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S2D: The Symptom to Diagnosis Podcast - Episode 06: Gastrointestinal Bleeding
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S2D: The Symptom to Diagnosis Podcast - Episode 06: Gastrointestinal Bleeding
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Segment:0 .
DR. CIFU: I'm Adam Cifu.
DR. STERN: And I'm Scott Stern.
DR. CIFU: And we're back with episode 6 of the Symptom to Diagnosis podcast. This podcast teaches evidence-based strategies for diagnosing common medical symptoms. Each episode is divided into four parts, we begin each episode with a case unknown to one of us. We then discuss five high yield features that help to accurately diagnose the cause of the symptom at hand. We then return to our case before finishing up with a discussion of fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge pertaining to the week's symptom.
DR. CIFU: The cases that we discuss are drawn from our clinical experiences but, because protecting patient privacy is part of our oath, we never discuss actual patients and most cases are composites.
DR. STERN: Well, our topic this week is GI bleeding. Adam, you are the expert of the day, do you have a case to present to me?
DR. CIFU: I do.
DR. STERN: Okay.
DR. CIFU: And I am feeling very expert-like.
DR. STERN: [chuckles] Okay.
DR. CIFU: So this patient is a 65-year-old man who presents without any past medical history with new exertional chest pain. He noticed a dull aching pain in his chest and shortness of breath with the brisk walk that he's accustomed to doing every morning. The symptoms have been present for about four weeks. He says they were barely noticeable at first, but now it become severe enough to lead us-- to lead him to this visit.
DR. CIFU: He otherwise feels actually completely well. His past medical history is unremarkable, I've been seeing this guy for 10-15 years. Interestingly, he had an EKG stress test a year before this visit, as part of a quote unquote, "executive physical" that he was sent to from his job. His review of systems were normal, he reported no change in bowel habits. He reported no change in appetite, no nausea or vomiting.
DR. CIFU: The only thing on his physical exam that was remarkable was that just kind of looking over his data from a year ago, is he'd lost about 10 pounds, he had not, he hadn't actually noticed this, he was a little bit of a heavy guy. So maybe not surprising. But it was documented from the weight that I had taken at a visit a year ago. So that's the case.
DR. STERN: Well, that's interesting, 'cause we're on GI bleeding, and this guy has come in with chest pain. So I have to admit, we need to put those two together. Clearly, the first thing that's going to be on your differential for this fellow would be some sort of ischemic heart disease, because he's a 65-year-old man, and whether he has risk factors or not, he is in a high-risk group.
DR. STERN: He did, you say, have a stress test a year ago, that I presumed was normal. But that doesn't exclude that possibility. Given the fact that we're GI bleeding, we do rarely see people who present with demand ischemia when they get anemic enough, that they present with chest pain and shortness of breath when they exert themselves. And so it is reasonable in patients who have chest pain to obtain a CBC in addition to the rest of your workup.
DR. STERN: But probably the initial start here would be to get a CBC and an EKG. And unless there's something really remarkable about the CBC consider stressing him again.
DR. CIFU: Good, good, sounds good. So I'll just maybe give you the start here, before we break. My thinking was really essentially the same. I guess maybe the one thing that I didn't tell you is that because he has an excellent primary care physician, he had a colonoscopy done at 60, five years before, which was completely normal. And they had recommended a repeat colonoscopy, when he was seven. I actually got an EKG in the room, which was normal.
DR. CIFU: I had one which I don't even know why he had it done about 10 years before, and that was unremarkable. And you are right, his EKG stress test at this executive physical, I did have the results of that too, and that was normal. I drew labs on the guy, I sent him home as sort of a little bit cautiously. But when those came back, his hemoglobin was 7.5. And I had a CBC also from three, four or five years before which was completely normal.
DR. CIFU: So this was obviously something new for him. His MCV on that was 62, 63, something remarkably low.
DR. STERN: Well, that's really interesting. So with that MCV and that hemoglobin, you'd almost be certain that this is an iron deficiency anemia, especially given a normal prior hemoglobin. Without that data, you could wonder about thalassemia, but obviously, if it's new, that's not the case. So now we have a patient who probably is having demand ischemia, and we can put that on the back burner briefly, while we try to figure out why he has what's really an iron deficiency anemia without a lot of other clear symptoms.
DR. STERN: He did have a negative colonoscopy five years ago, it makes an occult colon cancer less likely. He could still be bleeding from the colon. We don't know but it would make a cancer less likely, or it could be coming from an upper source, you know, ulcers, gastric carcinomas, esophageal carcinomas, all can present like this. You haven't mentioned that he's a drinker, alcoholism can present with varices but that typically presents as brisk breeding-- bleeding for other than occult low grade iron deficiency anemia.
DR. STERN: So it's pretty interesting story. And he would need a careful evaluation. I want to know about NSAIDs, because patients often take NSAIDs, and can have ulcers without pain shockingly enough, and can bleed without pain. And so I'd want to ask him about aspirin, Advil, Motrin, ibuprofen, and every single NSAID I could think of, and also just what he takes for pain, because this wouldn't be an unusual story for an ulcer.
DR. CIFU: First of all, I think alcohol use has been associated with brisk breeding in the past.
DR. STERN: [laughs]
DR. CIFU: But aside from that, your points are well taken. And interestingly, he had started a baby aspirin every day, a year ago, after his executive physical, which made me irritated given that with our current evidence, there was clearly absolutely no reason for that. Just before we move on to the next part, I'll ask you to put your nickel down. Where would you begin his evaluation? And what do you think is bleeding here?
DR. STERN: Well, it is really quite a guess with the data that we have. So normally had he not had the colonoscopy five years ago, I would start with the colon, 'cause colon cancer is more common than esophageal-- than gastric cancer in the United States in the West. I think given the negative colonoscopy in the past. So I'd probably start with the stomach and start with an endoscopy. Although, you know, frankly, whichever one you start with, if you don't get an answer, you're going to flip the patient upside down and do the other side.
DR. STERN: But I guess I'll put my nickel on ulcer.
DR. CIFU: Okay. Does the weight loss factor into that at all?
DR. STERN: It does, actually. So the causes of GI bleeding that can cause weight loss do include ulcers, a significant portion of people with ulcers do present with weight loss, and it's actually in the workup for unexplained weight loss is to consider an endoscopy. Obviously, the colon cancers can do the same, without a history of abdominal pain and diarrhea, IBD would be unlikely, I think to cause anemia and weight loss.
DR. STERN: A lot of the, it's interesting, a lot of the other causes of occult bleeding like angiodysplasia would be unlikely to cause weight loss and diverticular bleeding, as you know, doesn't present with microscopic low grade bleeding, but rather, you know, massive bleeding. So, again, that will point me towards upper rather than lower.
DR. CIFU: Okay. I'm just trying to, now that you've already missed the case, that the guy is having acute MI, I'm just trying to, get you even further off the mark.
DR. STERN: Thanks very much, I appreciate that. All right, so, Adam, why don't you give us some of the five key points about diagnosing GI bleeding to get us started?
DR. CIFU: Okay, so let me start, so my first point is that in an acute GI bleed, management proceeds diagnosis. You know, we're sort of all about diagnosis on this podcast. But at this time, basically, your diagnosis is GI bleed, and all the further details can wait. And so when I think about the initial management, I think, really about four steps. The first is risk stratifying people, how much should I worry about this people, and they're all-- this person, and there are all sorts of tools out there.
