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Bowel and rectum

Please see below for the policies relating to bowel and rectum. To view the policy, patient leaflet and additional information, please click on the relevant heading.


  • Upper GI endoscopy

    This guidance is produced by The Academy of Medical Royal Colleges (the Academy) as part of the Evidence-based interventions programme. It is based on recommendations from the Expert Advisory Committee and the National Institute for Health and Care Excellence (NICE).

    All guidance has been reviewed by the Birmingham and Solihull & Sandwell and West Birmingham CCGs’ Treatment Policy Clinical Development Groups (TPCDG). This was reviewed to establish if existing CCG policies were already in place which covered the proposed intervention / treatment in question.

    Where there was no current CCG policy for the area in question, the NHSEI policy has been implemented in full into the CCG’s Clinical Treatment Policy portfolio.

    Where there was a current CCG policy for the area in question, then the existing CCG policy has been reviewed by the TPCDG considering the NHSEI EBI policy rationale and evidence base.  A decision has then been taken by TPCDG based on the review as to the most appropriate policy for implementation by taking into account the healthcare needs of our local population.

    The aims of the Evidence Based Interventions programme is to ensure the quality and safety of patient care by, freeing up valuable resources such as time so that more effective interventions can be carried out, reducing harm or the risk of harm to patients, helping clinicians maintain professional practice, creating headroom for innovation, and maximising value and avoiding waste.

  • Colonoscopy to manage hereditary colorectal cancer

    This guidance is produced by The Academy of Medical Royal Colleges (the Academy) as part of the Evidence-based interventions programme. It is based on recommendations from the Expert Advisory Committee and the National Institute for Health and Care Excellence (NICE).

    All guidance has been reviewed by the Birmingham and Solihull & Sandwell and West Birmingham CCGs’ Treatment Policy Clinical Development Groups (TPCDG). This was reviewed to establish if existing CCG policies were already in place which covered the proposed intervention / treatment in question.

    Where there was no current CCG policy for the area in question, the NHSEI policy has been implemented in full into the CCG’s Clinical Treatment Policy portfolio.

    Where there was a current CCG policy for the area in question, then the existing CCG policy has been reviewed by the TPCDG considering the NHSEI EBI policy rationale and evidence base.  A decision has then been taken by TPCDG based on the review as to the most appropriate policy for implementation by taking into account the healthcare needs of our local population.

    The aims of the Evidence Based Interventions programme is to ensure the quality and safety of patient care by, freeing up valuable resources such as time so that more effective interventions can be carried out, reducing harm or the risk of harm to patients, helping clinicians maintain professional practice, creating headroom for innovation, and maximising value and avoiding waste.

  • Repeat colonoscopy

    This guidance is produced by The Academy of Medical Royal Colleges (the Academy) as part of the Evidence-based interventions programme. It is based on recommendations from the Expert Advisory Committee and the National Institute for Health and Care Excellence (NICE).

    All guidance has been reviewed by the Birmingham and Solihull & Sandwell and West Birmingham CCGs’ Treatment Policy Clinical Development Groups (TPCDG). This was reviewed to establish if existing CCG policies were already in place which covered the proposed intervention / treatment in question.

    Where there was no current CCG policy for the area in question, the NHSEI policy has been implemented in full into the CCG’s Clinical Treatment Policy portfolio.

    Where there was a current CCG policy for the area in question, then the existing CCG policy has been reviewed by the TPCDG considering the NHSEI EBI policy rationale and evidence base.  A decision has then been taken by TPCDG based on the review as to the most appropriate policy for implementation by taking into account the healthcare needs of our local population.

    The aims of the Evidence Based Interventions programme is to ensure the quality and safety of patient care by, freeing up valuable resources such as time so that more effective interventions can be carried out, reducing harm or the risk of harm to patients, helping clinicians maintain professional practice, creating headroom for innovation, and maximising value and avoiding waste.

  • Rectal bleeding

    What is rectal bleeding?

    Rectal bleeding is loss of blood from the bottom or anus. It is a very common and usually occurs at irregular intervals and will often resolve on its own.

    Sudden heavy blood loss, requiring emergency hospital admission and intervention, can occur, but is uncommon.

    Most cases of painless rectal bleeding are due to non-cancerous (benign) anal conditions such as piles (hemorrhoids) or anal tears (fissures).

    However, in some cases, bowel and colon cancer (colorectal) could be the cause of unexplained rectal bleeding for patients aged over 50 years. In adults under 50, rectal bleeding with abdominal pain, changes in bowel habit, sudden weight loss, or iron deficiency anaemia, should also be treated as suspected cancer.

    Bowel and colon cancer (colorectal) is the third most common cancer in the UK after breast and lung cancer and the second most common cause of death, with approximately 41,265 new cases diagnosed in 2014 in the UK (Cancer Research UK).

    Patients with long standing inflammatory diseases of the bowel, such as Crohn’s disease or ulcerative colitis, may also have an increased risk of developing colorectal cancer. People who have a rare genetic conditions in which benign tumours called polyps are found in the lining of the colon, have an increased risk of developing bowel cancer.

