Mrs G, a 63-year-old secretary, had a past medical history of hypertension and mild clinical depression. She presented to her GP, Dr B, with a history of two small PR bleeds in the previous week. She reported a small amount of fresh blood but was uncertain if the blood was mixed in with the stool or not. Mrs G had also been suffering from intermittent constipation and occasional loose stool for approximately one month.
She stated she occasionally felt the need to strain to pass stool but there was no pain on defecation. She had previously had a regular bowel habit, passing stool daily. On examination Dr B found Mrs G had a soft, nontender abdomen, rectal examination was normal and showed an empty rectum with no fresh blood or melaena. Dr B advised Mrs G to take a high fibre diet, drink more fluids, start taking Fybogel and return with any further problems. No referral or precise follow-up plans were made and no further investigations organised.
Over the next few months Mrs G returned to the surgery on two occasions and saw Dr B’s colleagues. Neither of them referred back to the previous consultation or asked about her constipation or further bleeding.
On one occasion she presented with dysuria and was treated for a urinary tract infection. Another time she came to seek advice regarding antidepressant medication. Mrs G had been on fluoxetine ten years previously to treat a depressive episode. Recently her daughter had had a miscarriage and was pregnant again. Mrs G was concerned that she wasn’t sleeping and was very anxious about her daughter’s pregnancy.
Dr B’s colleague gave practical advice for dealing with anxiety symptoms. Mrs G did not mention her ongoing constipation, occasional diarrhoea and a further episode of PR bleed as she didn’t want to take up too much of the doctor’s time.
Three months after the initial consultation, Mrs G attended the surgery to see Dr B after further episodes of PR bleeding. She gave a history of occasional PR bleed with small amounts of fresh red blood. The laxatives had helped briefly but she had continued to get intermittent constipation and a few episodes of loose stool over the past few months.
Mrs G also complained of occasional lower abdominal pain which was colicky in nature. When asked about her family situation she admitted to anxieties that she related to her daughter’s pregnancy. Dr B arranged a non-urgent referral for a colonoscopy to investigate the PR bleed but explained to Mrs G that her symptoms were most likely due to Irritable Bowel Syndrome (IBS) made worse by her anxiety. He attributed the PR bleed to straining following episodes of constipation. Dr B prescribed an antispasmodic for the abdominal pain.
Mrs G accepted this explanation and waited 12 weeks for her nonurgent appointment. Following her colonoscopy she was immediately admitted to a surgical ward with a diagnosis of cancer of the sigmoid colon. Mrs G underwent a sigmoid colectomy which successfully resected the tumour. She made a good recovery from the surgery.
A GP expert reviewing the case was critical of the delay in the diagnosis of colon cancer. This delay was attributable to two causes. Firstly, that no definite follow up or investigation plans were made after the initial presentation of a worrying symptom (PR bleeding).
This meant that other symptoms and problems took precedence and the PR bleeding was not asked about directly. Secondly, the referral for further investigation was made non-urgently rather than urgently. These errors led to a significant delay in diagnosis of a serious condition. The case was settled for a moderate sum.
- The symptom of PR bleeding should always prompt further questioning, examination including PR, appropriate investigation and follow up. There should be enquiries about the type of bleeding, abdominal pain, change in bowel habit, anal symptoms, weight loss and family history of colorectal cancer.
- If IBS is suspected other possible diagnoses need to be considered and investigated particularly in the presence of “red flag” symptoms and risk factors, eg, weight loss, PR bleeding or faecal occult blood, family history of colorectal cancer and older age.1
- Urgent referrals should be made when symptoms suggest a possible cancer diagnosis in accordance with suspected cancer referral guidelines, eg, in this case rectal bleeding with preceding altered bowel habit, not associated with anal symptoms, requires further investigation and urgent referral especially in older patients.3,4
References and further information
- Hatlebakk J.G, Hatlebakk M.V (2004). Diagnostic Approach to Suspected Irritable Bowel Syndrome. Best Practice & Research Clinical Gastroenterology;18(4):735–746.
- The GP notebook website provides a good overview of IBS including appropriate investigations and criteria for diagnosis. Available online at www.gpnotebook.co.uk
- For the UK, Department of Health referral guidelines for suspected cancer, including PDF downloads, are available online at www.dh.gov.uk
- In the UK, NICE referral guidelines for suspected cancer, including PDF downloads, are available online at www.nice.org.uk