Wednesday, June 27, 2012
“It was really scary. I’ve never felt the urge to pass out every time you stand up, and I really didn’t know what was going on. When the doctor said, ‘Come to my office and we’ll check you out,’ I said, ‘I can’t get there. I can’t walk.’
Clay Buchholz, Boston Red Sox pitcher
Elite athletes get lightheaded when they are dehydrated during practice or competition. They don’t usually feel that way because they are bleeding, but Mr. Buchholz ended up in ICU because of a GI bleed, and in his case presumably bleeding from his esophagus. That’s an unusual place to have major bleeding. More often it’s from the stomach or duodenum because of inflammation or an ulcer but regardless, the initial treatment is the same.
Patients who are bleeding from their gastrointestinal (GI) tract can get sick in a hurry. Because the bleeding is hidden, you don’t know how much or how little they have bled. There are a few clues. The first is the bowel movements that have turned black and tarry because of digested hemoglobin in red blood cells. Not all black is bad though. Iron turns stool black and so does beets, black licorice and PeptoBismol.
A quick digression: ER docs hate Pepto because the bismuth turns stool black and since it is often taken for an upset stomach, it can confuse the issue whether the stool really has blood in it.
Back to the issue at hand. Black stool, upset stomach, lightheaded equals bleeding from the upper GI tract, the esophagus, stomach or small intestine. The diagnosis is usually made by history and physical exam, including the dreaded rectal exam so that a sample of stool can be tested to see if contains blood. Blood pressure and heart rate may be taken both laying and standing to look for hidden fluid loss. The body tries to compensate for bleeding by increasing the heart rate and having the muscles that surround blood vessels squeeze a little tighter. This helps maintain blood pressure but if enough blood is lost, the body’s compensation fails, pulse rate rises and blood pressure falls. Mr. Buchholz stated it well: I’ve never felt the urge to pass out every time you stand up.
Treatment usually before the cause of the bleeding is known. IVs get put in and fluid resuscitation can begin. Using normal saline or salt water, the volume of blood can be replaced, but not necessarily the oxygen carrying capabilities. Often, if the bleeding stops spontaneously, blood transfusion isn’t needed but there needs to be blood ready just in case. Medications that decrease acid secretion similar to Zantac or Prilosec can be injected intravenously and oxygen can be administered to pack every red blood cell full.
While stabilization occurs, there also needs to be definitive treatment to find where the bleeding is located and stop it. Unlike a cut on the skin where you can hold pressure to control bleeding, reaching down somebody’s throat isn’t an option. This is where a gastroenterologist comes in handy. They use an endoscope, a thin tube with a camera that is passed through the mouth, down the esophagus, into the stomach and into the duodenum, (the first part of the small intestine) to not only look for the bleeding site but also to cauterize or burn the blood vessels that are the culprit causing the bleeding.
Bleeding from the esophagus is pretty common in college kids after a night of drinking or for that matter, anybody who has had significant vomiting. Throwing up is a violent act and the stomach literally turns itself inside out as it pushes up into the esophagus and can cause a Mallory Weiss tear (named after the two doctors who described the syndrome in the 1920s) where the lining of the esoghagus can develop a minor tear and some bleeding. More extensive bleeding occurs when the esophagus has major inflammation or ulceration. Patients with cirrhosis can develop varices or swollen veins within the esophagus that can cause life threatening bleeding.
Now that the crisis is passed, Mr. Buchholz and his doctors will try to find out why the bleeding occurred and hopefully prevent future episodes. Meanwhile, his body will need to recover and replenish the blood he has lost. It may take a few weeks for his bone marrow to crank out enough red blood cells for him to perform as an elite athlete. Waiting may be the hardest thing for athletes to do, especially in the middle of the season. Perhaps the people who will suffer the most are Red Sox fans who don’t want to wait for their winning pitcher to return.