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This Issue
Teachable Moment
Less Is More
December2018
SarojaBangaru,MD1; DavidTang,MD2; DeepakAgrawal,MD3
Author Affiliations Article Information
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1Department of Internal Medicine, University Texas Southwestern Medical Center, Dallas
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2Digestive and Liver Specialists of Houston, Houston, Texas
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3Division of Digestive and Liver Diseases, University Texas Southwestern Medical Center, Dallas
JAMA Intern Med. 2018;178(12):1702-1703. doi:10.1001/jamainternmed.2018.5553
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Peter E.Wu,MD, MSc, FRCPC
JAMA Internal Medicine
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SarojaBangaru,MD; DeepakAgrawal,MD
JAMA Internal Medicine
Full Text
A 58-year-old man with bilateral knee osteoarthritis presented to the emergency department with 1 week of dizziness and intermittent dark stools. He denied dyspnea on exertion, angina, history of liver disease, or recent dietary or medication changes. Home medications included as-needed ibuprofen. On physical examination, he was afebrile, blood pressure was 100/65, and heart rate 98 beats per minute. Abdominal examination disclosed a soft, nontender, nondistended abdomen with normal bowel sounds. Digital rectal examination (DRE) revealed black, tarry, foul-smelling stool but no fresh or frank blood. Fecal occult blood testing (gFOBT) was performed reflexively after rectal examination and returned negative results. Laboratory testing results revealed hemoglobin 11.0 mg/dL (baseline, 13.6 mg/dL 3 months previously; to convert to g/dL, multiply by 10.0), platelets 278 000 mm3, blood urea nitrogen of 28 mg/dL (to convert to mmol/L, multiply by 0.357), serum creatinine of 0.98 mg/dL (to convert to µmol/L, multiply by 76.25), and normal coagulation parameters. He was admitted to the hospital but a gastroenterology consultation was initially deferred given the negative results from the FOBT. The admitting clinicians consulted gastroenterology 7 hours later when the patient again had a black tarry bowel movement. The patient was subsequently given intravenous pantoprazole, and upper endoscopic findings revealed three 1.5-cm duodenal ulcers, 1 of which had a visible vessel, which was treated with epinephrine injection and hemostatic clips. The ulcers were attributed to ibuprofen use. The patient was given oral pantoprazole on discharge to be taken for 2 months or as long as he continued to use ibuprofen. He had no recurrence of GI tract bleeding at 9 months’ follow-up.
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Less is More Gastrointestinal Cancer Gastroenterology and Hepatology Teachable Moment Bleeding and Transfusion Gastroenterology Geriatrics Osteoarthritis Rheumatology Emergency Medicine Gastroduodenal Ulcer
Citation
Bangaru S, Tang D, Agrawal D. Inappropriate Use of Fecal Occult Blood Testing. JAMA Intern Med. 2018;178(12):1702–1703. doi:10.1001/jamainternmed.2018.5553
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