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 has been started on Fiber Lax (psyllium) twice a day?

From the Guidelines

I strongly recommend referring this 41-year-old male patient with a positive Hemoccult test and family history of colon cancer for a colonoscopy. Despite his denial of current bleeding, black stools, or diarrhea, the combination of a positive Hemoccult test and family history (grandfather with colon cancer) represents significant risk factors that warrant further investigation, as noted in the guidelines for cancer screening in the United States, 2010 1. While starting Fiber Lax twice daily for 6 months may help with his reported bloating, cramping, and multiple bowel movements, this treatment addresses only his symptoms and not the underlying concern of possible colorectal pathology.

The repeated Hemoccult test and CBC labs are appropriate interim measures, but a colonoscopy is the gold standard for evaluating the colon directly, allowing for visualization of the entire colon and rectum, identification of any polyps or masses, and tissue sampling if necessary. Early detection of colorectal lesions significantly improves treatment outcomes, especially given his family history which places him at higher risk than the general population. The guidelines for colonoscopy surveillance after polypectomy also support the use of colonoscopy for individuals with a family history of colorectal cancer, as it is the preferred test for diagnostic investigation and screening 1.

Furthermore, the updated guidelines for colorectal cancer screening and surveillance emphasize the importance of risk stratification and recommend more intensive surveillance for individuals at higher risk, including those with a family history of colorectal cancer 1. Therefore, a colonoscopy is the most appropriate next step in the management of this patient, given the potential for early detection and treatment of colorectal lesions, and the improvement in morbidity, mortality, and quality of life that it can provide.

From the FDA Drug Label

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. 2 The patient had a positive Hemoccult test, which may indicate rectal bleeding. According to the drug label, this is a reason to stop use and ask a doctor.

• The patient denies any bleeding or black stools lately, but the previous positive Hemoccult test result suggests that bleeding may have occurred.
• The patient is being started on Fiber Lax, which contains psyllium, and the label instructs to stop use if rectal bleeding occurs. Given the patient's history of a positive Hemoccult test, it is prudent to consult a doctor before starting the patient on Fiber Lax.

From the Research

Patient Presentation and History

• The patient is a 41-year-old male with a positive Hemoccult test result from a month ago, but currently denies any bleeding or black stools, and also denies any diarrhea.
• He has a family history of colon cancer, specifically his grandfather on his mother's side.
• The patient exhibits normal bowel sounds in all four quadrants and does not experience pain upon palpation.

Diagnostic Approach

• According to 3, a stepwise evaluation can identify the cause of bleeding in the majority of patients, with esophagogastroduodenoscopy (EGD) and colonoscopy finding the bleeding source in 48 to 71 percent of patients.
• The study 4 suggests that in patients without symptoms indicating an upper gastrointestinal tract source, or in patients older than 50 years, colonoscopy is usually performed first.
• Given the patient's positive Hemoccult test result and family history of colon cancer, a colonoscopy may be an appropriate next step in the diagnostic process, as recommended by 3.

Treatment and Management

• The patient will be started on Fiber Lax twice a day for the next 6 months, which may help with his reported bloating and cramps.
• The patient's regular bowel movements and occasional need to go to the bathroom multiple times may be addressed through this treatment.
• It is essential to continue monitoring the patient's symptoms and adjust the treatment plan as needed, based on the patient's response to the Fiber Lax and the results of the repeated hemocult and CBC labs.

Importance of Comprehensive Patient History

• Taking a comprehensive patient history is crucial for accurate diagnosis and effective management, as emphasized by 5 and 6.
• A thorough patient history can help identify potential causes of symptoms and guide the diagnostic process, as seen in this patient's case with his family history of colon cancer.
• The patient's history of regular bowel movements, occasional bloating, and cramps should be considered in the context of his positive Hemoccult test result and family history, as noted in 3 and 4.