Objective: Patients with rectal bleeding are being over investigated because of the fear of missing colorectal cancers. This study aimed to identify the percentage of patients ,45 years of age who undergo flexible sigmoidoscopy for rectal bleeding, and to assess and compare the incidence of colorectal cancers and polyps above and below this age. Methods: Patients who underwent flexible sigmoidoscopy for rectal bleeding between 1 January 2000 and 31 December 2002 were reviewed. Patients were divided into two groups: group 1 consisted of patients aged >45 years and group 2 patients ,45 years. The histopathology of biopsy specimens taken was also studied. Results: Altogether 18.9% of the patients who had flexible sigmoidoscopy for rectal bleeding were ,45 years. The incidence of colorectal cancers in group 1 was 3.5%; all these cases were confirmed on histopathology. Only one patient in group 2 was diagnosed with colorectal cancer on flexible sigmoidoscopy, but the histopathology disproved it. The incidence of polyps was 16.6% in group 1 and 7.9% in group 2. Following histopathology, the incidence of adenomatous polyps was 6.8% in group 1 and 2.1% in group 2. There was a significant difference between the two groups, with a p value of ,0.0001. Conclusion: The incidence of colorectal cancers and adenomatous polyps in patients aged ,45 years with rectal bleeding is very low. A flexible sigmoidoscopy costs approximately £330. If new guidelines are implemented considering the age of the patient, considerable cost savings could be made, and the available resources could be appropriately used in groups with high incidences of colorectal cancers.

Pathophysiologically, we suppose that air and gasforming microorganisms leaked chronically from the colorectal anastomosis into the adjacent presacral space. Abscess formation therein promoted fistulization of the leak through a low-resistance path, passing between the L5-S1 vertebrae into the spinal canal and meninges. Within the meninges, air migrated into the subdural and subarachnoid spaces causing pneumospine ( Fig. 1) and, via rostral migration, pneumocranium (inset, Fig. 1). We recognize a possible contribution to this entire process by the initial diverticular mass operated 2 years ago, which at laparotomy was adherent to the sacrum and pelvic side-wall rendering it a potential source of residual inflammation and fistulization. The meningeal involvement and pneumocranium would account for his headache and positive Kernig's sign. The inflammation at L5-S1 would explain his back pain.In conclusion, we describe a previously unreported pneumocranium and pneumospine as sequelae of chronic leakage of a colorectal anastomosis. In patients presenting with neurological symptoms following previous gastrointestinal surgery, one should consider the possibility of anastomotic leak and amongst its complications, pneumocranium and pneumospine. Early recognition and prompt treatment including neurosurgical input can result in a positive clinical outcome.

Intussusception of the appendix is a rare condition. We present the case of a 72-year-old woman with multiple polyps in the colon with an appendix completely intussuscepted into a polyp within the caecum. The clinical features, preoperative diagnosis, classification and treatment of this condition are discussed with reference to literature.

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