Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
9 January 2008

INTERNAL BLEEDING

            One of the most common problems that healthcare providers run into is the person that comes to the clinic or the hospital with a history of passing blood through their bowels or vomiting blood or coughing up blood.  If one gets a cut or a scratch and it bleeds a little, local application of light pressure to stop the bleeding may be all that is needed.  Sometimes we have to sew a person up when they get a bad cut but the reason for that bleeding is pretty obvious when there is a cut and what to do is equally obvious.  When a person comes to medical attention because of coughing up or vomiting up blood or passing blood through their rectum, there is no place to apply local pressure to put on it and whatever cutting and sewing needs to be done is a big deal. The bleeding may be minor from a hemorrhoid or it may be major and life threatening, such as if it comes from an ulcer.  Below are described 4 patients that came to medical attention in December and how we take of care of this type of problem. 

            The first patient was a 96-year-old gentleman who was awakened in the early morning hours with urgent need to have a bowel movement.  When this occurred, he noted that there was a large amount of blood in the stool.  He saw that the stool was jet black in addition to having a large amount of blood.  He said that he felt kind of dizzy so he called his son who brought him on to the hospital.  On arrival in the emergency room, it was seen that he had a blood count in the low normal range, his blood pressure was only 90/60 and his pulse was quite rapid.  If he sat up, his blood pressure dropped and he became slightly nauseated.  To make a long story short, this was the classical presentation for a stomach ulcer.  He was given two units of blood, started on a medicine that would stop stomach acid, and started on a medicine called sucralfate that sticks to ulcers and decreases their bleeding.  To be complete, he really should have had a tubed passed down to his stomach to see what the bleeding site was for sure but he refused that.  He said that at 96-years-of-age, just fix the bleeding problem and he didn’t need all that extra commotion.  So the following day, his blood count was near normal and his blood pressure had repaired. He had never had any pain.

 Talking to him, it was found that he was taking over-the-counter ibuprofen for his arthritis.  He had been taking 2 pills four times a day and said that it really made his arthritis feel better.  While ibuprofen helps arthritis, it also dissolves the lining in the stomach that protects the stomach from itself.  The stomach can digest carrots, meat, eggs, or bread or anything else that is put down there.  People sometime ask why they don’t digest their own stomach.  It is because the stomach has a protective lining which unfortunately is eroded away by ibuprofen.  When this was explained to this gentleman, he said that is all he needed to know and he wanted to go home now.  It was several days before Christmas and against good medical judgement, he went home.  Follow up this past week indicated that he wasn’t bleeding any further and his medicine to let the ulcer heal seemed to be working.  He didn’t want any more diagnostic studies done and hopefully will do well in the future.

            The second person came in on a Monday morning after a weekend of Christmas celebration.  He indicated that his stomach was hurting terribly and he vomited blood twice on Sunday night but decided to make wait to the next day to get checked.  He said he knew that he had more to drink than was a wise choice.  This was a young individual and he did agree to have his stomach checked by gastroscopy.  This is a procedure where the person is put lightly to sleep and a tube is passed down to the stomach to see where the bleeding is coming from.  On this particular young man, he had a diffuse irritation of the whole gastric lining.  Just like ibuprofen can dissolve the stomach lining, too much alcohol does the same thing and has the additional bad effect of making the stomach make more acid.  No protective lining and lots of acid is a sure formula for gastritis that sometimes bleeds and very often hurts.  This young man was treated with the same two medicines that the 96-year-old gentleman had.  He said please don’t lecture him on his drinking; he already knew that he had been drinking more than he ought too.  Fortunately, when he came back last week, his blood count was normal and he was feeling better. 

            The third person was a bit more of a problem.  She came to the clinic because she was tired. When we checked her blood count, it was seen that it was very low and that she was very iron deficient.  In a 70-year-old lady, this is a sure sign that there is bleeding in the bowel some place.  Her stools were checked and found to have “hidden” blood in them that the person had never seen.  A procedure called a colonoscopy was carried out. The person is put lightly to sleep and a tube is passed into the colon that can look for the site of the bleeding.  This lady was found to have several areas of what is called angiodysplasia.  These can be thought of as varicose veins on the inside of the colon that bleed a little bit intermittently and slowly drain the person’s blood supply down.  Unfortunately short of removing the colon, there is nothing that really changes this and she will probably have to have intermittent transfusions in the future and be on an iron pill to supplement her iron levels.  It wasn’t the cancer that she was sure she had.

            The last person to talk about was not so lucky.  He came to the clinic because he had seen purple, dark blood in his stool.  He said that this had occurred several times in the past week and he wondered about what the problem might be.  He had heard that bleeding like this might represent a cancer and this thought was very disturbing for him.  Indeed when the colonoscopy was done, he had a cancer that was bleeding a little at a time.  A chest film and evaluation of his liver did not indicate the presence of the cancer spreading to these sites.  He is due to have the left side of his colon removed in the very near future.  Following this, a course of chemotherapy will also be administered.  It has been shown that this “adjuvant chemotherapy” leads to better survival after colon cancer surgery than those who don’t receive it.  If he is lucky, he will be re-examined in six months, one year, three years and five years.  It was pointed out to his 2 brothers that their risk for a colon cancer is now substantially more than it was before a cancer was found in their brother.  It was strongly recommended that they both undergo colonoscopy to remove any polyps to prevent the cancer from ever coming. 

            When a person vomits blood or coughs up blood or passes blood per rectum, a “treasure hunt” is begun to find the source of the bleeding and fix it.  The healthcare providers at your local clinics are the place to start with this evaluation unless the bleeding is substantial and then the person should get to the emergency room immediately.  The evaluations for internal bleeding are pretty straight-forward and fixing things early can be lifesaving.  As a preventive piece of advice, avoiding alcohol excess and those over-the-counter arthritis medicines can save everybody a lot of trouble.

This and other columns available at www.macpierre.com.