Blood coming out the wazoo

Feb 17 2011 Published by under Medicine

The ICU can be a terrifying place for an intern.  Of course, the patients are probably a bit more frightened, but then, many of them are unconscious.  Rounds are endless in the ICU; new admissions, work rounds, teaching rounds, evaluations for transfer, afternoon rounds, lasix rounds (don't ask), all punctuated by CPR codes on the floor, and your own patients trying their hardest to die.

One of the more sobering ICU experiences is the gastrointestinal (GI) bleed.  One night while making some sort of middle-of-the-night rounds, I saw a patient sitting up in bed watching TV.  She was middle aged, hair done but mussed from plasticized hospital pillows, and quite awake.  I grabbed her chart and stopped in, happy to have someone conscious to talk to.  She came to the hospital when she noticed dark black stools, and in the ER she was found to have a low blood count.  But she looked fine, and given how busy our ICU was, I wondered how the hell she warranted a bed.

We chatted casually for a bit about nothing in particular, she as happy as I to have someone to talk to, and in mid-sentence her eyes rolled back and her telemetry alarms went off.  Her blood pressure tanked, her heart rate soared, and she was clearly in shock.  Just like that: fine one moment, dying the next.  Thankfully, we saved her, but that taught me a valuable lesson: every GI bleed is potentially life-threatening, at least until you have a good idea about what's going on inside the patient.

The gut, from mouth to anus, is a continuous tube, and a long one.  Blood can come from any part of it, but some problems are more common and some more dangerous than others.  In general, we tend to divide GI bleeds into "upper" (from the mouth to upper part of the small intestine) and "lower" (all the rest).

Human Digestive Tract

This division helps us develop a differential diagnosis, a list of possible causes of the problem.  In general, upper GI bleeding shows up in vomitus either as red blood or as vomit mixed with "coffee-grounds".  If the blood makes it all the way through, it generally turns black and comes out as black, tarry stool (melena).

Lower GI bleeding generally shows up as bright red blood from the rectum.  The list of potential diagnoses is huge, but a few of them are most common.  Upper GI bleeds are often the result of ulcers, and lower GI bleeds are often caused by diverticulosis, arteriovenous malformations, or growths, either benign or malignant.

Once we manage to stabilize a patient, which often involves transfusion of saline and/or blood, we can take a look into the stomach and the colon via endoscopy.  Usually we can find a cause, but in somewhere between 5-25% of cases, endoscopy doesn't give us an answer.

EGD, or esopaphagogastroduodenoscopy, allows direct visualization of the upper GI tract.  Not only can an expert take a good look around, but she has many tools for stopping ongoing bleeding, including cauterization and injection of drugs.  All of this can be done without opening up a patient.

The same specialist can do a colonoscopy, where a scope is passed from the rectum all the way to the cecum, where the small intestine meets the large.  But these two procedures leave a lot of gut unexplored.  Sometimes an specialized EGD can be used to look a little bit further into the small bowel, but for the most part, the small bowel is a dark zone when it comes to direct visualization.   If the bleeding is bad enough, and a source isn't found by scope, the surgeons can dig in and try to locate and stop the bleeding, but people with hemorrhagic shock are not the easiest to operate on.  They can develop blood clotting disorders, and start bleeding from literally everywhere.

The gold standard for identifying severe, obscure GI bleeding is angiography.  A catheter can be threaded into the arterial system, dye can help localize bleeding, and then the bleeding can be stopped using various angiography-related techniques.  This is very invasive, and only useful during severe bleeding. We have two other high-tech, relatively non-invasive tools to look for obscure GI bleeding: tagged red blood cell scan, and capsule endoscopy.  In tagged RBC scans, RBCs are literally tagged with a radioactive isotope and if there is enough bleeding, the radioactive RBCs can be detected by the appropriate equipment.  This technique has several limitations.  Another technique is capsule endoscopy.  This one is pretty cool.

In capsule endoscopy, the patient swallows a small capsule with a camera inside.  This is then, um, recovered, and the films viewed.  It can be quite successful.  Another new technique, called "push enteroscopy", can also be quite effective, but requires very specialized training and a lot of time.

As I proofread this piece (not all that carefully...why change now?) I'm wondering what the point here is, and I suppose it's this:

The human body is full of surprises, and so is human invention.  In my career I've watched several people bleed to death, and I'll never be able to erase those memories.  Properly-developed medical technology saves lives, and techniques available today would have saved some of the people I've seen die, people whose blood drawn into a syringe looked  like dilute cranberry juice before their hearts stopped, people who complained about how cold they felt as they died of shock.

