Rectal exam before Lovenox?

[GeneralVeers]

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Several of my ED attendings have stated that a rectal exam MUST be done before giving any patient Lovenox or Plavix. I've tried to find literature to support this, however I can find none. The contraindications list "Significant, active bleeding" , however heme positive stool wouldn't necessarily fit into this category.

I've asked the cardiologists, and for the most part they do not check stool for blood before giving Lovenox or Plavix. Additionally, I doubt every patient in the hospital who's on the DVT prophylactic dose of 40 mg gets a rectal exam.

I want to know what you guys think the standard of care (based on evidence) should be.

This also raises another question. Should we be checking stool for blood on every chest pain patient before we give them an aspirin?

 

[mikecwru]

Several of my ED attendings have stated that a rectal exam MUST be done before giving any patient Lovenox or Plavix. I've tried to find literature to support this, however I can find none. The contraindications list "Significant, active bleeding" , however heme positive stool wouldn't necessarily fit into this category.

I've asked the cardiologists, and for the most part they do not check stool for blood before giving Lovenox or Plavix. Additionally, I doubt every patient in the hospital who's on the DVT prophylactic dose of 40 mg gets a rectal exam.

I want to know what you guys think the standard of care (based on evidence) should be.

This also raises another question. Should we be checking stool for blood on every chest pain patient before we give them an aspirin?

I doubt you would find an evidence basis for this, let alone a common sense basis for this.

I would be a little nervous with melena, but not for brown hemoccult positive stool. If the person were having a PE or a STEMI, I would anticoagulate them.
So, I don't do rectals before. Now, I may for the weak and dizzy 90 year old who is in afib RVR and has a bunch of other issues, but not for the above.

mike

 

[bulgethetwine]

I doubt you would find an evidence basis for this, let alone a common sense basis for this.

I would be a little nervous with melena, but not for brown hemoccult positive stool. If the person were having a PE or a STEMI, I would anticoagulate them.
So, I don't do rectals before. Now, I may for the weak and dizzy 90 year old who is in afib RVR and has a bunch of other issues, but not for the above.

mike

Depends on clinical situation, but for the most part, I agree, someone was overzealous in their conservative approach to initiate this largely unnecessary "pseudo-standard" of care in otherwise hemodynamically, non-dizzy etc. adults. And I think it could result in a lot of people being denied a blood thinner in whom it is actually clinically indicated.

Illustrates again, though, a lot of what we do doesn't have evidence. And that doesn't necessarily make it wrong, either, even if for this example the lack of evidence would probably be borne out even if we did the study.

 

[Caffiend_79]

If the rectal exam come back positive, what are you suppose to do? Do you withold tx or DVT, PE, MI, etc. until the pt has a complete work-up for a source of his GI bleed? That could take days and sounds absurd.

Maybe if you were starting a prophylactic blood thinner it would make more sense. However, I have seen many pts started on Plavix for stents or heparin for clots without any of them developing significant GI bleeding. I have, though, seen several pt's present with severe GI bleeding from over anti-coagulation with coumadin. Anti-coagulants at appropriate doses just don't increase your risk of bleeding that much.

 

[GeneralVeers]

I consider the rectal exam to be an invasive (and uncomfortable procedure), therefore I do it only if it's going to change my diagnosis and/or disposition.

If a patient doesn't have a drop in hemoglobin, doesn't report hematemesis or black stool, and doesn't have a coagulopathy, I don't think the rectal exam has any utility.

The other day I had a 61 year old lady who looked like she was going to die from a massive inferior MI. We gave her Lovenox per the cardiologist. If I'd done a rectal and had heme positive result, I would not have held the Lovenox.

 

[SolidGold]

I agree, having a positive hemeoccult isn't going to stop anybody from anticoagulating someone who needs it. The one argument that I heard is that you can't reverse plavix, lovenox, or fragmin so if you are considering using them, knowing if they are bleeding is a good idea. At that point you could change to heparin if you wanted.

 

[GeneralVeers]

I agree, having a positive hemeoccult isn't going to stop anybody from anticoagulating someone who needs it. The one argument that I heard is that you can't reverse plavix, lovenox, or fragmin so if you are considering using them, knowing if they are bleeding is a good idea. At that point you could change to heparin if you wanted.

Actually the cardiologists do give Protamine for Lovenox. It's not completely effective, but it will reduce the anticoagulation effect somewhat.

 

[docB]

Interesting discussion. Not to offend my academic colleagues but I personally found a lot of this during residency. rectal exams on everyone, pelvics on women with epigastric pain, pelvics on patients who present for Plan B, etc. I have come to the conclusion that many of the practices are due to the fact that in academic centers the attending executes a rectal by telling someone else to do it as opposed to having to do it themselves.

