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Questions over timely investigation of “alarm symptoms”

Questions over timely investigation of “alarm symptoms”

Many patients presenting to their doctor with certain alarm symptoms, such as difficulty swallowing or rectal bleeding, may not be receiving a timely diagnosis, finds a study published on bmj.com today.

Certain symptoms, such as blood in the urine (haematuria), coughing up blood (haemoptysis), difficulty swallowing (dysphagia), and rectal bleeding, are generally regarded as "red flags" because of their association with serious disease.

They should prompt clinicians to conduct investigations in order to make an early accurate diagnosis.

The predictive value of these red flag or alarm symptoms for a diagnosis of cancer have now been established, but little is known about their predictive value for non-cancer diagnoses, which might also have considerable implications for patients' health.

So researchers based at King's College London tracked 762,325 patients presenting to general practice with first episodes of haematuria, haemoptysis, dysphagia or rectal bleeding in 1994.

A list of potentially important diagnoses associated with each of the alarm symptoms were identified and these were compared with actual diagnoses recorded at 90 days and three years after the first recorded alarm symptom.

In patients with haematuria, haemoptysis, dysphagia, and rectal bleeding around one in five had an associated diagnosis at 90 days.

However, after three years, over three quarters of patients presenting with rectal bleeding did not have a definite diagnosis, with comparable figures of about 67% for dysphagia, 64% for haematuria, and 46% for haemoptysis.

The authors estimate that for every four to seven patients evaluated for haematuria, haemoptysis, dysphagia, or rectal bleeding, relevant diagnoses will be identified in one patient within 90 days.

The authors point out that this proportion would almost certainly have been higher in patients with multiple symptoms. However, they suggest that patients presenting with these symptoms merit timely investigation for non-cancer diagnoses and potential cancer diagnoses, rather than a policy of watchful waiting.

BMJ

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