What to do with a patient who has 2nd degree hemorrhoids, normal Complete Blood Count (CBC), ultrasound (US), and abdominal (AB) exams, but a fecal immunochemical test detecting 25ug of Hemoglobin (Hb)?

Management of Positive FIT in Patient with 2nd Degree Hemorrhoids

The fecal immunochemical test is abnormal and requires further investigation with colonoscopy—hemorrhoids cannot be assumed to be the source of a positive FIT result, even when present on examination. 1

Why This FIT Result is Abnormal

The detection of 25 μg/g of hemoglobin on FIT exceeds the threshold for a positive test in most screening programs. 2

• Most screening programs use positivity thresholds between 7-20 μg/g feces, with emerging evidence suggesting optimal cut-offs between 7-10 μg/g for symptomatic patients. 2
• The British Society of Gastroenterology reports that FIT has a high negative predictive value (0.99) at thresholds of 7-10 μg/g, meaning values above this range warrant investigation. 2
• Your patient's result of 25 μg/g is clearly above these established thresholds and cannot be dismissed as normal. 2

Critical Pitfall: Do Not Attribute Positive FIT to Hemorrhoids

The most important clinical error to avoid is attributing a positive fecal occult blood test to hemorrhoids without complete colonic evaluation. 1

• Hemorrhoidal bleeding typically presents as bright red blood visible in the toilet bowl, not as occult (hidden) blood detected on FIT. 1
• When a positive fecal occult blood test is found in a patient with hemorrhoids, complete colonic evaluation by colonoscopy is mandatory. 1
• The estimated risk of colorectal cancer in patients with rectal bleeding ranges from 2.4-11%, making it essential to rule out malignancy. 2
• Anemia due to hemorrhoidal disease is extremely rare (0.5 patients per 100,000 population), so other sources must be excluded. 1

Required Next Steps

Immediate Action Required

Refer for colonoscopy regardless of the presence of hemorrhoids. 1

• Complete colonic evaluation is indicated when a patient has a positive stool test, even if hemorrhoids are present. 1
• In patients with rectal bleeding and f-Hb ≥10 μg/g, significant bowel disease (colorectal cancer, high-risk adenoma, or inflammatory bowel disease) was found in 35.7% of cases at colonoscopy. 3
• Anoscopy and flexible sigmoidoscopy represent the minimum evaluation, but complete colonoscopy is mandatory with a positive FIT. 1

Patient Communication

Tell the patient that the fecal immunochemical test is not normal and requires further investigation to rule out serious conditions including colorectal cancer. 1

• Explain that while hemorrhoids are present, they cannot account for a positive FIT without excluding other causes. 1
• Emphasize that this is a screening test designed to detect hidden blood that may indicate cancer or precancerous polyps. 2

Why Conservative Management Alone is Inadequate

While hemorrhoid management is appropriate, it does not address the positive FIT:

• Dietary and lifestyle changes with increased fiber and water intake are first-line therapy for hemorrhoids themselves. 2
• However, these measures do not eliminate the need for colonoscopy when FIT is positive. 1
• Flavonoids may relieve hemorrhoid symptoms but do not address the underlying concern for colorectal neoplasia. 2

Answer to Your Question

Option b is correct: Tell the patient the fecal immunochemical test is not normal. However, the appropriate next step is not simply prescribing medication, but rather urgent referral for colonoscopy to exclude colorectal cancer and other significant bowel disease. 1, 3

Option a is incorrect and potentially dangerous: Reassuring the patient that a FIT of 25 μg/g is normal contradicts established screening thresholds and could delay diagnosis of colorectal cancer. 2, 1