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Date of last update: 10/15/2017.

Forum Name: Gastroenterology Topics

Question: Anemia, diarrhea, occult and frank blood in stool.

 Annedith - Sat Sep 22, 2007 8:49 pm

Mother, sister, brother, and daughter have Crohns Disease.

I am a 41 yo female 5'3" 125lb and healthy. History of periods of diarrhea and painful hemmoroids

1. July and August 2007- pre-existing external hemmoroids became more inflamed and painful. There was minor (thin, bright red) bleeding on tissue and in water.

2. July 2007- I had some mild-moderate pain and diarrhea after eating daily.

3. More frequent, heavy diarrhea and stomach pain on 8/14/07. Headaches and lightheadedness. Diarrhea watery. No blood. Significant hemmoroid pain.

4. Next 10 days: Diarrhea at least 6x per day. Very large amount of thick darker marroon colored blood (very different) mixed with loose or watery stool, blood heavy for four days. Pain in stomach (grinding pain.) Bloating. Joint pain and leg cramps. Marked fatigue. Headaches. Breathless.

5. 8/27/07: Seen in urgent care, began on Phenobarb/Belladonna - 2 pills/4x per day. Diarrhea was only 2-3x per day. No more visible blood. Tried to taper off and diarrhea increased. Took meds for five more days. Diarrhea stopped on 9/2/07

6. 8/29-9/4/07 Stool tests from 8/27 came back negative for parasites, C. Diff., E. Coli, Salmonella.

7. 9/4/07 Extreme Fatigue continues. Went for blood tests: RBC 3.04 HGB 6.4 HCT 23.3. WBC's are also low: 3.7, total WBC, LYM 1.7, MID 0.4, GRA, 1.5. All other tests (liver, kidney, protein, bili, thyroid) normal.

8. Colonoscopy: normal. No internal hemmoroids or ulcerations of any kind. Stool specimen is watery and mucousy and contains no occult blood

9. 9/11/07 Blood tests: RBC 2.82 HGB 6.0 HCT 21.4. Given blood transfusion - 2 units.

10. 9/11/07 Diarrhea w/o visible blood restarts after eating. No cramps or stomach pain. I have diarrhea after every meal. Flora Q prescribed; diarrhea is mostly resolved by 9/21/07 with frequent but normal-appearing stools.

11. Barium CT of abdomen and pelvis. Normal.

12. 9/14/07 Post transfusion blood tests: HGB 9.0 HCT 32.0. WBC results are in normal range.

13. Inflammatory Bowel Disease blood test comes back with "Low Probability."

13. 9/14/07 Endoscopy. Stomach normal. Flecks of a small amount of blood "stigmata" seen at mouth of small intestine.

14. 9/15/07 Menstrual Period: atypical, just two days in duration with sparse, old blood.

15. 9/18/07 CT/Barium with small bowel flow through. Micro results not yet back. Verbal preliminary results from doc: she saw no blockages or masses.

16. 9/22/07 Blood tests show that RBC figures are nearly identical with the 9/14/07 draw following the transfusion. WBC, however, is back to 3.7, down from 6.2.

My doc is planning a capsule (camera) endoscopy of the small intestine, next. He was very surprised to have done all these tests and have no evidence of Crohn's Disease. I wondered about a transitory illness or some other fluke that could have caused these rather severe symptoms, but he felt that this was unlikely. I remain easily fatigued and pale. I have a good appetite, and I eat carefully to maintain weight. I am doing rather well symptomatically with the FloraQ and the transfusion, but what could be the source of my presenting problems? Do you feel at this point that Crohns is unlikely and that I will continue to improve? Can something like Celiac cause bleeding and anemia?

I just wanted to say thank you in advance for reading my lengthy case. I did a lot of reading on this site this evening, and I appreciate having this resource.
 Dr. Chan Lowe - Sat Sep 22, 2007 10:27 pm

User avatar Hi Annedith,

Reading through your history of symptoms I am very suprised that no indication of Crohn's has been found.

