Rectal Cancer Bleeding Mistaken for Hemorrhoids

This case involves a fifty-six-year-old female patient who presented to her family physician complaining of increased rectal bleeding during bowel movements. The patient had a history of hemorrhoids and had several ligation procedures in attempts to remedy the issue. The physician advised her to take stool softeners and bulk agents to prevent straining during defecation and to return if the issue continued. The physician neglected to perform a full physical exam at the time of this visit and did not choose to inspect the anal region for masses or lesions. The patient’s bleeding stopped on its own, and no follow-up was performed for eight months. Spontaneously, the patient began bleeding again, associated with abdominal pain, during bowel movements. The patient went to the emergency room where she received a thorough workup that included a rigid proctoscopy. It identified suspicious tissue in the rectum. The tissue was sent for analysis and came back with histopathologic features such as poor differentiation, lymphovascular, and perineural invasion. The patient was worked up further and the tissue was indicative of a T4 tumor stage with significantly elevated CEA levels, which were all associated with increased recurrence rates and poor survival rates.

Question(s) For Expert Witness

1. Should this patient have been sent home without a proper workup for possible malignancy and a full physical exam including a rectal inspection with a digital exam?

Expert Witness Response E-000293

All patients should undergo a complete history (including a family history) and assessment of risk factors for the development of rectal cancer. Many rectal cancers produce no symptoms and are discovered during digital or proctoscopic screening examinations. Bleeding is the most common symptom of rectal cancer, occurring in 60% of patients. Bleeding often is attributed to other causes (eg, hemorrhoids), especially if the patient has a history of other rectal problems. Bleeding may be accompanied by the passage of mucus, which warrants further investigation.