DR. CIFU: A lot of people will refer to the Glasgow-Blatchford scale for upper GI bleeds. And for lower GI bleeds, the greatest predictors of severity of bleed or actually of a poor outcome related to the bleed, is the hemoglobin on admission, the age of the patients, abnormal vital signs, and gross blood. Once you risk stratify, you have to prepare, and prepare basically means having good IV access.
DR. CIFU: And that means two large bore IVs. Let me just repeat that, two large bore IVs. It's important that they're large bore IVs. Because if you think about back to, I don't know, college physics, you remember that the flow rate is equal to the differential in pressure from where the fluids come fromfor where it's going. That's basically the same for us when you're giving blood as long as you're not, I guess, squeezing the bag of blood.
DR. CIFU: So it's the change in pressure times pi, times radius of the catheter to the fourth, okay? So that tells you why having a large bore IV is very, very powerful. Every time you decrease the bore of that IV, you're decreasing the flow by the fourth exponent, right? However you'd say that. And then that's divided by eight times the viscosity of the fluid, we can't do a whole lot to change the viscosity of saline or the viscosity of blood, times the length of the catheter, okay?
DR. CIFU: And so that's why we like, short, large bore peripheral IVs which are short. If you think about your central line, central lines are not only not large bore, but they're very long.
DR. STERN: So it is kind of weird, 'cause we always think of central lines as being the better way to deliver everything.
DR. CIFU: Yeah right.
DR. STERN: And this is one case where even if you had a central line, you'd be better off putting it in a large peripheral line.
DR. CIFU: Absolutely, absolutely.
DR. STERN: That's really surprising.
DR. CIFU: So after you've risk stratified and prepared, the next thing is resuscitation, okay. And you're going to start with fluids, you're going to start with fluids with some solute, so lactated ringers or normal saline. And then you're going to move on to blood, when you give blood maybe it's a little bit controversial, or not exactly clear. But in general, if someone's lost a lot of blood, you give the blood.
DR. CIFU: So people will say 30% blood loss, hard to measure if the person's bleeding plus their tachycardic, hypertensive, tachypneic, if their urine output is down, those people need blood. If you've already given two liters of fluid, and they're not volume replete at that time, give them blood. And if they come in bleeding, and their hemoglobin is less than nine, give them blood.
DR. CIFU: We may underdo that these days, 'cause there's pretty good data, right? That if someone's, that we can hold off on transfusions until someone's hemoglobin gets below seven. But that's not true if they're actively bleeding.
DR. STERN: That's really important. I do think right now, everyone tends to think that no one needs blood, and it's just a different animal when someone's hemorrhaging in front of you.
DR. CIFU: Absolutely true. And then the last one in this first point is to think about if they're initial, sort of specific empiric therapies, which you should throw out there. So is the patient anticoagulated? Do you need to reverse anticoagulation? Is this very likely to be an ulcer? In which case you'd want to give them a PPI. Is this likely to be an esophageal variceal bleed, where you'd want to give them octreotide.
DR. CIFU: My second point is to differentiate upper from lower bleeds. This is not always possible, but sometimes it is. So take a history is this someone who've had previous diverticular bleeds in the past or previous variceal bleeds? As you mentioned, Scott, are they on NSAIDs? Are they a drinker? Do they have vascular disease, right? Where they may be bleeding from ischemic colitis.
DR. CIFU: Have they had pelvic radiation in the past? Are they febrile? Is this part of an illness where maybe they've got infectious colitis? Or do they have the classic history of like, I went out I drank last night, I threw up two times, and on the third time, all of a sudden blood started coming. Where you'd think about a--
DR. STERN: Mallory-Weiss tear.
DR. CIFU: Thank you very much. [both doctors chuckle]
DR. CIFU: Have you jumped in there while I was having a TIA and couldn't remember the name. And then there's some clinical features, right? So obviously, if someone's throwing up blood, it's from above, melena suggestive of an upper bleed, and hematochezia for the most part is suggestive of a lower bleed.
DR. STERN: So just if I understand you correctly, your profound comment was if they're throwing up blood it's from above?
DR. CIFU: Yes.
DR. STERN: Okay just want to make sure.
DR. CIFU: Third key point, in acute bleeding, we usually start with an EGD, rather than a colonoscopy, if we really don't know where it's coming from. And that's because someone with an acute GI bleed, the people who are at the highest risk are going to bleed from an upper source, either peptic ulcer disease, eroding into a vessel or an esophageal bleed. It's very unusual for someone to exsanguinate from a lower GI source.
DR. STERN: Right. And I have seen people and I'm sure you have too, who've bled to death from varices.
DR. CIFU: Yeah, and I think we'll probably underline that a few times during this is take GI bleeding seriously,
DR. STERN: There we go.
DR. CIFU: Fourth key point. And this is big as an outpatient general internist, which I think both Scott and I consider ourselves first and foremost, is never, ever, ever ignore iron deficiency. A lot of people get into trouble with saying, oh, iron deficiency anemia, the treatment for that is iron. You know, no. Yes, the person should be on iron, oral or IV iron, whatever, but you have to figure out a cause.
DR. CIFU: And so never, ever, ever just replete iron. On the other hand, make sure that when you have someone who's got an iron deficiency anemia, that you don't go GI bleed and close your mind otherwise, right? There are people who actually have iron deficiency anemia from other causes, celiac disease, just poor iron intake. And it's worth thinking about those things.
DR. STERN: I like to say that if you give people iron who are older adults, who aren't menstruating without thinking about the cause of iron deficiency, you should just write out a check to the opposing attorneys you sign and they can put out how many zeros they want on that, because you can't defend it.
DR. CIFU: Give the patient the blank check with their prescription for iron, right?
DR. STERN: Right.
DR. CIFU: And my fifth and final key point is maybe something that I already said, is just don't get lackadaisical about GI bleeds. When I was a resident, and I know my residents now when they present cases to me kind of the night before I come in, just give you one liners, it's often, "Oh, and the last one is a 65-year-old with a GI bleed." And it's just like, here's an easy admission, this is someone who's going to come in, they're going to get scoped tomorrow, they'll go home the next day.
DR. CIFU: And that's great, that's an easy one, we don't have to think about it. And for the most part, that's true. But occasionally, you're going to have someone just do terribly. And when I say don't get lackadaisical, it's that think about it, be concerned about the person and make sure you have those two large bore IVs. Because when the person is exsanguinated, you don't want to walk in there and find out that they have a 22 gauge IV hanging out of their thumb or something.
DR. CIFU: 'Cause you don't want to be scrounging for good venous access at the point where the person's bleeding.
DR. STERN: Right, 'cause you know, once they're depleted, you can't find the veins to put it in.
DR. CIFU: Great point, great point. And when was the last time you put in an intraosseous line or something right?
DR. STERN: Oh, my goodness, I get chest pain. All right, well, that's terrific. Do you want to-- let's go back to our case, and can you give us some follow up on what happened?
DR. CIFU: Sure, so I call this guy back. I tell him he's incredibly anemic. And that's probably the cause of his chest pain. And I have to decide what my first test is. Scott, you suggested--?
DR. STERN: An EGD.
