Re: Blood Results

From: Howard McCollister (nospam_at_nospam.net)
Date: 07/09/04 

Date: 9 Jul 2004 08:07:40 -0500

"Lisa" <raphieraph@hotmail.com> wrote in message
news:bd3aeb81.0407082147.4940ca0c@posting.google.com...
> "Howard McCollister" <nospam@nospam.net> wrote in message
news:<40ed6d24$0$370$45beb828@newscene.com>...
> > "Beachhouse" <sendnomail@please.com> wrote in message
> > news:ccjgp9$12lg$1@spnode25.nerdc.ufl.edu...
> > > a. we don't know why Lisa was in the ER getting "blood results" to
begin
> > > with...
> > > b. we don't know what her GI bleed was due to or how it was treated
> > > c. we don't know what her hematocrit was during/immediately following
her
> > > "GI Bleed"... maybe it was 21% and her Hct is now markedly improved...
> > > d. we don't know Lisa's age -- is she currently menstruating?
> > > e. we don't know diddly about this person
> >
> > Yes, I skipped a step. I assumed that she would not just order her own
EGD
> > and colonoscopy and go through her GI doctor, who would in turn draw
his/her
> > own conclusions based on the things mentioned above.
> >
> > THEN do the EGD and colonoscopy.
> >
> > HMc
>
> ----------
>
> I've always valued your opinions HMc. Just how many EGD's and
> Colonoscopy's can I possibly take? I've been getting them done every
> few months for 1.5 years. Heck, I've had them done so many times that
> I have to go under a general now because I don't sedate well now.
> There has got to be a way out. :)

OK, let me be a little less flip about it.

Occult GI blood loss can be an extremely frustrating problems to diagnose,
both for patients and for doctors. I assume that you have had a complete
anemia workup and ruled out other causes such as primary iron deficiency,
bone marrow problems, etc. Once those things are done, EGD and colonscopy
are done to look at the esophagus, stomach and first half of the duodenum.
The former is done to look for inflammation, ulceration, erosions, or tumors
all of which might be a source of chronic, occult blood loss. Colonoscopy is
done to look for inlfammation, but also polyps or other tumors, including
cancer.

These two tests are done because inflammatory or neoplastic pathology of the
upper GI tract and/or the colon represent by far the most common sources of
GI blood loss, but also because they are the only part of the GI tract that
we can see easily and well. Bear in mind that between the 3 feet of the
upper and 6 feet of the lower GI tracts, there is about 23 feet of small
intestine that really can't be seen well at all. Also, the pancreatic and
biliary tracts.

If EGD and colonoscopy are completely negative, and GI blood loss is still
suspected, it's time to look at the small intestine. First place to start
might be an upper GI xray with small bowel follow through - track the barium
as it travels through the small intestine. This is difficult, time
consuming, and notoriously inaccurate. A better option might be
enteroclysis, which is sort of the same thing, but more difficult and time
consuming (radiologists REALLY hate to do these). Another test might be a
tagged red cell study - a radioisotope is attached to the red cells and the
patient is scanned with a gamma camera to look for where these cells might
be pooling. This test is even more of a long shot unless the patient is
bleeding fairly rapidly. Sometimes enteroscopy will be done. This
essentially uses a VERY long gastroscope to try to look at the entire small
intestine. It is difficult, available in few centers, and not likely to be
complete-able. Finally, a useful option might be M2A wireless capsule
endoscopy. This is the much overhyped swallow-the-tv-camera-in-a-pill device
you've heard about. It also has a fairly high false-negative rate, is not
commonly available, and your insurance company may refuse to pay for it.

I had a patient a several years ago who had occult GI blood loss we just
could not nail down, He would drift up and down. Had many, many EGDs and
colonoscopies. Three contrast studies of the small intestine over about a
year were negative. He finally got frustrated with us and went to the Mayo
clinic. They started from scratch and worked him up from head to toe,
including enteroscopy, which they couldn't complete. No diagnosis. He came
back to us next time his HGB was low and we did yet another small bowel xray
follow-through (desparation) and the radiologist thought that he MIGHT have
seen a faint something-or-other in the distal small bowel. I operated and
found a walnut-sized carcinoid tumor of the small intestine. It was almost
pure luck. These days, I would probably have done a diagnostic laparoscopy
earlier in the course. More recently, I had a patient in the same situation,
who finally agreed to pay himself for M2A capsule endoscopy (his insurance
company has declared it "investigational"). It found several small
hemangiomas (blood vessel "nests") in thedistal small bowel.

Again, this all assumes that a non-GI anemia workup has been done. Others
here can describe that in better detail than I can. If it is indeed GI blood
loss, and the easy stuff is all negative, be prepared to get frustrated.
They may not be able to tell you what you have, yet, but at least they can
tell you some important things you DON'T have. Good luck.

HMc

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