The clinical assessment of patients with large bowel symptoms by general practitioners

Abstract

Objective: To describe the nature and extent of the clinical assessment of patients prior to referral for barium enema examinations within a health district in the UK.

Method: By means of a modified barium enema request form, general practitioners' clinical practices prior to making requests for a barium enema examination were examined over the course of one year. Using a request form with a ‘tear-off’ slip, GPs in Hudders-field, UK, were asked to indicate up to two primary reasons for referral, provide some simple demographic details on patients and to indicate what specific clinical activities had been undertaken prior to ordering a barium enema.

Results: Over the course of the one-year study period, 275 modified x-ray request forms were returned. In relation to the 326 primary reasons given for referral these were subdivided into change in bowel habit (101 [42%]), abdominal pain (55 [23%]), frank or occult rectal bleeding (26 [11%]), weight loss (21 [9%]), iron-deficiency anaemia (6 [3%]), and other (117 [49%]). Patients presenting for barium enema examinations were only likely to have had a rectal examination in 72% of situations, an abdominal examination in 89% and a full blood count in 38%. Proctoscopy was very infrequently performed. In relation to the primary reason for referral, 72% had undergone a rectal examination if they had had a change in bowel habit (90% an abdominal examination). If the patients being referred had experienced abdominal pain, 60% of these would have had a rectal examination and 91% an abdominal examination. No significant effect of age on the tendency to perform rectal or abdominal examinations was noted. Any patient presenting for a barium enema was significantly more likely to have had an abdominal than a rectal examination (odds ratio=3.23 [1.99-5.27]).

Conclusions: This study, taken in context, highlights a need to encourage the adoption of a more rational approach to the assessment of patients within primary care settings. Unfortunately the available evidence to assist general practitioners in the diagnosis of colorectal cancer amongst the types of patients they encounter and in the settings where they work remains unsatisfactory.

Key Words:

• rectal examination
• barium enema
• lower bowel symptoms
• general practice