DR. CIFU: An EGD. And I did start with an EGD on the guy and he had a large ulcer with a visible vessel actually, amazing. He was not bleeding at the time, but the gastroenterologist who scoped him said, "Well, there's your answer!" Stopped his aspirin, put him on a PPI, biopsies were done at the time, both for gastric cancer and for H. pylori, those were negative. We actually re-scoped the guy six weeks later, 'cause the gastroenterologist was concerned enough about the size of his ulcer, even despite that negative biopsy, they wanted to make sure that it healed, make sure there wasn't a cancer there, it was biopsied again, at that point, it was normal, that was probably overkill.
DR. CIFU: And the guy actually just on oral iron came up nicely. Chest pain was gone within a week. And I'm trying to think back, I'm pretty sure I did not transfuse this guy, which as I think back on it maybe was kind of gutsy.
DR. STERN: Yeah, it might have, especially with the chest pain, right?
DR. CIFU: Yeah, especially with the chest pain. So let me ask you once he was better, and this is a real question, would you have stressed? So he's better, he's actually back to his normal exercise, he's feeling fine, we just trust him at that point.
DR. STERN: Well, so as you've mentioned in another podcast, I'm kind of a pathological over tester. I think you can easily make the argument not to stress him 'cause he's now asymptomatic, and you probably have demand ischemia. So at best you're going to uncover atherosclerotic disease, that's not currently symptomatic. So you could make a rational argument not to do it, I probably knowing my own personal biases and terrors would probably have done it.
DR. STERN: But I think the rational approach would be to say it's reasonable not to. What did you do?
DR. CIFU: I did not do it. And I think had I told you about the case at the time, and you said to do it, I would have scoffed it.
DR. STERN: Yeah probably.
DR. CIFU: But I agree, it was sort of a tough call. I got to actually look up this case now. Because reading this and going over it, I think I probably should have transfused him, and I hope I did. Maybe we'll get back with the answer to that on a future podcast.
DR. STERN: All right, to be continued. All right, so let's go on now and talk about some fingerprints, common misconceptions, our favorite pet peeves and other random pearls of knowledge. Adam, do you want to give us some fingerprints for GI bleeding?
DR. CIFU: Okay, my first fingerprint is one of those ones that is just going to shock everybody listening here. The presence of clots in the stool, blood clots in the school-- stool, has a likelihood ratio of 14 for a lower GI bleed. So if you see blood clots in the stool, that person is bleeding from below the ligament of Treitz.
DR. STERN: And what if you see blood clots in the school, what does that mean?
DR. CIFU: That means everybody should go home and do school and zoom for the rest of the year.
DR. STERN: All right, so my first fingerprint is, on the other hand, black stools, or blood or coffee grounds when people vomit or on NG aspirate is highly suggestive of an upper GI bleed with likelihood ratios of over 10, of 25 for melenic stools. So it's really helpful, black tarry stools really focuses you on the upper pathology, as of course, does throwing up blood and coffee grounds.
DR. CIFU: Great.
DR. STERN: All right, common misconceptions.
DR. CIFU: Okay, so my first misconception here is that in occult GI bleeding, so much like our case here, a colonoscopy is all you need. So there was a time actually that we sort of said, iron deficiency, anemia, occult GI bleeding, just do a colon and only go beyond that if you don't find anything on the colon. Most experts nowadays and most guidelines actually recommend an EGD after a colonoscopy for a patient with heme positive stools, and iron deficiency anemia.
DR. CIFU: Now, of course, if you find and obstructing colon cancer, that's not necessary. But the fact is most of the things that you're going to find on a colonoscopy, small patch of NSAID related colitis, polyps and diverticula, that's not a definitive cause of an iron deficiency anemia.
DR. STERN: I think that's really a good point, it'd be easy to stop when you find a polyp. And everybody has polyps basically, right?
DR. CIFU: Right.
DR. STERN: That's helpful. Well, my common misconception, and I see this not infrequently, is that a normal hematocrit on presentation rules out a significant hemorrhage, and that's just crazy. I mean, when people bleed, they bleed whole blood. And what's left behind in their vasculature is whole blood of the same concentration as before, until you dilute it with IV fluids or PO fluids. So when you're acutely bleeding, if you were shot, stabbed, or have a massive GI bleed, your hematocrit is the same for a while.
DR. STERN: And so we can't use that to judge severity.
DR. CIFU: Yeah, and that's actually been supported, I mean, you know this, with sort of incredible studies.
DR. STERN: Okay.
DR. CIFU: So there are, this is back to Vietnam, where there are people with penetrating trauma and blood loss. And first blood counts on those people we're normal.
DR. STERN: Makes total sense.
DR. CIFU: Absolutely.
DR. STERN: Right.
DR. STERN: All right, so pet peeves, you have any?
DR. CIFU: Okay, oh of course I've got pet peeves.
DR. STERN: Oh come on.
DR. CIFU: This first one is going to make me sound like a complete and utter nut. So my pet peeve is that people often think that patients are expert diagnosticians. And that's the case for a lot of things. And maybe as an aside, I often ask people, what do you think is going on, especially when I'm confused about a diagnosis, because patients often have something to add. But when patients tell you that they have hemorrhoids, you should ignore what they say.
DR. CIFU: And that's especially the case when they say, "You know I've got some blood that I'm seeing in the toilet, it's from my hemorrhoids." Okay? Patients don't know what they're talking about in this point there's almost no way for a patient to actively examine their bottom, right? And most people, anything that's going wrong with their sort of anal rectal area says it's hemorrhoids, because they've watched, Preparation H commercials for I don't know, two generations.
DR. CIFU: So when you're seeing that person, you got to look, you got to look at the outside, you should probably do an anoscopy in the office to see this. And there's a really key study which underlines this, which I just always talk to people about. So wonderful study, which looked at 201 patients from a VA who came to the doctor for an unrelated complaint.
DR. CIFU: They had all these people fill out review systems, written review systems, and any of them who said that they were having symptoms consistent with rectal bleeding, they tortured the poor people, and they work them up to the end to find out what was going on. And what was amazing is that these 201 people who were having rectal bleeding, but not severe enough to actually tell the doctor about, 24% of them had what they considered serious disease, a polyp 13%, colon cancer 6.5%, IBD in 4%.
DR. CIFU: The people who are the highest risk, not surprisingly, were older people, people who had a very short history of bleeding, and people who actually saw blood mixed with the stool as opposed to just blood on the toilet paper. Importantly, they found no cancers in patients under 50, small sample 200 patients, but no cancer is in patients under 50. And this thing, which might undermine my duodenoscopy, is that in 6 of the 37 patients who had a clear source of anal bleeding, so hemorrhoids that you could see either externally or on anoscopy, those people also had polyps or cancer further up in the colon.
DR. STERN: That's pretty scary.
DR. CIFU: Yeah.
DR. STERN: So the moral of the story is it's better to be under 50 than over 50.
DR. CIFU: [chuckles] One of those things, which none of us ever realized before. Yeah, for me, what I take away from this, is that if someone complains to me 45 and above maybe of any sort of rectal bleeding, I don't care, I'll take a history but they're getting a colonoscopy no matter what.
DR. STERN: Right, right.
DR. CIFU: And even people younger than that, who I'm really going to, work to get a good look, do a good anoscopy, try to give them good therapy for their hemorrhoids or their fissure or whatever, you know, I think is going on. I'm still going to keep those people on a pretty close leash. And if it sounds like this didn't get better with therapy, I'm going to look.
