What is the next step in managing a 41-year-old male patient with a history of positive Hemoccult (Guaiac Fecal Occult Blood Test) and family history of colon cancer, presenting with bloating, cramps, and regular bowel movements, who is to be started on Fiber Lax (Psyllium) twice a day?

From the Guidelines

I strongly recommend referring this 41-year-old male patient for a colonoscopy due to his positive Hemoccult test and family history of colon cancer. While repeating the Hemoccult test and CBC labs is appropriate, these should not delay colonoscopy referral 1. The patient's symptoms of bloating, occasional cramping, and multiple bowel movements in a day, combined with his family history (grandfather with colon cancer), represent significant risk factors that warrant thorough investigation. According to the guidelines for colorectal cancer screening and surveillance, colonoscopy is the preferred test for the diagnostic investigation of patients with findings on screening and for screening patients with a family history of hereditary nonpolyposis colorectal cancer 1.

Starting Fiber Lax twice daily for six months may help manage his symptoms of bloating and irregular bowel movements, but it should not be considered a substitute for diagnostic evaluation. The American Gastroenterological Association medical position statement on irritable bowel syndrome suggests that a therapeutic trial of fiber may be sufficient for constipation-predominant symptoms, but if symptoms are persistent, further evaluation may be indicated 1. However, in this case, the patient's positive Hemoccult test and family history of colon cancer take precedence, and a colonoscopy is necessary to rule out colorectal pathology.

The absence of visible bleeding or black stools does not rule out colorectal pathology, as many lesions can cause occult bleeding without visible symptoms. Early detection through colonoscopy is crucial, as colorectal cancer is highly treatable when caught early. The patient should be educated about the importance of this procedure despite being in a prison setting, as standard of care should be maintained regardless of incarceration status.

Key points to consider in this patient's management include:

• The patient's family history of colon cancer, which increases his risk for developing colorectal cancer
• The positive Hemoccult test, which indicates the presence of occult blood in the stool
• The patient's symptoms of bloating, occasional cramping, and multiple bowel movements in a day, which may be indicative of underlying colorectal pathology
• The importance of colonoscopy in the diagnostic evaluation of patients with a family history of colon cancer and positive screening tests 1.

From the FDA Drug Label

Purpose Fiber laxative Stop use and ask a doctor if • constipation lasts more than 7 days • rectal bleeding occurs • you fail to have a bowel movement These may be signs of a serious condition. The patient is being started on Fiber Lax, which contains psyllium, for 6 months. Key considerations for this patient include:

• Monitoring for rectal bleeding as it may be a sign of a serious condition 2
• The patient's family history of colon cancer and recent positive Hemoccult test should be taken into account when assessing the patient's condition
• The patient's symptoms of bloating and cramps should be monitored while on the medication
• Patient should be advised to stop use and ask a doctor if constipation lasts more than 7 days or if they fail to have a bowel movement 2

From the Research

Patient Assessment and Screening

• The patient is a 41-year-old male with a family history of colon cancer, presenting for a follow-up on a positive Hemoccult test a month ago 3.
• The patient denies any bleeding or black stools, and also denies any diarrhea, but reports feeling bloated at times and experiencing cramps 3.
• The patient's bowel sounds are normal in all four quadrants, and he does not experience any pain upon palpation 3.

Hemoccult Test Results and Interpretation

• The sensitivity of the Guaiac test for the diagnosis of colorectal cancer varies from 0.13 to 1.00, and specificity ranges from 0.69 to 0.99 3.
• The sensitivity of the immunochemical test for the diagnosis of CRC ranges from 0.42 to 0.94, with specificity ranging from 0.40 to 1.00 3.
• A study found that the sensitivity of Hemoccult II for colorectal carcinoma diagnosed within 1 year of testing was 50%, and specificity was 99% 4.

Screening for Colon Cancer

• Colorectal cancer is a leading cause of morbidity and mortality, and reducing mortality may be achieved by the introduction of population-based screening programmes 5.
• Screening for colorectal cancer using the faecal occult blood test (guaiac or immunochemical) reduces colorectal cancer mortality by 16% 5.
• The benefits of screening include a modest reduction in colorectal cancer mortality, a possible reduction in cancer incidence, and potentially less invasive surgery 5.

Treatment and Follow-up

• The patient will repeat the hemocult and CBC labs, and will be started on Fiber Lax twice a day for the next 6 months 3.
• Ongoing screening and surveillance should be a shared decision-making process with the patient, based on multiple factors including the patient's morbidity and mortality risk from CRC and underlying comorbidities 6.