of change in bowel habit. He previously opened his bowels once a day, with normal soft brown stools. Now he opens them anywhere between once and four times a day. He denies any change in colour, or the presence of blood or mucous. The consistency now ranges between normal stool to liquid. He denies any appetite loss, nausea, vomiting, abdominal pain, weight loss or any other symptoms. He has not changed his diet and has had no recent travel history. He has no significant past medical history and does not take any regular medication. His observations and examination are unremarkable.
What should you do next?
- Ask the patient to keep a food diary and to review in 2 weeks
- Investigate for inflammatory bowel disease with blood tests and a faecal calprotectin
- Request a routine stool test for MC&S
- Request a faecal immunochemical test (FIT)
- Refer the patient using a routine lower GI referral
- Refer the patient via a 2-week-wait lower GI pathway
A ‘change in bowel habit’ is a vague symptom that includes changes in frequency, consistency or calibre of the stool. The differential diagnosis in this patient is therefore wide, ranging from irritable bowel syndrome, to inflammatory bowel disease, as well as colorectal cancer. An infection may also be considered, but these are typically self-limiting and resolve after a few days (up to 2 weeks).
Cancer is important to rule out early as it is the most common cause of premature death in the UK. Bowel cancer in particular has been on the rise in young adults, with rates rising on average 7.3% per year since 2005 in 30-39 year olds. The cause of this increase is currently unknown, but it is thought that a sedentary lifestyle, obesity and diet are all playing a part.
The most appropriate test to investigate the patient for colorectal cancer is a faecal immunochemical test (FIT). Based on the NICE DG30 guidance, the Pan-London guidance suggests we should:
Offer a FIT test before referring to assess for colorectal cancer in adults WITHOUT RECTAL BLEEDING who meet the following criteria:
- ≥50 years with unexplained abdominal pain or weight loss
- <60 years with changes in their bowel habit or iron deficiency anaemia
- ≥60 years and have anaemia even in the absence of iron deficiency
As with any other direct-access diagnostic test, it is important to safety-net these patients appropriately. For the FIT test, patients who have a positive test should be referred on a lower GI 2-week-wait cancer referral pathway; but if the test is negative, then the patient should be reviewed for other causes. However, with these sorts of tests it can be easy to lose a patient to follow-up. Therefore, a safety-netting tool is imperative.
C the Signs automates this process for you. If you risk assess the patient using C the Signs, we will show you the pathways the patient should be placed on, as well as automatically adding them to a safety-netting, practice-level, patient dashboard. Here you can track all patients on cancer pathways and quickly find all patients on FIT pathways (using the filter options). You can also retrospectively add a patient to the dashboard if you have already sent a test.
The practice dashboard is really easy to use and can be quickly updated as soon as the test result comes in. The patient’s medical record is also updated too.