DR. STERN: I mean, the only way you're going to go wrong is not to look frankly.
DR. CIFU: Exactly, exactly, exactly.
DR. STERN: Okay, so a pet peeve of mine is when it comes to NSAIDs, I often hear in a patient that comes in with GI bleeding in the hospital that they're not taking NSAIDs. And yet when I go in and take a careful history, I find that in fact, they are. So a good NSAID history is not "Are you taking NSAIDs?"
DR. CIFU: [chuckles]
DR. STERN: More rarely, I go through every over the counter NSAID I could think of, I do remember aspirin and then I literally ask them what do they take for pain at all? And so that I can uncover the NSAIDs that everyone says they're not taking.
DR. CIFU: That's a great point. I have actually documented notes that I asked the patient, if they're taking NSAIDs, and recognized that that's a bad thing to do. I've been burned actually on people who take, an Advil before bed. And I'm like, what is that all about? But they're like, "Oh, you know it helps me sleep, 'cause you know my joints."
DR. STERN: Right, I've heard that too.
DR. CIFU: And that's an easy thing to miss. I got one last pet peeve.
DR. STERN: Okay go ahead.
DR. CIFU: And this is that not all anemia is iron deficiency anemia. It's like not all AKI is ATN. GI evaluation is absolutely a part of most iron deficiency anemia, but GI evaluation is not a part of other kinds of anemia, right? So if you think someone has thalassemia you know what, a colonoscopy is not going to help make the diagnosis.
DR. STERN: Probably won't help them feel better either.
DR. CIFU: [chuckles]
DR. STERN: Just saying, just want to be out there.
DR. CIFU: It will help the gastroenterologist.
DR. STERN: It will help the gastroenterologist. Okay, so our last section is on clinical pearls, Adam why don't you start us off?
DR. CIFU: Okay, so my clinical pearl is a little bit of data. Just sort of interesting. So this is people who come in with a GI bleed. So 90 to 95% of bleeding will be diagnosed on an EGD or colonoscopy and right, this is what we think most bleeding is either upper GI bleeds, all the things we've talked about, varices, Dieulafoy, peptic ulcer disease.
DR. STERN: Mallory-Weiss.
DR. CIFU: A Mallory-Weiss tear, which I should have written down before this session, or from the colon colitis of all brands, polyps, cancer, diverticuli. Of the 5 to 10% of people not diagnosed on the EGD or colon, the next place to go with them is a small bowel evaluation. And unlike, say, 10-15 years ago, we're pretty good at evaluating the small bowel now.
DR. CIFU: And that's especially related to capsule endoscopy, and to all of the advanced endoscopies that we can do. And so that 5 to 10%, that you don't make a diagnosis on EGD or colon, 75% of those patients will have a small bowel source of their bleeding. So interestingly, that leaves 25% left, it's a small 25%, right, 'cause it's 25% of the 5 to 10%, you didn't make the initial diagnosis on.
DR. CIFU: It turns out that almost all of those people, you can find out what was bleeding just by repeating the colonoscopy or the EGD. And it tends to be things like ulcers in hiatal hernias, or polyps behind foals in the colon, just things that even a well done endoscopy may miss.
DR. STERN: So joy, the only thing worse than one colonoscopy is two colonoscopies.
DR. CIFU: [chuckles] It's not just two colonoscopies, it's two colonoscopies, one EGD, and one pill before you get your diagnosis.
DR. STERN: Oh my goodness.
DR. STERN: All right, so my last clinical pearl, are you ready with your bell?
DR. CIFU: I am, I am.
DR. STERN: It's the importance of orthostatic vital signs [bell chimes] in patients who you think are bleeding. So we've already mentioned that the hemoglobin isn't reliable in acute bleeding. And it's actually important to appreciate that the sitting vital signs can be normal in someone despite massive blood loss. And the only way to document that someone's had massive blood loss is sometimes to stand them up, check their blood pressure and pulse again, don't order it, do it yourself, so it actually happens and record and see if there's a big difference.
DR. STERN: And the importance of this was shown in a study in the 1940s. I tried to repeat this but my IRB was a little reticent. In this study in the 40s, they actually bled the medical students, not of money this time, but actually drew a liter and a half of blood from them to see what would happen to their vital signs. And remarkably, most of the medical students after they lost a liter and a half of blood, were not hypotensive, and were not tachycardic, 'cause laying down, they could recruit enough of their venous return to maintain a normal blood pressure and pulse.
DR. STERN: But when you stood them up, that blood that pulled in the legs was enough to make 97% of them either tachycardic or hypotensive. So when you get someone like this, they're in the emergency room, they've had some bleeding, and you said, they don't look bad, their vital signs look okay, geez, just stand them up and check their blood pressure and pulse again, 'cause if you have a big change, you better get on it.
DR. CIFU: I'm going to throw in another pet peeve.
DR. STERN: Oh you get an extra.
DR. CIFU: I do.
DR. STERN: Okay.
DR. CIFU: It's the ordered orthostatic hypotension.
DR. STERN: Right, thank you.
DR. CIFU: Orthostatic vitals. It takes what, by definition, three minutes.
DR. STERN: Actually, there's no good data that you should wait, you can just literally stand them up and take it again.
DR. CIFU: Okay, so let's say 90 seconds.
DR. STERN: Right.
DR. CIFU: And there are times that orthostatic vital signs are not time critical. I think of when we get to talk about hyponatremia, right?
DR. STERN: Right.
DR. CIFU: But a lot of the time, it is really important to know fast. And like putting an order in Epic for orthostatic vital signs, that's like anathema to me.
DR. STERN: Well I kind of think that people who cannot do that, should get a different job. I mean, if you don't care enough to check the blood pressure, again, when you stand the person, just get another job, be a lawyer do something else, it's okay.
DR. CIFU: [chuckles] We may have to delete that. [both doctors laugh] And one other thing, interesting listening to your last clinical pearl then, which is I think just something that I need to look up. 'Cause I remember there being data, which we haven't actually talked about at all thus far in this podcast of the fact that an elevated BUN is suggestive of an upper GI bleed.
DR. STERN: Right.
DR. CIFU: And that is true that is supported by data, which is in the Symptom to Diagnosis textbook. And what it is, is that people's BUN is higher than you'd expect just based on the volume depletion. And that's because they've basically gotten a high protein meal right?
DR. STERN: Right.
DR. CIFU: And I think there's actually data on there of infusing dog blood into volunteers via an NG tube to see that happen. And so these are people who therefore were not volume deplete, but show that you can push up the BUN in that way.
DR. STERN: Oh interesting, it's a weird study.
DR. CIFU: Yeah, that may totally be apocryphal, I maybe making it up. But man, it's a good story.
DR. STERN: It's fun anyway. – Yeah.
DR. CIFU: Okay, so we hope you enjoyed this episode of the Symptom to Diagnosis podcast. We hope you found it useful as well. As a reminder, our textbook "Symptom to Diagnosis: An Evidence-Based Guide" takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations. The book is available in print through all the usual places, and also available and fully searchable on the Access Medicine website, which is available worldwide from McGraw Hill.
DR. CIFU: It's also now available for download on pretty much any device like an iPhone, and that's a really excellent version that I know Scott, you use frequently.
DR. STERN: I use it all the time.
DR. CIFU: There we go.
DR. STERN: All right, so thank you.
