Altered bowel habit

If you are concerned about Colorectal Cancer in the context of Altered Bowel Habit please see the page on the pathway to follow.

The most common cause of altered bowel habit in those under 50 years is Irritable Bowel Syndrome (IBS). Coeliac and Inflammatory Bowel Disease should also be considered. Please see separate Diagnostic & Management pathways.

Factors more likely to indicate the presence of serious pathology (e.g. colorectal cancer):

Age over 40 years (risk rises aged 50 and rises sharply over 60 years)
A change in bowel habit to looser or more frequent stools

An isolated change to firmer or less frequents stools seldom indicates serious pathology

Presence of unexplained weight loss accompanied by any of:

Rectal bleeding
Abnormal FBC

Iron deficiency anaemia
Anaemia (in the presence of other symptoms)
High platelet count

Elevated Faecal calprotectin

NB calprotectin is NOT a test for cancer and its use is currently unproven in those over the age of 50 years

Who to refer, who not to refer, how to refer

Who to refer:

If any of the following High-risk features are present, consider an urgent referral to the Borders Colon Service

Bleeding

Repeated rectal bleeding without an obvious anal cause
Any blood mixed with the stool

Bowel habit

Persistent change in bowel habit especially to looser stools (more than 4 weeks)

Mass

Right-sided abdominal mass
Palpable rectal mass

Iron deficiency anaemia

Unexplained iron deficiency anaemia (i.e. not menstrual blood loss)

Other

Past history of lower gastrointestinal cancer with any of the symptoms above

How to refer:

Patients should be referred via the separate diagnostic pathways for the possible diagnosis depending on the initial investigations.

These pages would include:

Borders colon service

Irritable bowel syndrome

Coeliac

Inflammatory bowel disease

Primary care management

Basic investigations in Primary Care

FBC, Ferritin (+/- Iron and transferrin)
LFTs, TFTs, Ca, Alb
Coeliac screen (anti tTG antibody)
Faecal calprotectin (those under 50 years old)

For patients with chronic diarrhoea please consider offering HIV testing for patients.

Primary care management

A 4-week Watch & Wait Policy is reasonable in those with Low-risk features such as:

Transient symptoms (less than 4 weeks)
Patients under 40 years in absence of high-risk features

Watch and wait Policy (4 weeks)

Assessment and review
Consider bowel diary
Appropriate information, counselling and agreed plan for review with GP
Refer if symptoms persist or recur

Resources and links

Cancer referral Guidelines - lower gastrointestinal cancer

Who to refer, who not to refer, how to refer

Who to refer:

How to refer:

Primary care management

Resources and links

Editorial Information