Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • potentially life-threatening bleed evidenced by:
    • hypotension
    • syncope
    • large volume ongoing bleeding
  • acute severe ulcerative colitis ≥ 6 bloody bowel stools per 24 hours (Truelove and Witts criteria) as well as any of the following:
    • temperature > 37.8°C
    • pulse rate > 90 bpm
    • haemoglobin (Hb) < 105 gm/l
    • C-reactive protein (CRP) > 30mg/L at presentation (or erythrocyte sedimentation rate (ESR) > 30 mm)

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Exclusions

Second opinions for conditions already seen by the same specialty

Triage categories

Category 1 — appointment clinically indicated within 30 days

  • Rectal bleeding with any red flags:
    • age > 40
    • new onset, not previously investigated
    • symptoms suggestive of inflammatory bowel disease (IBD) colitis, specify symptoms
    • weight loss ≥ 10% in previous 3 to 6 months, imaging needed
    • abdominal/rectal mass, digital rectal exam (DRE) needed
    • suspected obstruction
  • iron deficiency in males and postmenopausal women or unexplained iron deficiency in premenopausal women, exclude inadequate iron intake, menorrhagia
  • patient and/or family history of young onset first degree relative with bowel cancer

Category 2 — appointment clinically indicated within 90 days

  • per rectum (PR) bleeding without red flags
  • suspected haemorrhoidal bleeding, refer to ‘clinical management advice and resources’
  • suspected anal fissure, refer to ‘clinical management advice and resources’
  • previously investigated or recurrent known cause rectal bleeding e.g. radiation therapy, ulcerative colitis

Category 3 — appointment clinically indicated within 365 days

  • nil

For information on referral forms and how to import them, please view general referral information.

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

  • identifies as Aboriginal and/or Torres Strait Islander
  • identify within your referral if you feel your patient is from a vulnerable population and/or requires a third party to receive correspondence on their behalf
  • interpreter requirements

History

  • detailed history of bleeding (volume, frequency, duration, bowel habit, constipation, straining, associated bowel symptoms, blood alone or mixed with stools, clots, mucous, tenesmus, recurrent per rectum (PR) bleeding previously investigated
  • associated red flags:
    • change in bowel habit
    • weight loss
    • new onset of anal or abdominal pain
    • abdominal or rectal mass
  • past history of gastrointestinal (GI) disease (cancer, polyps, inflammatory bowel disease (IBD), coeliac disease, irritable bowel syndrome (IBS), haemorrhoids)
  • family history of GI disease, e.g. cancer, polyps, IBD, including age and specific relationship to the patient
  • dietary history if iron deficient
  • menstrual history if iron deficient and female
  • current medications including aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), novel oral anticoagulants and warfarin
  • up-to-date health summary

Examination

  • abdominal and digital rectal exam (DRE) required for all rectal bleeding referrals
  • body mass index (BMI)
  • general cardiorespiratory exam (fitness for endoscopic procedures)

Investigations

  • complete blood examination (CBE)
  • urea, electrolytes, and creatinine (UEC), if suspected impairment
  • liver function tests (LFTs) if relevant abdominal pain or significant weight loss
  • iron studies if haemoglobin (Hb), mean corpuscular volume (MCV) or mean corpuscular Hb are low
  • C-reactive protein (CRP) (suspected colitis/IBD)
  • computed tomography abdomen if abdominal mass palpable, significant weight loss, obstructive symptoms, or persistent change in bowel output over a 6 week period
  • other previous GI investigations and results if available

Clinical management advice

Every patient with overt rectal bleeding needs a digital rectal exam (DRE) before referral.

Unless previously or recently investigated, all overt rectal bleeding, except on paper alone when wiping, will require a flexi-sigmoidoscopy (< 40 years) or colonoscopy for older persons, or those presenting with other risk factors.

Category 3 referrals are accepted at the discretion of the triaging clinician. If you are concerned that your patient requires specialist review, but the referral is declined, you are encouraged to contact the triaging clinician to discuss your concerns.

If a patient has been fully investigated within last 2 years and symptoms remain unchanged, clinician discretion is needed to appropriately refer and triage. In general, there is little value in repeat specialist assessment and/or endoscopic procedures in this scenario.

Clinical resources

Consumer resources