DR. CIFU: Great, bye bye. The music for the S2D Podcast is courtesy of Dr. Maylyn Martinez.
Segment:0 .
DR. CIFU: I'm Adam Cifu.
DR. STERN: And I'm Scott Stern.
DR. CIFU: And we're back with episode 6 of the Symptom to Diagnosis podcast. This podcast teaches evidence-based strategies for diagnosing common medical symptoms. Each episode is divided into four parts, we begin each episode with a case unknown to one of us. We then discuss five high yield features that help to accurately diagnose the cause of the symptom at hand. We then return to our case before finishing up with a discussion of fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge pertaining to the week's symptom.
DR. CIFU: The cases that we discuss are drawn from our clinical experiences but, because protecting patient privacy is part of our oath, we never discuss actual patients and most cases are composites.
DR. STERN: Well, our topic this week is GI bleeding. Adam, you are the expert of the day, do you have a case to present to me?
DR. CIFU: I do.
DR. STERN: Okay.
DR. CIFU: And I am feeling very expert-like.
DR. STERN: [chuckles] Okay.
DR. CIFU: So this patient is a 65-year-old man who presents without any past medical history with new exertional chest pain. He noticed a dull aching pain in his chest and shortness of breath with the brisk walk that he's accustomed to doing every morning. The symptoms have been present for about four weeks. He says they were barely noticeable at first, but now it become severe enough to lead us-- to lead him to this visit.
DR. CIFU: He otherwise feels actually completely well. His past medical history is unremarkable, I've been seeing this guy for 10-15 years. Interestingly, he had an EKG stress test a year before this visit, as part of a quote unquote, "executive physical" that he was sent to from his job. His review of systems were normal, he reported no change in bowel habits. He reported no change in appetite, no nausea or vomiting.
DR. CIFU: The only thing on his physical exam that was remarkable was that just kind of looking over his data from a year ago, is he'd lost about 10 pounds, he had not, he hadn't actually noticed this, he was a little bit of a heavy guy. So maybe not surprising. But it was documented from the weight that I had taken at a visit a year ago. So that's the case.
DR. STERN: Well, that's interesting, 'cause we're on GI bleeding, and this guy has come in with chest pain. So I have to admit, we need to put those two together. Clearly, the first thing that's going to be on your differential for this fellow would be some sort of ischemic heart disease, because he's a 65-year-old man, and whether he has risk factors or not, he is in a high-risk group.
DR. STERN: He did, you say, have a stress test a year ago, that I presumed was normal. But that doesn't exclude that possibility. Given the fact that we're GI bleeding, we do rarely see people who present with demand ischemia when they get anemic enough, that they present with chest pain and shortness of breath when they exert themselves. And so it is reasonable in patients who have chest pain to obtain a CBC in addition to the rest of your workup.
DR. STERN: But probably the initial start here would be to get a CBC and an EKG. And unless there's something really remarkable about the CBC consider stressing him again.
DR. CIFU: Good, good, sounds good. So I'll just maybe give you the start here, before we break. My thinking was really essentially the same. I guess maybe the one thing that I didn't tell you is that because he has an excellent primary care physician, he had a colonoscopy done at 60, five years before, which was completely normal. And they had recommended a repeat colonoscopy, when he was seven. I actually got an EKG in the room, which was normal.
DR. CIFU: I had one which I don't even know why he had it done about 10 years before, and that was unremarkable. And you are right, his EKG stress test at this executive physical, I did have the results of that too, and that was normal. I drew labs on the guy, I sent him home as sort of a little bit cautiously. But when those came back, his hemoglobin was 7.5. And I had a CBC also from three, four or five years before which was completely normal.
DR. CIFU: So this was obviously something new for him. His MCV on that was 62, 63, something remarkably low.
DR. STERN: Well, that's really interesting. So with that MCV and that hemoglobin, you'd almost be certain that this is an iron deficiency anemia, especially given a normal prior hemoglobin. Without that data, you could wonder about thalassemia, but obviously, if it's new, that's not the case. So now we have a patient who probably is having demand ischemia, and we can put that on the back burner briefly, while we try to figure out why he has what's really an iron deficiency anemia without a lot of other clear symptoms.
DR. STERN: He did have a negative colonoscopy five years ago, it makes an occult colon cancer less likely. He could still be bleeding from the colon. We don't know but it would make a cancer less likely, or it could be coming from an upper source, you know, ulcers, gastric carcinomas, esophageal carcinomas, all can present like this. You haven't mentioned that he's a drinker, alcoholism can present with varices but that typically presents as brisk breeding-- bleeding for other than occult low grade iron deficiency anemia.
DR. STERN: So it's pretty interesting story. And he would need a careful evaluation. I want to know about NSAIDs, because patients often take NSAIDs, and can have ulcers without pain shockingly enough, and can bleed without pain. And so I'd want to ask him about aspirin, Advil, Motrin, ibuprofen, and every single NSAID I could think of, and also just what he takes for pain, because this wouldn't be an unusual story for an ulcer.
DR. CIFU: First of all, I think alcohol use has been associated with brisk breeding in the past.
DR. STERN: [laughs]
DR. CIFU: But aside from that, your points are well taken. And interestingly, he had started a baby aspirin every day, a year ago, after his executive physical, which made me irritated given that with our current evidence, there was clearly absolutely no reason for that. Just before we move on to the next part, I'll ask you to put your nickel down. Where would you begin his evaluation? And what do you think is bleeding here?
DR. STERN: Well, it is really quite a guess with the data that we have. So normally had he not had the colonoscopy five years ago, I would start with the colon, 'cause colon cancer is more common than esophageal-- than gastric cancer in the United States in the West. I think given the negative colonoscopy in the past. So I'd probably start with the stomach and start with an endoscopy. Although, you know, frankly, whichever one you start with, if you don't get an answer, you're going to flip the patient upside down and do the other side.
DR. STERN: But I guess I'll put my nickel on ulcer.
DR. CIFU: Okay. Does the weight loss factor into that at all?
DR. STERN: It does, actually. So the causes of GI bleeding that can cause weight loss do include ulcers, a significant portion of people with ulcers do present with weight loss, and it's actually in the workup for unexplained weight loss is to consider an endoscopy. Obviously, the colon cancers can do the same, without a history of abdominal pain and diarrhea, IBD would be unlikely, I think to cause anemia and weight loss.
DR. STERN: A lot of the, it's interesting, a lot of the other causes of occult bleeding like angiodysplasia would be unlikely to cause weight loss and diverticular bleeding, as you know, doesn't present with microscopic low grade bleeding, but rather, you know, massive bleeding. So, again, that will point me towards upper rather than lower.
DR. CIFU: Okay. I'm just trying to, now that you've already missed the case, that the guy is having acute MI, I'm just trying to, get you even further off the mark.
DR. STERN: Thanks very much, I appreciate that. All right, so, Adam, why don't you give us some of the five key points about diagnosing GI bleeding to get us started?
DR. CIFU: Okay, so let me start, so my first point is that in an acute GI bleed, management proceeds diagnosis. You know, we're sort of all about diagnosis on this podcast. But at this time, basically, your diagnosis is GI bleed, and all the further details can wait. And so when I think about the initial management, I think, really about four steps. The first is risk stratifying people, how much should I worry about this people, and they're all-- this person, and there are all sorts of tools out there.
