“It’s just my piles playing up again”

Rectal bleeding that is mixed with stool, accompanied by a change in bowel habit (looser, more frequent) and unintentional weight loss at age 52 is a lower-GI suspected cancer pathway picture — NOT a haemorrhoid story to be treated blindly with cream. The NICE NG12/FIT pathway applies: offer quantitative FIT (NICE HTG690) and refer on a colorectal suspected cancer pathway if FIT is positive (≥10 µg Hb/g); with this symptom cluster, a FIT below 10 does not end the matter if strong concern persists (NICE HTG690). His father’s cancer at 60 is not in itself a moderate-risk family history (BSG/ACPGBI/UKCGG 2019) — the symptoms drive the referral. The suspected cancer pathway aims for a diagnosis or all-clear within 28 days (NHS England Faster Diagnosis Standard). Examination (abdominal + DRE, anal inspection) and an FBC and ferritin for iron-deficiency anaemia (itself a FIT indication) are essential — and must not be skipped because the patient booked a video; visible piles can coexist with cancer and never excuse stopping the work-up. The examinable hidden agenda is bereavement-driven denial: his father died of bowel cancer, and "piles/cream/video" is avoidance of the examination and answer he dreads. Surface the fear gently, balance honesty with the fact most bleeding is benign, accommodate the examination reluctance and his practical barriers, and complete the FIT and suspected cancer pathway with follow-up.