Original article doi:10.1111/j.1463-1318.2011.02918.x Is whole colonic imaging necessary for symptoms of change in bowel habit and ⁄ or rectal bleeding? S. Badiani, A. Desai and M. A. S. Chapman Department of Colorectal Surgery, Heart of England NHS Foundation Trust, Birmingham, UK Received 14 August 2011; accepted 1 November 2011; Accepted Article online 18 December 2011 Abstract Aim Following the introduction of a 2-week-wait (2ww) cancer pathway, many units are triaging patients with change in bowel habit (CIBH) and ⁄ or rectal bleeding (RB) straight to colonoscopy. Evidence suggests that right-sided colonic cancer does not present with these symptoms, hence imaging the left colon only is satisfac- tory. If this were substantiated, patients could be offered a flexible sigmoidoscopy (FS) alone. This study aimed to review presenting symptoms of patients diagnosed with a right-sided colonic malignancy and assess whether their tumours would be missed based on this practice. Method This is a retrospective analysis of patients who underwent curative resection for a proximal colonic malig- nancy over a 4-year period. Two-week-wait referral proforma and case notes were analysed for mode of presentation. Results Of 206 elective right hemicolectomies per- formed, 20 ⁄ 206 (9.7%) patients presented in the absence of either iron deficiency anaemia or palpable abdominal mass. Twelve patients had polyposis identified in the left colon and eight patients had no left-sided colonic pathology. One patient had a strong family history of colon cancer (two first-degree relatives) in the group absent of left-sided pathology. Conclusion Twelve patients who had left-sided polyp- osis and one patient with a strong family history would have undergone whole colonic imaging based on current colorectal cancer management guidelines. The remaining seven patients with right-sided cancer would have been missed if FS were the only investigation used. Patients presenting on the 2ww with symptoms of a CIBH and ⁄ or RB can be adequately investigated with a FS with a 3% chance of missing a proximal cancer. Keywords Colorectal cancer, two week wait, flexible sigmoidoscopy, symptoms, investigations What is new in this paper? The 2-week wait pathway has increased the number of patients referred with high-risk colorectal symptoms. The challenge lies in the selection of the most appropriate investigation, either flexible sigmoidoscopy or whole colonic imaging. This paper uses data to support the argument that rectal bleeding and ⁄ or change in bowel habit can be adequately investigated with flexible sig- moidoscopy alone by evaluating a cohort of patients with a proximal colonic cancer. Introduction Colorectal cancer (CRC) is the second most common cause of death and the third most common cancer diagnosed worldwide. In the United Kingdom there is approximately a 4% (1:25) lifetime risk of developing CRC. In 2008, just under 40 000 new cases were diagnosed in the UK and 1.24 million cases diagnosed worldwide [1]. Several symptoms may be associated with CRC, but most have a low predictive value [2,3]. Introduction of government targets state that all patients with symptoms suggestive of bowel cancer must be seen within 2 weeks. This has resulted in a rise in referrals to colorectal clinics [4]. The challenge that most clinicians are faced with is the choice of large bowel investigation used to adequately diagnose or excluded a CRC. Whole colonic imaging (WCI) is perhaps performed in preference to flexible sigmoidoscopy (FS) for fear of missing a cancer. The Portsmouth group conducted a large prospective study and concluded that selective use of FS detects 95% of large bowel cancers and the diagnostic yield of WCI after FS is low in patients presenting with rectal bleeding and ⁄ or change in bowel habit [5]. Advantages of FS over WCI include little or no requirement for sedation, better patient tolerance, less onerous bowel preparation and a shorter completion time. However, patients presenting Correspondence to: Mr Sarit Badiani, Clinical Research Fellow, Department of Colorectal Surgery, Good Hope Hospital, Rectory Road, Sutton Coldfield, Birmingham B75 7RR, UK. E-mail: saritbadiani@doctors.org.uk Ó 2011 The Authors Colorectal Disease Ó 2011 The Association of Coloproctology of Great Britain and Ireland. 14, 1197–1200 1197