DR. CIFU: A lot of people will refer to the Glasgow-Blatchford scale for upper GI bleeds. And for lower GI bleeds, the greatest predictors of severity of bleed or actually of a poor outcome related to the bleed, is the hemoglobin on admission, the age of the patients, abnormal vital signs, and gross blood. Once you risk stratify, you have to prepare, and prepare basically means having good IV access.
DR. CIFU: And that means two large bore IVs. Let me just repeat that, two large bore IVs. It's important that they're large bore IVs. Because if you think about back to, I don't know, college physics, you remember that the flow rate is equal to the differential in pressure from where the fluids come fromfor where it's going. That's basically the same for us when you're giving blood as long as you're not, I guess, squeezing the bag of blood.
DR. CIFU: So it's the change in pressure times pi, times radius of the catheter to the fourth, okay? So that tells you why having a large bore IV is very, very powerful. Every time you decrease the bore of that IV, you're decreasing the flow by the fourth exponent, right? However you'd say that. And then that's divided by eight times the viscosity of the fluid, we can't do a whole lot to change the viscosity of saline or the viscosity of blood, times the length of the catheter, okay?
DR. CIFU: And so that's why we like, short, large bore peripheral IVs which are short. If you think about your central line, central lines are not only not large bore, but they're very long.
DR. STERN: So it is kind of weird, 'cause we always think of central lines as being the better way to deliver everything.
DR. CIFU: Yeah right.
DR. STERN: And this is one case where even if you had a central line, you'd be better off putting it in a large peripheral line.
DR. CIFU: Absolutely, absolutely.
DR. STERN: That's really surprising.
DR. CIFU: So after you've risk stratified and prepared, the next thing is resuscitation, okay. And you're going to start with fluids, you're going to start with fluids with some solute, so lactated ringers or normal saline. And then you're going to move on to blood, when you give blood maybe it's a little bit controversial, or not exactly clear. But in general, if someone's lost a lot of blood, you give the blood.
DR. CIFU: So people will say 30% blood loss, hard to measure if the person's bleeding plus their tachycardic, hypertensive, tachypneic, if their urine output is down, those people need blood. If you've already given two liters of fluid, and they're not volume replete at that time, give them blood. And if they come in bleeding, and their hemoglobin is less than nine, give them blood.
DR. CIFU: We may underdo that these days, 'cause there's pretty good data, right? That if someone's, that we can hold off on transfusions until someone's hemoglobin gets below seven. But that's not true if they're actively bleeding.
DR. STERN: That's really important. I do think right now, everyone tends to think that no one needs blood, and it's just a different animal when someone's hemorrhaging in front of you.
DR. CIFU: Absolutely true. And then the last one in this first point is to think about if they're initial, sort of specific empiric therapies, which you should throw out there. So is the patient anticoagulated? Do you need to reverse anticoagulation? Is this very likely to be an ulcer? In which case you'd want to give them a PPI. Is this likely to be an esophageal variceal bleed, where you'd want to give them octreotide.
DR. CIFU: My second point is to differentiate upper from lower bleeds. This is not always possible, but sometimes it is. So take a history is this someone who've had previous diverticular bleeds in the past or previous variceal bleeds? As you mentioned, Scott, are they on NSAIDs? Are they a drinker? Do they have vascular disease, right? Where they may be bleeding from ischemic colitis.
DR. CIFU: Have they had pelvic radiation in the past? Are they febrile? Is this part of an illness where maybe they've got infectious colitis? Or do they have the classic history of like, I went out I drank last night, I threw up two times, and on the third time, all of a sudden blood started coming. Where you'd think about a--
DR. STERN: Mallory-Weiss tear.
DR. CIFU: Thank you very much. [both doctors chuckle]
DR. CIFU: Have you jumped in there while I was having a TIA and couldn't remember the name. And then there's some clinical features, right? So obviously, if someone's throwing up blood, it's from above, melena suggestive of an upper bleed, and hematochezia for the most part is suggestive of a lower bleed.
DR. STERN: So just if I understand you correctly, your profound comment was if they're throwing up blood it's from above?
DR. CIFU: Yes.
DR. STERN: Okay just want to make sure.
DR. CIFU: Third key point, in acute bleeding, we usually start with an EGD, rather than a colonoscopy, if we really don't know where it's coming from. And that's because someone with an acute GI bleed, the people who are at the highest risk are going to bleed from an upper source, either peptic ulcer disease, eroding into a vessel or an esophageal bleed. It's very unusual for someone to exsanguinate from a lower GI source.
DR. STERN: Right. And I have seen people and I'm sure you have too, who've bled to death from varices.
DR. CIFU: Yeah, and I think we'll probably underline that a few times during this is take GI bleeding seriously,
DR. STERN: There we go.
DR. CIFU: Fourth key point. And this is big as an outpatient general internist, which I think both Scott and I consider ourselves first and foremost, is never, ever, ever ignore iron deficiency. A lot of people get into trouble with saying, oh, iron deficiency anemia, the treatment for that is iron. You know, no. Yes, the person should be on iron, oral or IV iron, whatever, but you have to figure out a cause.
DR. CIFU: And so never, ever, ever just replete iron. On the other hand, make sure that when you have someone who's got an iron deficiency anemia, that you don't go GI bleed and close your mind otherwise, right? There are people who actually have iron deficiency anemia from other causes, celiac disease, just poor iron intake. And it's worth thinking about those things.
DR. STERN: I like to say that if you give people iron who are older adults, who aren't menstruating without thinking about the cause of iron deficiency, you should just write out a check to the opposing attorneys you sign and they can put out how many zeros they want on that, because you can't defend it.
DR. CIFU: Give the patient the blank check with their prescription for iron, right?
DR. STERN: Right.
DR. CIFU: And my fifth and final key point is maybe something that I already said, is just don't get lackadaisical about GI bleeds. When I was a resident, and I know my residents now when they present cases to me kind of the night before I come in, just give you one liners, it's often, "Oh, and the last one is a 65-year-old with a GI bleed." And it's just like, here's an easy admission, this is someone who's going to come in, they're going to get scoped tomorrow, they'll go home the next day.
DR. CIFU: And that's great, that's an easy one, we don't have to think about it. And for the most part, that's true. But occasionally, you're going to have someone just do terribly. And when I say don't get lackadaisical, it's that think about it, be concerned about the person and make sure you have those two large bore IVs. Because when the person is exsanguinated, you don't want to walk in there and find out that they have a 22 gauge IV hanging out of their thumb or something.
DR. CIFU: 'Cause you don't want to be scrounging for good venous access at the point where the person's bleeding.
DR. STERN: Right, 'cause you know, once they're depleted, you can't find the veins to put it in.
DR. CIFU: Great point, great point. And when was the last time you put in an intraosseous line or something right?
DR. STERN: Oh, my goodness, I get chest pain. All right, well, that's terrific. Do you want to-- let's go back to our case, and can you give us some follow up on what happened?
DR. CIFU: Sure, so I call this guy back. I tell him he's incredibly anemic. And that's probably the cause of his chest pain. And I have to decide what my first test is. Scott, you suggested--?
DR. STERN: An EGD.
