In last month’s episode, we dealt with patients who were obviously bleeding to death. Most patients with GI bleeding present with far less drama. The stakes here are high because the mortality of patients with GI bleeding are substantial.
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Paul N. - May 2, 2016 12:20 AM
Does a rectal exam really change your management of a patient in the ED?
If someone has a negative guaiac are they still not bleeding? Is it an intermittent bleed?
Example: Elderly man came into the ED after he told his Hematologist/Oncology doctor that he was bleeding. He had a negative guaiac and stable H and H. He was sent home told to continue his coumadin. He came back later at night with dark stool and hypotension.
If someone tells you their stool is black do you not believe them?
Steve P - May 4, 2016 12:59 AM
the guaiac might not change your management but what you see and feel on rectal exam can DRASTICALLY change it
Mizuho M. - June 7, 2016 6:07 PM
Agree with Steve. I do think it's an impt part of the evaluation. If the guaic is negative & they are hemodynamically stable, outpatient workup would likely be a better option. But as in your case Paul you would give strict return precautions.
Clinical gestalt, resources both in house & outpatient also play into your decision making. Bottom line is that management of these pts is NOT easy! Thx for listening!
Dallas H. - May 20, 2016 1:38 AM
What about stool guaiac in undifferentiated anemia as an incidental finding? Should be we be performing these routinely?
Mizuho M. - June 7, 2016 6:08 PM
Hi Dallas. If you are searching for a source of acute anemia in the ED, yes I think it's appropriate to perform to rule it out. If your asking if we should be doing these on everyone...id say no. ;)
docshardy - June 5, 2016 8:50 PM
I still feel like there is a disconnect between hospitalist medicine and or GI/surgery and us (EPs) regarding disposition on these cases. It is close to impossible to get an urgent endoscopy in my community setting without the patient basically being in shock from their GI bleed. Is this consistent with others in their communities? Using those clinical calculators for risk just makes me more nervous when sending them home, cause it is impossible getting them scoped unless actively dying!
Mizuho M. - June 7, 2016 6:16 PM
Completely empathize Steven! I work in similar community setting that sounds similar. And many docs work with much less in very remote areas. It can be very frustrating & stressful.
Can your Ed group initiate a collaboration with the other specialists (namely GI & medicine) to develop a management protocol? It's worth looking into.
We think that Understanding whose high risk is important particularly when we engage with consultants to attempt admission.
In the end there is no easy solution. These patients are challenging to dx, let alone manage with 1 hand tied behind our backs. Hang in there! Thanks for listening.