Gastroenterology  |  Colorectal Cancer Pathway - Other Diagnoses


Colorectal Cancer Pathway - Other Diagnoses

Ulcerative Colitis:  

Frequently presents with diarrhoea, urgency and bleeding. Weight loss is rare. Examination of the stool reveals white cells +- red cells, with a negative culture. Tumours can present with similar symptoms but there are no white cells, although there may be red cells. Calprotectin will always be elevated in colitis, but not necessarily so with a tumour. Most easily distinguished from malignancy by a proctoscopy or sigmoidoscopy will show inflamed mucosa.

Crohn's Disease: 

As Crohn's can affect all areas of the GI tract, it can present with a variety of symptoms, including the foregut (loss of appetite, nausea, and epigastric pain). Most frequently however it will involve the small and large bowel. Central abdominal pain, bloating distension, borborygmi, loss of appetite, early satiety, weight loss, as well as diarrhoea may be present. The calprotectin is always elevated, although may not be as high as those with ulcerative colitis. It can also present with a palpable mass. Patients tend to be younger, but there is a second peak incidence in the older age group. It is accepted that some patients in this group will be thought to have cancers which turn out to be Crohn's. White cells in the stool are helpful to differentiate but are much less likely to be present.    

Irritable Bowel Syndrome (IBS) for further information see NICE Guidelines

IBS/IBD Decision Algorithim


  • Inflammation of large bowel diverticula.
  • Often presents with L)IF pain and tenderness, fever and raised WCC. May also have nausea/vomiting, diarrhoea or constipation.  Often a clinical diagnosis but can also be shown on an acute CT scan.
  • Severe episodes may require hospital admission.  CT colonography and colonoscopy are contraindicated for at least 6 weeks after an acute episode due to risk of perforation.
  • Mild attacks can be managed in the community with fluids, bowel rest and oral antibiotics.
  • All first episodes not needing admission require elective referral for imaging to exclude colorectal cancer via the suspected bowel malignancy pathway (they will qualify under the CAPER scoring).
  • Ongoing management is with high fibre diet.  There is no evidence seeds and nuts cause attacks of diverticulitis.  
  • May require surgery if complications (perforation, abscess etc) or recurrent attacks.

Outlet symptoms:

Outlet bleeding is defined as bleeding that occurs on defaecation or after, and appears on the paper, may drip into the pan, is usually bright red and is not mixed in with the stools. This may be associated with other anal symptoms, such as pain on defaecation, or prolapse. Common causes include:

  • Haemorrhoids
  • Anal fissure

These conditions are usually amenable to GP management but if the diagnosis is unclear or  the symptoms are persistent or severe then referral to Surgical out-patients is indicated.

Last updated : Friday, August 21, 2015
Next review date : Saturday, August 20,2016

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