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, for whom Fiber Lax (psyllium) will be prescribed?

From the Guidelines

I strongly recommend referring this 41-year-old male patient for a colonoscopy, regardless of the repeat Hemoccult test results, due to his family history of colon cancer and current symptoms. The patient's symptoms of bloating, cramping, and multiple bowel movements in one day could be related to irritable bowel syndrome or could potentially indicate a more serious condition like inflammatory bowel disease or colorectal cancer. Given his age and family history of colon cancer (grandfather on mother's side), he is at a higher risk for colorectal cancer, as stated in the guidelines by the American Cancer Society 1. The guidelines recommend more intensive surveillance for individuals at higher risk for CRC, including those with a family history of either CRC or colorectal adenomas diagnosed in a first-degree relative 1. Although the patient's grandfather is not a first-degree relative, the guidelines still emphasize the importance of family history in assessing risk 1. Starting Fiber Lax twice daily for six months is appropriate to address his reported symptoms of bloating, cramping, and multiple bowel movements. However, it's crucial not to delay diagnostic evaluation with colonoscopy, as early detection of colorectal cancer significantly improves outcomes. Additionally, documenting the characteristics of his stools (consistency, presence of mucus, etc.) would provide valuable clinical information during follow-up visits. The plan to repeat the Hemoccult test and CBC labs to confirm the initial finding is also appropriate, but should not delay the referral for colonoscopy. It's essential to prioritize the patient's risk factors and symptoms when making decisions about his care, and in this case, a colonoscopy is the most appropriate next step 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's symptoms of bloating, cramps, and constipation may be addressed with Fiber Lax (psyllium) twice a day for the next 6 months, as it is a fiber laxative 2. However, it is crucial to monitor the patient's condition, especially given the family history of colon cancer and the recent positive Hemoccult test. The patient should be instructed to stop use and ask a doctor if constipation lasts more than 7 days, rectal bleeding occurs, or if they fail to have a bowel movement, as these may be signs of a serious condition 2.

From the Research

Patient Presentation and History

• The patient is a 41-year-old male with a family history of colon cancer, specifically his grandfather on his mother's side.
• He presented for a follow-up on a positive Hemoccult test a month ago, but denies any bleeding or black stools lately.
• The patient reports being very regular with his bowel movements, but sometimes has to go to the bathroom multiple times, and experiences bloating and cramps at times.

Diagnostic Approach

• The patient will undergo a repeat Hemoccult test and CBC labs to further investigate the initial positive result.
• The use of fecal occult blood tests (FOBTs), such as the Hemoccult test, is a common screening method for colorectal cancer, as discussed in 3 and 4.
• The sensitivity and specificity of FOBTs can vary, with immunochemical tests generally showing better results for detecting colorectal cancer, as seen in 3 and 5.

Treatment and Management

• The patient will be started on Fiber Lax twice a day for the next 6 months to help manage his symptoms.
• The importance of follow-up colonoscopy after a positive FOBT result is highlighted in 6, which found that delayed colonoscopy was associated with a higher risk of colorectal cancer and advanced-stage disease.
• The choice of screening test and follow-up procedures should be based on individual patient risk factors and medical history, as discussed in 7.

Screening Test Characteristics

• The Hemoccult test, a guaiac-based FOBT, has been shown to have varying sensitivity and specificity for detecting colorectal cancer and adenomatous polyps, as reported in 3 and 5.
• Immunochemical tests, such as the ones mentioned in 3 and 7, may offer improved sensitivity and specificity for detecting colorectal neoplasia.