There is a more complete blood work panel for Crohns that can be sent. The typical panel has 3 antibodies in it. The more complete one has, I believe, 7 antibodies in it. If you have not had this one I would recommend it.

The capsule camera will be helpful because Crohn's can have affected areas throughout the small intestine and does not always affect the colon.

Celiac can cause problems with diarrhea, etc. It is worth testing for this as well. There is an antibody panel for this but the best way to make the diagnosis is by endoscopy of the esophagus, stomach and duodenum to get a biopsy of the typically affected area.

Continued follow up with your GI doctor is important.

Best wishes.
 Annedith - Sun Sep 23, 2007 9:20 am

I will ask my doctor about the more thorough blood test for Crohns.

My mother (who has Crohns) also had the three-antibody panel, and the results showed Low Probability, so I know the test is not always accurate.

Because my endoscopy and colonoscopy were effectively normal, no biopsies were taken, so I am wondering if a healthy looking stomach and already rules out Celiac Disease.

I agree that there may be some Crohns in the small intestine...I am certainly not hoping for Crohns, but it is hard to be without any diagnosis and feeling unwell.

I will keep you informed as to how things progress.

Thank you very much.
 Annedith - Sun Sep 23, 2007 9:22 am

Annedith wrote:
Because my endoscopy and colonoscopy were effectively normal, no biopsies were taken, so I am wondering if a healthy looking stomach and already rules out Celiac Disease.

That was meant to read, "healthy looking stomach and colon"
 Annedith - Sun Sep 23, 2007 9:54 pm

Here is a medical update which may or may not be relevent. (9/23/07)

After I had my colonoscopy (see medical timeline in first post) I developed a painful phlebitis at the IV site. It resolved in about 5 days with applied NSAID's were used due to the anemia.

The area has been smooth and uninfected.

Today, I began to have pain in the superficial vein, beginning in the inner elbow, and traveling down towards my wrist. My hand was dusky and very cold, and the vein became very pronounced.

My doctor told me to go have it checked, and the ultrasound showed partial clotting in the area of the original phlebitis, and then full clotting below. I am to apply heat, and talk to my doctor tomorrow about using NSAID's.

I have had many other IV's that have not become irritated in this way, so I am not completely worried, but I am a little bewildered by these odd symptoms. I do not smoke, I am thin and fit...could this reflect a medical issue or be part of the other problems in any way?
 Dr. Chan Lowe - Sun Sep 23, 2007 11:27 pm

User avatar Hi Annedith,

It is a little unfortunate that you did not have biopsies done at the time of the endoscopies. Usually celiac and crohn's generally do have characteristics looks but mild cases can be missed without the biopsies (especially celiac disease).

It's a bit of a long shot, but sometimes phlebitis can be associated with a hypercoagulation disorder. Potentially this could also be causing some clotting of the veins of the GI tract leading to problems. This is a real long shot but may be worth evaluating.

Best wishes.
 Annedith - Wed Sep 26, 2007 11:55 am

Tomorrow is my camera endoscopy test. I will also be tested for hypercoagulation, and I thank you for that. My doctor thought that it was a very good idea, if only for ruling out. I also had some trouble with another (nearby) superficial vein location. Thank you, Dr. Lowe. I will stay in touch.
 Annedith - Fri Oct 12, 2007 6:19 pm

Results from my hypercoagulation panel came back today, and were all negative/within normal range.

I expect to get my results from the capsule endoscopy on Monday.

If the capsule endoscopy doesn't show anything that explains the bleeding, are there other tests I should request? Should I get a referral to a specialist? Or, should I just treat the unexplained anemia with iron supplements and get rechecked if further problems develop? I worry a bit because my blood loss was so significant.

I have not had any more visible digestive bleeding beyond a small amount of hemmoroidal bleeding (I continue to have some painful external hemmoroids, but they do not bleed excessively and never have...they just hurt.)

