Logical clinical decisions in the investigation and management of non-urgent rectal bleeding

The benefits of assessment for non-urgent rectal bleeding derive from a combination of yield, risk factors, cost and patient comfort. Prospective studies have been completed which assign patients to investigative and management programmes based on graded bleeding patterns, the yield and true extent of flexible sigmoidoscopy and the safety and efficacy of immediate anorectal management. Between 1986 and 1989, 2268 new patients with bleeding were categorised by symptom grouping and entered into programmes of investigation and management. Flexible sigmoidoscopy (n = 936) eliminated or identified proximal bleeding in most (n = 882; 94.23%) and was confirmed to be generally specific for sigmoid assessment by "blinded" image intensifier confirmation of the level reached. No cancers are known to have been missed by clinical categorisation of patients. Between 1985 and 1988, 2112 patients underwent immediate sclerotherapy and triple banding for haemorrhoids, Significant secondary bleeding occurred in 9 patients (0.43%) and moderate to severe pain in 45 (2.13%) No deaths occurred. Further therapy to residual mucosal pedicles was required in 234 patients (11.08%) at one month, in 135 (6.39%) at a further month, and 67 patients (3.18%) subsequently. Careful clinical assessment, immediate investigation and management of the majority of anorectal disease in an ambulatory setting has been shown to be safe, highly cost efficient and relatively comfortable.