A gentleman was recently brought to the clinic by his family because he seemed weak and he got dizzy whenever he stood up.  They indicated that he had been under a great of stress recently helping care for his wife who had been quite ill.  She had a severe heart condition and was not expected to improve.  The gentleman had some arthritic pains and had been using Aleve as an over-the-counter arthritic medicine.  When he was seen in the clinic, he was very pale with almost a slight tinge of yellow to his skin.  He was obviously fatigued.  He was still able to converse easily and volunteered that, “My get up and go just got up and went.  I have nothing left.”

     Normally, a man’s blood contains between 42 and 52% red blood cells.  The test is done by spinning the blood very rapidly so all of the red cells go down to the bottom of the tube leaving a pale fluid on top and then the proportion of the blood count of his red cells can be read as a percent and is called the hematocrit.  On this gentleman, his hematocrit was 17%.  In other words, he had lost about 2/3 of his red cells some place.

      If this happens slowly, the body will contain the blood volume by adding water to the blood.  But as the number of red cells decreases below a critical amount, there is just not enough oxygen carrying capacity in the red cells left, to have the body function normally.  This gentleman was immediately hospitalized and blood was matched with his own so he could be transfused to get his hematocrit back up to 30%.  This required three units of blood to be given.  With this, he got some color back in his cheeks and felt much better.

     The next step was to determine where his blood had been lost.  Everyday about 2% of a normal person’s blood is broken down to get rid of old red cells.  2% of the blood is made as new red cells so the amount stays constant day to day.  The workup of a low blood count is remarkably simple.  Either the person is not making enough or they are losing too much.  The not making enough part has a relatively short list of causes.  The person may have a Vitamin B-12 deficiency as for pernicious anemia in a recent column or the person may have a problem with leukemia or other such diseases.

     By far the most common cause of a low blood count in an adult is bleeding into the gastrointestinal tract.  When this occurs faster than the body can absorb iron, the new production of red cells simply can’t keep up with the amount of bleeding that is going on and the person’s blood count progressively drops.  If the person bleeds a lot in a hurry, they will develop the weakness and dizziness described in this gentleman.  Instead, if the bleeding occurs very slowly over a long period of time, the person may adjust remarkably well until the hematocrit gets to about 24% or less.

     In this particular gentleman, it was found that his stools had a substantial amount of blood in them although this is only detectable by a chemical test.  He indicated that he wasn’t aware that he was bleeding in his bowels.  This is often the case when the amount of blood is so small that it is not visible in the stool.

     Once it was seen in the gentleman’s stool and examination of his stomach and his colon was carried out.  Through the use of modern fiberoptic technology, a hose about the size of a ballpoint pen can be slide into the person’s stomach or into the colon to examine where the bleeding might be coming from.  There are about 28 feet of intestinal tract from the person’s mouth clear down to the rectum.  Surprisingly, bleeding into the intestinal tract only seems to occur in the last six feet in the large bowel or in the first four feet to the esophagus  and stomach and to duodenum.  Thus, the 18 feet of small intestine rarely ever has a bleeding site.

     By far the most common cause of a person bleeding into the gastrointestinal tract is gastritis.  Gastritis is the word used to describe and irritation to the stomach lining.  Note that the stomach is protected from itself by hormones called prostaglandins.  Prostaglandins coat the stomach and protect it from digesting itself.  You can digest meat and potatoes and broccoli and a whole bunch of things.  But the person does not digest his or her own stomach because of prostaglandins that coat it.

     Certain situations will predispose the person to losing the protective coating and the result is a rare irritated stomach surface that can bleed profusely.

     In this particular gentleman, he had been taking Aleve which works well to stop his arthritis but it worked even better to turn off his protective stomach lining and he was digesting his own stomach.  This raw surface area in his stomach had bleed profusely over several weeks time and resulted in his low blood count.  The extra acid that his stomach had been making in his stressed situation added fuel to the fire.

     He was started on medications and provided with a pill called Sucralfate.  Sucralfate is a magic medicine that binds to raw surfaces and protects them from further bleeding.  In addition, that pill was given to turn off his stomach acid and he improved very quickly and went home.  He will have to remain on protective medications for about a month while the stomach lining heals.  Following this, a pill to cut down his stomach acid might be useful to prevent further problems in the future.  He was instructed to use something different than over the counter arthritis medicine such as Motrin, Nuprin, Aleve, Advil, Aspirin, or Orudis.  All of these pills prevent the stomach from protecting itself because they turn off the stomach’s production of prostaglandins.

     In times of increased stress, worsening fatigue, unusual weakness, or the person noticing they are having black stools, there is a real possibility that the person may be bleeding into their stomach or colon.  Evaluation at your local clinics can often catch these problems at an early time and prevent an unpleasant outcome.