As for me, I ask about rectal bleeding, dark stools, etc. If the patient answers yes then I do the rectal. I only hold the anticoags for melena or gross blood.

 

[kungfufishing]

Interestingly enough, I have been on the other end - unintentional but excellent pun - of a patient who got lovenoxed with a GI bleed, during a unit month a couple years ago. Lots of bitching about the ED and the patient actually did get transfused, but the guy's bone marrow worked and he got better.

Completely agree with the above.

 

[j-snake]

I had never heard this before until the attending told me to do it on our 31 year old with a PE before starting Heparin. He told me it was partly for medicolegal reasons--so that if the patient turned out to have a significant bleed, they couldn't point their fingers at the ED. I think that if it was positive, we still would have heparinized her, but we would be aware of any potential problems. Still, I think the other posters are right--if there is no pretest suspicion for a bleed, the yield is going to be pretty low.

 

[DrQuinn]

I had never heard this before until the attending told me to do it on our 31 year old with a PE before starting Heparin. He told me it was partly for medicolegal reasons--so that if the patient turned out to have a significant bleed, they couldn't point their fingers at the ED. I think that if it was positive, we still would have heparinized her, but we would be aware of any potential problems. Still, I think the other posters are right--if there is no pretest suspicion for a bleed, the yield is going to be pretty low.

That's the exact reason I DON'T do it. Its not going to ultimately change what I am going to do, unless there's a damn river of melena pouring out of their butt.

Its just like when an MS4 or a PGY1 says "We should get a CBC to check for a white count."

Honey, it ain't gonna change what I'm gonna do, so why order it?

I agree, as usual, with docB, I think it has more to do with academic ivory towers of having someone else do teh rectal so you can document it. When I was in residency a wee 13 months ago, man, I had to do rectals on everyone, it was horrific. Then when I came to where I'm at now, I was surprised to see that the vast majority of my colleagues didn't do rectals on their abd pains.

Q

 

[southerndoc]

We also do rectal exams on anyone who is being anticoagulated (therepeutic, not prophylactic).

I've had attendings state that any patient who presents with syncope should have a rectal exam. I can't see how a heme positive stool, even if there is melena, will cause you to syncopize with a normal hemoglobin.

 

[MedicinePowder]

saw a lady get put on lovenox and coumadin from the ED for a dvt who returned the next day with melena and a significant drop in her h/h. no previous hx of g.i. bleed.

the question as it has been raised, what if they DID do a rectal and it was positive, then what do u do?

any attendings out there?

 

[docB]

saw a lady get put on lovenox and coumadin from the ED for a dvt who returned the next day with melena and a significant drop in her h/h. no previous hx of g.i. bleed.

the question as it has been raised, what if they DID do a rectal and it was positive, then what do u do?

any attendings out there?

At least three have weighed in so far. The consensus seems to be that heme pos, brown stool would not result in witholding anticoagulation.

The case you describe represents a known complication of the indicated therapy. Fortunately the patient came back (persuant to her excellent discharge instructions I'm sure) to be treated.

I'd have done the same thing to my mom in that case and my mom would have had the same thing happen.

 

[DrQuinn]

I'd have done the same thing to my mom in that case and my mom would have had the same thing happen.

Gross. You would have done a rectal on your mom?

Oh wait, you and I wouldn't have done the rectal.

When I come up with sometimes questionable decisions in the ED, I often talk to the patients, and have a small discussion with them. "I can give you this blood thinner to prevent your blood clot or heart attack from killing you, but it might make you have some blood in your poop." I have never had a patient even question it.

Q

 

[docB]

Gross. You would have done a rectal on your mom?

Mother and I have a special relationship.😉

 

[bigtuna]

We also do rectal exams on anyone who is being anticoagulated (therepeutic, not prophylactic).

I've had attendings state that any patient who presents with syncope should have a rectal exam. I can't see how a heme positive stool, even if there is melena, will cause you to syncopize with a normal hemoglobin.

Sometimes people have syncope during an acute GI bleed due to a vagal reaction but you would have to catch the CBC pretty early for it to still have a normal H/H.

 

[FoughtFyr]

At least three have weighed in so far. The consensus seems to be that heme pos, brown stool would not result in witholding anticoagulation.

Make it four. I agree.

- H

 

[Seaglass]

If I'm a fellow does that count? If so count me in. But I still make the residents do it. Because it's their finger.

Actually my rationale when asked is "It's better to know" if there is anything there but if I was practicing on my own I would rarely do it.

 

[rndmguy21]

I agree it would take alot of blood to make me forgo anticoagulation in an AMI or PE.

HOWEVER.......