DR. CIFU: An EGD. And I did start with an EGD on the guy and he had a large ulcer with a visible vessel actually, amazing. He was not bleeding at the time, but the gastroenterologist who scoped him said, "Well, there's your answer!" Stopped his aspirin, put him on a PPI, biopsies were done at the time, both for gastric cancer and for H. pylori, those were negative. We actually re-scoped the guy six weeks later, 'cause the gastroenterologist was concerned enough about the size of his ulcer, even despite that negative biopsy, they wanted to make sure that it healed, make sure there wasn't a cancer there, it was biopsied again, at that point, it was normal, that was probably overkill.
DR. CIFU: And the guy actually just on oral iron came up nicely. Chest pain was gone within a week. And I'm trying to think back, I'm pretty sure I did not transfuse this guy, which as I think back on it maybe was kind of gutsy.
DR. STERN: Yeah, it might have, especially with the chest pain, right?
DR. CIFU: Yeah, especially with the chest pain. So let me ask you once he was better, and this is a real question, would you have stressed? So he's better, he's actually back to his normal exercise, he's feeling fine, we just trust him at that point.
DR. STERN: Well, so as you've mentioned in another podcast, I'm kind of a pathological over tester. I think you can easily make the argument not to stress him 'cause he's now asymptomatic, and you probably have demand ischemia. So at best you're going to uncover atherosclerotic disease, that's not currently symptomatic. So you could make a rational argument not to do it, I probably knowing my own personal biases and terrors would probably have done it.
DR. STERN: But I think the rational approach would be to say it's reasonable not to. What did you do?
DR. CIFU: I did not do it. And I think had I told you about the case at the time, and you said to do it, I would have scoffed it.
DR. STERN: Yeah probably.
DR. CIFU: But I agree, it was sort of a tough call. I got to actually look up this case now. Because reading this and going over it, I think I probably should have transfused him, and I hope I did. Maybe we'll get back with the answer to that on a future podcast.
DR. STERN: All right, to be continued. All right, so let's go on now and talk about some fingerprints, common misconceptions, our favorite pet peeves and other random pearls of knowledge. Adam, do you want to give us some fingerprints for GI bleeding?
DR. CIFU: Okay, my first fingerprint is one of those ones that is just going to shock everybody listening here. The presence of clots in the stool, blood clots in the school-- stool, has a likelihood ratio of 14 for a lower GI bleed. So if you see blood clots in the stool, that person is bleeding from below the ligament of Treitz.
DR. STERN: And what if you see blood clots in the school, what does that mean?
DR. CIFU: That means everybody should go home and do school and zoom for the rest of the year.
DR. STERN: All right, so my first fingerprint is, on the other hand, black stools, or blood or coffee grounds when people vomit or on NG aspirate is highly suggestive of an upper GI bleed with likelihood ratios of over 10, of 25 for melenic stools. So it's really helpful, black tarry stools really focuses you on the upper pathology, as of course, does throwing up blood and coffee grounds.
DR. CIFU: Great.
DR. STERN: All right, common misconceptions.
DR. CIFU: Okay, so my first misconception here is that in occult GI bleeding, so much like our case here, a colonoscopy is all you need. So there was a time actually that we sort of said, iron deficiency, anemia, occult GI bleeding, just do a colon and only go beyond that if you don't find anything on the colon. Most experts nowadays and most guidelines actually recommend an EGD after a colonoscopy for a patient with heme positive stools, and iron deficiency anemia.
DR. CIFU: Now, of course, if you find and obstructing colon cancer, that's not necessary. But the fact is most of the things that you're going to find on a colonoscopy, small patch of NSAID related colitis, polyps and diverticula, that's not a definitive cause of an iron deficiency anemia.
DR. STERN: I think that's really a good point, it'd be easy to stop when you find a polyp. And everybody has polyps basically, right?
DR. CIFU: Right.
DR. STERN: That's helpful. Well, my common misconception, and I see this not infrequently, is that a normal hematocrit on presentation rules out a significant hemorrhage, and that's just crazy. I mean, when people bleed, they bleed whole blood. And what's left behind in their vasculature is whole blood of the same concentration as before, until you dilute it with IV fluids or PO fluids. So when you're acutely bleeding, if you were shot, stabbed, or have a massive GI bleed, your hematocrit is the same for a while.
DR. STERN: And so we can't use that to judge severity.
DR. CIFU: Yeah, and that's actually been supported, I mean, you know this, with sort of incredible studies.
DR. STERN: Okay.
DR. CIFU: So there are, this is back to Vietnam, where there are people with penetrating trauma and blood loss. And first blood counts on those people we're normal.
DR. STERN: Makes total sense.
DR. CIFU: Absolutely.
DR. STERN: Right.
DR. STERN: All right, so pet peeves, you have any?
DR. CIFU: Okay, oh of course I've got pet peeves.
DR. STERN: Oh come on.
DR. CIFU: This first one is going to make me sound like a complete and utter nut. So my pet peeve is that people often think that patients are expert diagnosticians. And that's the case for a lot of things. And maybe as an aside, I often ask people, what do you think is going on, especially when I'm confused about a diagnosis, because patients often have something to add. But when patients tell you that they have hemorrhoids, you should ignore what they say.
DR. CIFU: And that's especially the case when they say, "You know I've got some blood that I'm seeing in the toilet, it's from my hemorrhoids." Okay? Patients don't know what they're talking about in this point there's almost no way for a patient to actively examine their bottom, right? And most people, anything that's going wrong with their sort of anal rectal area says it's hemorrhoids, because they've watched, Preparation H commercials for I don't know, two generations.
DR. CIFU: So when you're seeing that person, you got to look, you got to look at the outside, you should probably do an anoscopy in the office to see this. And there's a really key study which underlines this, which I just always talk to people about. So wonderful study, which looked at 201 patients from a VA who came to the doctor for an unrelated complaint.
DR. CIFU: They had all these people fill out review systems, written review systems, and any of them who said that they were having symptoms consistent with rectal bleeding, they tortured the poor people, and they work them up to the end to find out what was going on. And what was amazing is that these 201 people who were having rectal bleeding, but not severe enough to actually tell the doctor about, 24% of them had what they considered serious disease, a polyp 13%, colon cancer 6.5%, IBD in 4%.
DR. CIFU: The people who are the highest risk, not surprisingly, were older people, people who had a very short history of bleeding, and people who actually saw blood mixed with the stool as opposed to just blood on the toilet paper. Importantly, they found no cancers in patients under 50, small sample 200 patients, but no cancer is in patients under 50. And this thing, which might undermine my duodenoscopy, is that in 6 of the 37 patients who had a clear source of anal bleeding, so hemorrhoids that you could see either externally or on anoscopy, those people also had polyps or cancer further up in the colon.
DR. STERN: That's pretty scary.
DR. CIFU: Yeah.
DR. STERN: So the moral of the story is it's better to be under 50 than over 50.
DR. CIFU: [chuckles] One of those things, which none of us ever realized before. Yeah, for me, what I take away from this, is that if someone complains to me 45 and above maybe of any sort of rectal bleeding, I don't care, I'll take a history but they're getting a colonoscopy no matter what.
DR. STERN: Right, right.
DR. CIFU: And even people younger than that, who I'm really going to, work to get a good look, do a good anoscopy, try to give them good therapy for their hemorrhoids or their fissure or whatever, you know, I think is going on. I'm still going to keep those people on a pretty close leash. And if it sounds like this didn't get better with therapy, I'm going to look.
DR. STERN: I mean, the only way you're going to go wrong is not to look frankly.
