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Colorectal Risk Management Recommendations

Related to: Ambulatory, Clinical Guidelines, Diagnosis, Primary Care, Other Specialties

Patient Safety and Risk Management Recommendations

Patients Age <50 With Rectal Bleeding

Mismanagement of patients with self-reported rectal bleeding is among the most common factors in allegations of missed colorectal cancer diagnoses.

  • Aggressively and completely investigate the cause of rectal bleeding, regardless of the patient’s personal or family history.41
  • Evidence that incidence of colorectal cancer is increasing among adults <50 suggests due vigilance for younger patients who present with symptoms such as rectal bleeding and/or abdominal pain.42
  • Do not test for occult blood, as this may delay the ordering and completion of a colonoscopy.

Collecting a Meaningful History

An updated patient and family history should precede selection of screening initiation, modality, and follow up. Obtaining an accurate family history is critical to determining if a patient has a genetic predisposition to the development of adenomas or cancer.

  • A family history indicative of prior polyps (i.e., not specifically adenoma) is typically not adequate to determine the appropriate starting period for colon cancer screening or the appropriate surveillance interval.
  • Current guidelines recommend that advanced* polyps or a family history of colon cancer should prompt screening colonoscopy at an earlier age and more frequent surveillance intervals. If a patient is uncertain if a family member’s adenomas were “advanced,” document accordingly.
  • Additionally, family histories of polyposis syndromes or genetic cancer risks may necessitate earlier colon cancer screening and shorter intervals between surveillance colonoscopies.
  • In general, patients with a family history of colorectal cancer or advanced adenomas should begin screening at age 40 or 10 years earlier than the age of the relative at the time of diagnosis.
  • Patients treated with chemotherapy or abdominal radiation for non-gastrointestinal malignancies (e.g., childhood cancer survivors) are at significantly increased risk for the development of colorectal cancer.

*Adenomas consider ed advanced: a) ≥1cm in diameter, or b) <1cm in diameter with ≥25 percent villous features or high-grade dysplasia.

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November 11, 2019
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