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CRC is the initial differential diagnosis, but may not initially be the most likely cause. The guidelines only mention abdominal pain as a symptom of low risk Box 4. Abdominal pain is extremely prevalent in the general population.
The only features to significantly predict a neoplastic cause were: the pain having no specific character, the patient being male, increasing age, and a raised erythrocyte sedimentation rate. There are several inherited syndromes with CRC as a feature, such as polyposis coli, hereditary non-polyposis coli and Peutz—Jegers syndrome. Guidelines for the management of individuals with these syndromes have been published.
A postal questionnaire was sent to all patients aged 30—69 enquiring about any family history of CRC and led to the diagnosis of two cancers in symptomatic patients who had not consulted their doctor. The major single predictors of cancer are rectal bleeding and change in bowel habit towards increased looseness or increased stool frequency. These are strongly supported by research evidence. One of these symptoms, plus being aged over 60, is as powerful a predictor as any of the other symptom complexes described in the guidelines.
The evidence base is weak for the three rarer presentations of CRC, abdominal or rectal masses, or iron deficiency anaemia.
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This may not matter: all three presentations require investigation, and CRC is a likely diagnosis for them all. Although the UK guidelines were established to help GPs with referral decisions, local services will determine the exact patient pathway. In some instances, the GP may perform the initial investigations in primary care instead of selecting immediate referral to a rapid access clinic. However, two points in the UK guidelines are questionable. First, there is no evidence for deferring investigation of increased stool frequency for 6 weeks.
In the absence of a clear cause for diarrhoea, we suggest immediate referral. This applies particularly to the elderly. Even with an apparently clear cause, such as infective diarrhoea, it may be wise to set a time limit before referral lest the initial diagnosis be wrong.
Change in bowel habit is the symptom most associated with both patient and doctor delay: 33, 53 deferring investigation risks perpetuating this. It is also illogical to require a 6 week delay before requesting a referral with a maximum 2 week wait. No doubt this was a practical decision. However, it ignores the issue that patients select which symptoms to report and, once they have chosen to report a change in bowel habit, the PPV is already high enough to warrant referral.
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Secondly, it is debatable whether constipation can safely be regarded as low risk. A PPV of 1. We would caution against labelling all constipation as low risk.
The research literature largely bypasses one other important issue: the experience of the doctor and patient. The higher predictive value of symptoms in the population referred for investigation when compared with the predictive value on first presentation to primary care shows that doctors are able to identify at least partly those who are likely to harbour cancer. We wish to thank an anonymous referee for helpful comments on an earlier version. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.
Sign In or Create an Account. Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Volume This article was originally published in. Article Contents. The rationale for and derivation of guidelines. Mode of presentation. Symptomatic diagnosis.
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Diagnosis of colorectal cancer in primary care: the evidence base for guidelines William Hamilton. E-mail: w. Cite Citation. Permissions Icon Permissions.
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Abstract Background. A structured literature review was carried out. The Referral Guidelines have a reasonable evidence base. Colorectal cancer , diagnosis , primary care.
Referral guidelines relating to rectal bleeding. F igure 1. View large Download slide. Referral guidelines relating to change in bowel habit.
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Referral guidelines relating to masses and anaemia. Referral guidelines relating to abdominal pain. Pinterest A blood eagle execution. If their sagas are to be believed, the Vikings cruelly tortured their enemies in the name of their god Odin as they conquered territory. If the suggestion of a blood eagle was even uttered, one left town and never looked back. Viking sagas define blood eagle as one of the most painful and terrifying torture methods ever created.
The story describes:. One of the earliest accounts of the use of the blood eagle is thought to have occurred in It began a few years before, when Aella, king of Northumbria present-day North Yorkshire, England , fell victim to a Viking attack. Aella killed the Viking leader Ragnar Lothbrok by throwing him into a pit of live snakes. Ivarr the Boneless wanted to make an example out of Aella and to strike fear into the hearts of his enemies. Modern scholars debate how Vikings performed this ritual torture and in fact whether they even performed the gruesome method at all.
The process of the blood eagle is indeed so cruel and grisly that it would be difficult to believe that it could actually be carried out. Regardless of whether it is merely a work of literary fiction, there is no denying the fact that the ritual was stomach-churning. Still others say that blood sanguis is so called, because it is sweet suavis. Early modern medical practitioners continued to make the distinction between healthy blood and cruor.
Whilst St. As Nancy Vickers has shown, sixteenth-century poets reinforced the model of male authorship by poetically dismembering the female body. As Middleton appropriates familiar imagery from Shakespeare, his text further complicates the relationship between authorship and subjectivity. However, the theological connotations of this profane blood drinking are superseded by a medicalised image of pathogenic infection. In the poem, then, authorship, subjectivity, body, and agency, are inextricably linked.