I think there's a decent medico-legal reason to do a rectal. That is, imagine starting lovenox/heparin on a patient and then have them develop some sort of massive GI bleed on the floor, code and die. 😱 😱

Now imagine yourself in court, having started said anticoagulation trying to explain to that pesky plaintiffs attorney and an uneducated jury why you chose not to do a simple test to check for bleeding. Um, uh, well, you see......🙁🙁🙁 You end up looking lazy and cavalier even though you may not have altered your decision making.

Now imagine same scenario, but you did the rectal, it was heme positive, you weighed the risks and benefits, decided to anti-coagulate, notified the admitting team of your thought process and documented appropriately. You look thorough, thoughtful, complete and demonstrate a deep knowledge of medical decision making. Its alot easier to defend.🙂🙂🙂

 

[bartleby]

It isn't that I would withhold anticoagulation from somebody having a STEMI, but I think that would certainly secondarily change my management of this patient.

1) Unfractionated heparin vs Lovenox: If "some blood" (i.e. melena) turns into a lot of blood, you have the option of shutting the drip off. Aside from the joys (or lack thereof) of pissing around with protamine in somebody who clearly has an indication for anticoagulation in the first place, once you've given lovenox, it's out of your hands.

2) Bed disposition. Someone with a PE on heparin and heme neg stools could go to the floor. The same patient with melena should go to stepdown at the very least, if not the ICU for serial 'crits and close monitoring.

I am one of the stronger proponents in my academic group of avoiding rectals, pelvics and other uncomfortable intrusions, but I think it's hard not to argue that you're better off finding out about what is at least a treatment modifying pre-existing condition (GIB) before you start a medication (anticoagulant) which could significantly add to the patient's morbidity (if not outright mortality).

 

[Kamran Afzal MD]

Anticoagulation for DVT ( Deep Venous Thrombosis ) in a Heme positive patient. To do or not to do that is the question. I was asked this question by a local internist. It is not a simple question to answer. Active bleeding is listed as a contraindication to anticoagulation. It maybe debatable in court that heme positive stools is active bleeding or not. I actually approach it in the following manner.
Evaluate the risk of bleeding and the tolerance to massive bleed for individual patients : Amongst other things I inquire age, history of stomach ulcers or Bleeds, previous Gastrointestinal bleeds, history of blood transfusions, personal or family history of colon cancer or recent colonoscopy/endoscopy, antiplatelet treatments like asprin and plavix and previous experience to anticoagulation if there is any etc. Examine the medical records and review the lab: Amongst other things I generally look for the Hemoglobin to be normal, make sure MCV is not low,and also check if the patient has iron deficiency or coagulopathy.
Based on these questions a good clinician can stratify if the patient has mild moderate or severe risk of gastrointestinal bleed. Once that is established discuss with the patient about risks and benefits of giving anticoagulation and make the decision with the patient rather than for the patient. If a patient has a mild risk of bleed, I would most likely start patient on therapeutic heparin IV, q4 hourly Hb, ICU monitoring till cleared by Gastroenterology, temporary Inferior Vena Cava filter placement and a consult to gastroenterologist within 24 hours. If the risk of bleeding is high than the preferred option would be placing a permanent Inferior Vena Cava filter placement and a consult to gastroenterologist to see if the risks can be modified.
PS. these are my personal opinions, care of specific patients should be individualized by their doctors
kamran Afzal MD
Medical Director metro vein Clinic
Diplomat American Board of internal medicine
Diplomat American Board of Phlebology
RPVI
www.metroveinmn.com/blog

 

[xaelia]

The argument is moot, in any event.

There's plenty of evidence patients are harmed by major bleeding events from long-term outpatient systemic anticoagulation, and evidence for treatment is limited regarding equally severe patient-oriented outcomes (the evidence for systemic anticoagulation for acute PE is from 1960!), so, no reason to anticoagulate for VTE.

Systemic anticoagulation affects only short-term non-fatal MI in ACS - which equalizes within weeks - for no mortality benefit, so, given the risk for major bleeding events, no reason to anticoagulate ACS.

 

[Rendar5]

The argument is moot, in any event.

There's plenty of evidence patients are harmed by major bleeding events from long-term outpatient systemic anticoagulation, and evidence for treatment is limited regarding equally severe patient-oriented outcomes (the evidence for systemic anticoagulation for acute PE is from 1960!), so, no reason to anticoagulate for VTE.

Systemic anticoagulation affects only short-term non-fatal MI in ACS - which equalizes within weeks - for no mortality benefit, so, given the risk for major bleeding events, no reason to anticoagulate ACS.

I think you're oversimplifying a lot of the EBM out there, possibly just to act smart by being contrary to some standards of care practice. This stuff is not so cut and dry from either side. There are reasons to anticoagulate for ACS other than mortality benefit (if someone's going to be cathed, I'd rather start a treatment which reduces procedural complications whether or not that's affecting mortality from the disease), not to mention that ED management should not be aimed towards long-term outcomes, as we don't maintain these treatments, but rather short term outcomes with the follow-up or admittin docs aiming towards lon-term outcomes.