References

CAVE, D. (2005). Obscure Gastrointestinal Bleeding: The Role of the Tagged Red Blood Cell Scan, Enteroscopy, and Capsule Endoscopy Clinical Gastroenterology and Hepatology, 3 (10), 959-963 DOI: 10.1016/S1542-3565(05)00716-0

PENNAZIO, M. (2004). Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: Report of 100 consecutive cases Gastroenterology, 126 (3), 643-653 DOI: 10.1053/j.gastro.2003.11.057

15 responses so far

  • What's insurance providers take on capsule endoscopy? This sound really cool.

  • Dianne says:

    lasix rounds (don’t ask)

    I'm not asking per se, but I think lasix rounds are a good idea. A lot of ICU issues are fluid issues so why not specifically address them on lasix rounds (which I assume also covered spironolactone and IVF?)

  • brooksphd says:

    I remember my very last shift as a nurse assistant, 2 days before I moved to the States to start my PhD. And elderly gent had been complaining of something, bad ulcer, mild chest pains etc., I think so he was admitted to the genpop ward I worked on while they worked him up.

    His wife was coming to visit and he wanted to look nice. We closed the curtains and gave him a sitting bed bath to freshen him up. He started coughing, a wet rumbling cough, grimaced and then vomited up a frankly massive amount of dark, black, coffee-ground blood.

    All over me and the RN I was working with. nice white uniforms.

    She hit the code button and called for the MD; the senior sister put us both off the ward. both of us were in shock. His wife was crying and calling his name. "Will he be alright?"

    "He was dead before he fell back down." Said the RN to me.

    Shitty fucking last shift. Shitty last memory.

  • William Wallace says:

    The pill cameras are cool. Are they steerable? (Not as dumb as it might sound). Just looked. Tethered cameras are, not sure if they are available yet. I would hate to have an endoscopic exam with the larger versions. I was also thinking about a wireless, steerable camera, but that might make a patient more prone to vomiting.

    Anyway, if you're looking for blogging material, Wisconsin doctors writing excuse notes for protesters.

  • Whitecoattales says:

    Massive hematemesis and Massive hemoptysis are the only things I've seen since getting into medicine that still scare the crap out of me. Lots of things make me nervous, but those are the only things that make me wonder if I've lost control of my own GI tract.

  • ZenHousecat says:

    We called them "pee rounds". It always amazed me that one of my mentors could look with equanimity at a crashing acute leukemic with a temperature of 105 F, in DIC, with 10 circulating cells (9 of them blasts); yet REALLY didn't want to deal with an end-stage cirrhotic with a GI bleed (AKA "liver bomb").

    • PalMD says:

      Well, what scares you depends on what you're comfortable with, I suppose.

    • Dianne says:

      I entirely agree with your mentor. The leukemic is going to live or die and there's a fairly well known process you need to go through to optimize the chances of the former. The cirrhotic is likely to die no matter what you do-after throwing half digested blood all over you. Plus if it's alcoholic cirrhosis you're likely to see him or her again in a matter of days in the same shape. I'll take the leukemic.

  • Luna_the_cat says:

    ...And my sister wondered why I didn't want to be a doctor....

  • keithb says:

    I just saw a wireless pill camera on Nova a few weeks ago. I guess that can get you the results sooner, and keeps you from opening the pill. 8^)

  • scigirl2010 says:

    GI bleeds are never fun and the smell is often overwhelming. The strangest case I ever saw was an elderly woman that came into the ER and the initial diagnosis was anemia. The thinking was that she was elderly, lives alone, and likely wasn't eating much. That all changed when her blood was drawn and her cell counts in the ETDA tube were dropping. Yep, in the tube. Thought the machine was faulty until we noticed a drop of blood put on a slide would immediately lyse. Turns out that a couple of days prior she'd taken a fall in her bathroom and hit her abdomen on the sink. She turned out to be septic for clostridium. Unfortunately, she died within a few hours before we could figure this all out.

  • I got a call around 330 AM last Friday that my dad had called emergency responders around midnight complaining of severe back pain. He died at 22 minutes past midnight from aortic aneurysm. The minute I understood that he had ruptured a major internal vessel, I had a general overview of what was going on--thanks to this post.

    I understood why he died so quickly and why they were unable to resuscitate at the hospital. Because I "got it" we were able to move quickly into consent for cornea an bone tissue donation.

    I included a line in the obituary thanking emergency responders and hospital staff. I'm sure the scenario was grim all around.

    Thanks.

  • PalMD says:

    God, AU, I'm so sorry for your loss.

  • Thanks Pal,

    We weren't close, but still very sad. He was a heavy drinker and smoker for decades, ate terribly, had a family history of heart disease and stroke, and hadn't been to a doctor in at least 25 years. Multiple contributing factors, I'm sure. I have half-expected a call like this for years, but it's still difficult in any case.