    Occurrence of colorectal cancer is strongly related to age, with almost three-quarters of cases occurring in people aged over 65 years, although people under 40 with a strong family history of colorectal cancer have an increased risk of developing the disease.

    For all patients with suspected bowel or colon cancer an appointment for further investigations will be made within two weeks of visiting your GP.

    Patient eligibility criteria

    The patient's local NHS commissioning organisation will therefore fund further investigation of rectal bleeding in the following circumstances:

    • The patient is 50 years old or older and has unexplained rectal bleeding
    • The patient is UNDER the age of 50 years, has rectal bleeding AND
    • Abdominal pain, OR
    • Change in bowel habit, OR
    • Sudden weight loss, OR
    • Iron-deficiency anaemia.

    This means (for patients who DO NOT meet the above criteria) the CCG will ONLY fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG.

    Advice and guidance

    • For more information, search for ‘bleeding from the bottom’ at www.nhs.uk 
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.

    The patient should speak to their GP if:

    • If there has been blood in the patient's poo for three weeks
    • If there has been blood in the child's poo
    • If the patient's poo has been softer, thinner or longer than normal for three weeks
    • If the patient has a lot of pain around the bottom
    • If the patient has a pain or lump in their tummy
    • If the patient has been more tired than usual
    • If the patient has lost weight for no reason.

    Get an urgent appointment or call 111 if:

    • If the patient's poo is black or dark red
    • If the patient has bloody diarrhoea for no obvious reason.

    Go to A&E or call 999 if:

    • If the patient is bleeding non-stop
    • If the patient passes a lot of blood – for example, the toilet water turns red or large blood clots can be seen.
  • Surgical removal of piles

    What is surgical removal of piles?

    Piles or haemorrhoids are swellings that develop inside and around the back passage (anus). Symptoms range from temporary and mild, to persistent and painful. In many cases, piles are small and symptoms settle down without treatment.

    Surgical removal of piles (haemorrhoidectomy) can be used for third or fourth degree haemorrhoids, or for piles that are large and cannot be pushed back inside the anus (irreducible). It is usually carried out under general anaesthetic, which means the patient will be asleep during the procedure and won't feel any pain while it is carried out.

    Patient eligibility for the treatment option varies by haemorrhoid severity or grade one to four. Internal haemorrhoids are classified by the degree that the internal piles that protrude (prolapse) out of the back passage (anus) which helps determine management:

    • Grade one: no prolapse
    • Grade two: prolapse that goes back in on its own
    • Grade three: prolapse that must be pushed back in by the patient
    • Grade four: prolapse that cannot be pushed back in by the patient (often very painful).

    Not normally funded treatment or procedure:

    Haemorrhoidectomy for grades one or two are not normally funded by the patient’s local NHS commissioning organisation. This is because treatment of bleeding haemorrhoids depends on the degree of prolapse and severity of symptoms.

    A procedure in which the haemorrhoid is tied off at its base with rubber bands, cutting off the blood flow to the haemorrhoid (rubber band ligation) is currently the best available outpatient treatment for haemorrhoids with up to 80% of patients satisfied with short term outcomes.

    Patient eligibility criteria:

    Haemorrhoidectomy for grades three or four will be funded if the patient meets one or more of the following criteria:

    • Recurrent grade three or grade four combined with persistent pain or bleeding; or
    • Irreducible and large external haemorrhoids.

    This is because removing the piles or haemorrhoidal tissue by cutting it away (excisional haemorrhoidectomy) is more effective than which the haemorrhoid is tied off at its base with rubber bands, cutting off the blood flow to the haemorrhoid (rubber band ligation) in the long term and is the treatment of choice for recurrent grade two haemorrhoids and grade three/four haemorrhoids.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

    Haemorrhoid symptoms often settle down after a few days without needing treatment. Haemorrhoids that occur during pregnancy often get better after giving birth. Making lifestyle changes to reduce the strain on the blood vessels in and around the patient’s anus is often recommended. These can include:

    • Gradually increasing the amount of fibre in the patient’s diet – good sources of fibre include fruit, vegetables, wholegrain rice, whole wheat pasta and bread, pulses and beans, seeds, nuts and oats
    • Drinking plenty of fluid – particularly water, but avoiding or cutting down on caffeine and alcohol
    • Not delaying going to the toilet – ignoring the urge to empty the bowels can make the patients stools harder and drier, which can lead to straining when the patient does go to the toilet
    • Avoiding medication that causes constipation – such as painkillers that contain codeine
    • Losing weight if the patient is overweight
    • Exercising regularly – this can help prevent constipation, reduce the patient’s blood pressure, and help with weight loss.

    These measures can also reduce the risk of haemorrhoids returning or even developing in the first place. Medication that is applied directly to the patient’s back passage (topical treatments) or tablets bought from a pharmacy or prescribed by the patients GP may ease the symptoms and make it easier to pass stools.

    • For more information search for ‘haemorrhoids’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.

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