DR. CIFU: Exactly, exactly, exactly.
DR. STERN: Okay, so a pet peeve of mine is when it comes to NSAIDs, I often hear in a patient that comes in with GI bleeding in the hospital that they're not taking NSAIDs. And yet when I go in and take a careful history, I find that in fact, they are. So a good NSAID history is not "Are you taking NSAIDs?"
DR. CIFU: [chuckles]
DR. STERN: More rarely, I go through every over the counter NSAID I could think of, I do remember aspirin and then I literally ask them what do they take for pain at all? And so that I can uncover the NSAIDs that everyone says they're not taking.
DR. CIFU: That's a great point. I have actually documented notes that I asked the patient, if they're taking NSAIDs, and recognized that that's a bad thing to do. I've been burned actually on people who take, an Advil before bed. And I'm like, what is that all about? But they're like, "Oh, you know it helps me sleep, 'cause you know my joints."
DR. STERN: Right, I've heard that too.
DR. CIFU: And that's an easy thing to miss. I got one last pet peeve.
DR. STERN: Okay go ahead.
DR. CIFU: And this is that not all anemia is iron deficiency anemia. It's like not all AKI is ATN. GI evaluation is absolutely a part of most iron deficiency anemia, but GI evaluation is not a part of other kinds of anemia, right? So if you think someone has thalassemia you know what, a colonoscopy is not going to help make the diagnosis.
DR. STERN: Probably won't help them feel better either.
DR. CIFU: [chuckles]
DR. STERN: Just saying, just want to be out there.
DR. CIFU: It will help the gastroenterologist.
DR. STERN: It will help the gastroenterologist. Okay, so our last section is on clinical pearls, Adam why don't you start us off?
DR. CIFU: Okay, so my clinical pearl is a little bit of data. Just sort of interesting. So this is people who come in with a GI bleed. So 90 to 95% of bleeding will be diagnosed on an EGD or colonoscopy and right, this is what we think most bleeding is either upper GI bleeds, all the things we've talked about, varices, Dieulafoy, peptic ulcer disease.
DR. STERN: Mallory-Weiss.
DR. CIFU: A Mallory-Weiss tear, which I should have written down before this session, or from the colon colitis of all brands, polyps, cancer, diverticuli. Of the 5 to 10% of people not diagnosed on the EGD or colon, the next place to go with them is a small bowel evaluation. And unlike, say, 10-15 years ago, we're pretty good at evaluating the small bowel now.
DR. CIFU: And that's especially related to capsule endoscopy, and to all of the advanced endoscopies that we can do. And so that 5 to 10%, that you don't make a diagnosis on EGD or colon, 75% of those patients will have a small bowel source of their bleeding. So interestingly, that leaves 25% left, it's a small 25%, right, 'cause it's 25% of the 5 to 10%, you didn't make the initial diagnosis on.
DR. CIFU: It turns out that almost all of those people, you can find out what was bleeding just by repeating the colonoscopy or the EGD. And it tends to be things like ulcers in hiatal hernias, or polyps behind foals in the colon, just things that even a well done endoscopy may miss.
DR. STERN: So joy, the only thing worse than one colonoscopy is two colonoscopies.
DR. CIFU: [chuckles] It's not just two colonoscopies, it's two colonoscopies, one EGD, and one pill before you get your diagnosis.
DR. STERN: Oh my goodness.
DR. STERN: All right, so my last clinical pearl, are you ready with your bell?
DR. CIFU: I am, I am.
DR. STERN: It's the importance of orthostatic vital signs [bell chimes] in patients who you think are bleeding. So we've already mentioned that the hemoglobin isn't reliable in acute bleeding. And it's actually important to appreciate that the sitting vital signs can be normal in someone despite massive blood loss. And the only way to document that someone's had massive blood loss is sometimes to stand them up, check their blood pressure and pulse again, don't order it, do it yourself, so it actually happens and record and see if there's a big difference.
DR. STERN: And the importance of this was shown in a study in the 1940s. I tried to repeat this but my IRB was a little reticent. In this study in the 40s, they actually bled the medical students, not of money this time, but actually drew a liter and a half of blood from them to see what would happen to their vital signs. And remarkably, most of the medical students after they lost a liter and a half of blood, were not hypotensive, and were not tachycardic, 'cause laying down, they could recruit enough of their venous return to maintain a normal blood pressure and pulse.
DR. STERN: But when you stood them up, that blood that pulled in the legs was enough to make 97% of them either tachycardic or hypotensive. So when you get someone like this, they're in the emergency room, they've had some bleeding, and you said, they don't look bad, their vital signs look okay, geez, just stand them up and check their blood pressure and pulse again, 'cause if you have a big change, you better get on it.
DR. CIFU: I'm going to throw in another pet peeve.
DR. STERN: Oh you get an extra.
DR. CIFU: I do.
DR. STERN: Okay.
DR. CIFU: It's the ordered orthostatic hypotension.
DR. STERN: Right, thank you.
DR. CIFU: Orthostatic vitals. It takes what, by definition, three minutes.
DR. STERN: Actually, there's no good data that you should wait, you can just literally stand them up and take it again.
DR. CIFU: Okay, so let's say 90 seconds.
DR. STERN: Right.
DR. CIFU: And there are times that orthostatic vital signs are not time critical. I think of when we get to talk about hyponatremia, right?
DR. STERN: Right.
DR. CIFU: But a lot of the time, it is really important to know fast. And like putting an order in Epic for orthostatic vital signs, that's like anathema to me.
DR. STERN: Well I kind of think that people who cannot do that, should get a different job. I mean, if you don't care enough to check the blood pressure, again, when you stand the person, just get another job, be a lawyer do something else, it's okay.
DR. CIFU: [chuckles] We may have to delete that. [both doctors laugh] And one other thing, interesting listening to your last clinical pearl then, which is I think just something that I need to look up. 'Cause I remember there being data, which we haven't actually talked about at all thus far in this podcast of the fact that an elevated BUN is suggestive of an upper GI bleed.
DR. STERN: Right.
DR. CIFU: And that is true that is supported by data, which is in the Symptom to Diagnosis textbook. And what it is, is that people's BUN is higher than you'd expect just based on the volume depletion. And that's because they've basically gotten a high protein meal right?
DR. STERN: Right.
DR. CIFU: And I think there's actually data on there of infusing dog blood into volunteers via an NG tube to see that happen. And so these are people who therefore were not volume deplete, but show that you can push up the BUN in that way.
DR. STERN: Oh interesting, it's a weird study.
DR. CIFU: Yeah, that may totally be apocryphal, I maybe making it up. But man, it's a good story.
DR. STERN: It's fun anyway. – Yeah.
DR. CIFU: Okay, so we hope you enjoyed this episode of the Symptom to Diagnosis podcast. We hope you found it useful as well. As a reminder, our textbook "Symptom to Diagnosis: An Evidence-Based Guide" takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations. The book is available in print through all the usual places, and also available and fully searchable on the Access Medicine website, which is available worldwide from McGraw Hill.
DR. CIFU: It's also now available for download on pretty much any device like an iPhone, and that's a really excellent version that I know Scott, you use frequently.
DR. STERN: I use it all the time.
DR. CIFU: There we go.
DR. STERN: All right, so thank you.
DR. CIFU: Great, bye bye. The music for the S2D Podcast is courtesy of Dr. Maylyn Martinez.
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