I have 3-4 loose/diarrhea stools per day without any cramping or pain. That digestive pattern is improved from the acute illness, but not normal for me.

I am still easily fatigued, and have much less stamina with exercise than I did before my illness began. I can work, but I am exhausted by 7pm.

Could this just be from the anemia that lingers post-transfusion? (HGB around 9-10, and HCT around 32)

Is it possible that the cause of the bleeding will never be found, or do I need to advocate for more testing?

I know it seems premature to ask this before the capsule endoscopy results come back, but I have had a lot of diagnostics, and no answers. I want to feel really well again, and I also want to understand what happened, and to know what to do about it.
 Dr. Chan Lowe - Sun Oct 14, 2007 12:16 am

User avatar Hi Annedith,

The capsule results should be very helpful. It is possible that a cause may not be found. In this case, continued follow up is needed to see if any further bleeding occurs. Often it does not. Continuing the iron supplements is likely to be helpful to prevent future anemia.

Best wishes.
 Annedith - Thu Oct 18, 2007 1:32 pm

I wanted to report that I have had no visible bleeding since the summer, and that my blood tests came back with good gains:

RBC: 4.6 (reference range 3.8 to 6.5-NORMAL)
HGB: 11.2 (11.5 to 18.0-CLOSE TO NORMAL)
HCT 35.8 (37.0 to 54.0- CLOSE TO NORMAL)

I have further blood tests in progress that will give iron levels, and etc.

I have had continued problems most days with diarrhea, but it is less frequent (3x-day) and not every day.

My weight has been a problem. I have lost 13 pounds since September 19 despite keeping a careful food diary. I still do not have the endoscopy report back.
 Dr. Chan Lowe - Thu Oct 18, 2007 11:17 pm

User avatar Thanks for the update. It's good to hear that you are at least beginning to get better.

Best wishes.
 Annedith - Sat Oct 20, 2007 8:48 am

The nurse called this morning with a brief note from the doctor, who is not in the office until Monday.

The completed camera endoscopy report isn't at the office yet, but it is known that there were ulcers found in the small intestine. I am to take iron twice a day. Iron level is 23. The doctor wants the CBC and iron repeated in one month.

Here's the thing. The nurse did not give any conclusions. She said that I should avoid all NSAIDS.

What leaves me with a lot of questions is that there is no reason or treatment given for the ulcers...Crohns? H Pylori? Celiac? What about the weight loss and diarrhea? So, I made an appointment with my doctor for Monday morning to try to get a bit more information.

Doctor Lowe, you have been incredibly patient with my questions and updates, and I really hope to hear from you just once more.

Are there relatively benign small bowel ulcers that just develop and go away?

Do you think the doctor is waiting for further information before discussing conclusions?

Do you think this is Crohns?

I wonder if I will not be diagnosed because of the inability to biopsy and negative blood tests for IBD from Prometheus Labs?
 Annedith - Mon Oct 22, 2007 2:22 pm

I saw the doctor today and found that the ulcers are on the lower portion of the small bowel and do not look like Crohns. They were the cause of the bleeding. They are now observed to be healing. One idea is that my daily use of Advil over the summer could have caused the ulcers...

As for my weight loss, the doctor made a note of it and will recheck it in a month, along with the levels for anemia. I can supplement with nutritional shakes. He also told me to make sure that anxiety wasn't causing irritable bowel type symptoms and weight loss (I don't think it is a factor, but the illness has made me anxious, so I will keep an open mind here.)

My iron, ferritin, etc. are all relatively low along with still having anemia, will continue to supplement with iron and have the blood rechecked in a month. Energy should improve with weight gain and iron.

Thank you Dr. Lowe. Case closed. :)
 Dr. Chan Lowe - Mon Oct 22, 2007 10:03 pm

User avatar Thanks for the update. Ibuprofen (Advil) can do quite a number on the GI tract. Many people don't realize the impact this can have.

Hopefully, others may see your case and be able to figure out their case as well.

Best wishes.

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