 

[xaelia]

the second argument there makes no sense to me. There are reasons to anticoagulate for ACS other than mortality benefit (if someone's going to be cathed, I'd rather start a treatment which reduces procedural complications whether or not that's affecting mortality from the disease), not to mention that ED management should not be aimed towards long-term outcomes, but rather short term outcomes with proper follow-up aiming towards short-term outcomes.

Simplified version:
http://www.thennt.com/heparin-for-acute-coronary-syndromes

 

[Arcan57]

That being said, anticoagulation for ACS and VTE is standard of care. If you withold said anticoagulation without a solid contraindication then you will not be able to defend yourself on the witness stand.

And doing a rectal on someone for whom you have no suspicion of GI bleed prior to anticoagulation is not something that even crosses my mind.

 

[xaelia]

That being said, anticoagulation for ACS and VTE is standard of care. If you withold said anticoagulation without a solid contraindication then you will not be able to defend yourself on the witness stand.

Of course; I am being partially facetious and partially serious.

I think there's room in the diagnosis of minor PE or DVT to discuss the risks and benefit of treatment (submassive and massive are getting an entirely different discussion regarding impending doom), where you can relatively enumerate the risks for them to make their own decision.

Withholding anticoagulation in ACS...people will look at you like you have two heads. I'm not confident the interventional cardiology machine benefits everyone without subjecting many huge costs and morbidity of uncertain benefit, but that train has already left the station. You can also make an argument that the studies of systemic anticoagulation vs aspirin were performed prior to the advent of our advanced cardiac care and other adjunctive therapies, so it's possible that PCI, plavix, etc. result in a sustained benefit in reduction of nonfatal MI.

As long as you take your plavix with your new stent.

 

[Rendar5]

Simplified version:
http://www.thennt.com/heparin-for-acute-coronary-syndromes

I am familiar with the data for heparin from the cochrane study. as well as the higher NNH v. NNT with the outcomes measured. And I do know there's no mortality benefit. However, I'm not really satisfied with the endpoints looked at though in terms of saying there's no role for heparin. There's a lot of morbidity (CHF) and a lot of procedures surrounding ACS (catheterization) that will happen and will be performed regardless of what you do, and those don't really seem to be looked at when assessing a drug that is known to not have mortality benefit, especially when our concern should be the short-term and not long-term care of the patient.


In short, our knowledge is incomplete and there is little basis to open yourself up to a potential lawsuit by going against a standard of care with incomplete knowledge. Now if you were increasing the number of fatal outcomes, sure I can see a reason to go against the standard of care, but the data doesn't show that either.

What the data shows is that we should not believe that heparin is a mortality-benefit drug and that we should be doing more research to determine it's necessity in being started several hours earlier v. started by the cardiologist just prior to cathetherization (which has benefits other than PCI'ing, such as revealing disease more amenable to surgical intervention)) and to determine it's benefit in reducing the severe morbidities associated with MI's. It does not say that we should with-hold it from our care.

 

[GeneralVeers]

What the data shows is that we should not believe that heparin is a mortality-benefit drug and that we should be doing more research to determine it's necessity in being started several hours earlier v. started by the cardiologist just prior to cathetherization (which has benefits other than PCI'ing, such as revealing disease more amenable to surgical intervention)) and to determine it's benefit in reducing the severe morbidities associated with MI's. It does not say that we should with-hold it from our care.

Again, it's a matter of liability. Suppose that the cardiologist withholds the heparin for whatever reason, and the patient has a bad outcome. If there's a suit, I can guarantee you that the ED physician will be named as well. The question will obviously be raised as to why the ED physician didn't initiate Heparin or other anti-coagulation as it's standard of care.

 

[Painter1]

for medical-legal reasons, I would perform a rectal exam prior to starting anticougulation.

someone brought up a good point above that it would be harder to defend ureself in a case of massive GI if u didn't do a rectal prior to anticougulation.

if you find melena, then you can involve the cardiologist and the patient in the decision-making process.

with that said, i perform signficantly less rectals as an attending.

i had an attending as a resident who wanted us to do rectals on patients with epigastric pain. i no longer do that. had another guy want rectals on all syncopes even young patients which was outrageous.

 

[AmoryBlaine]

I completely agree that a great deal of what goes on in an academic ED is the result of the attending being able to just say "call X, do Y, then do a rectal/pelvic" and knowing that it will get done.

One of my attendings preaches the "pelvic exam on every female with abdominal pain" gospel, unless he is seeing the patient primarily.

Rectals are painful, violating, and RARELY chance management. I don't do them prior to anticoagulation unless the history suggests I should.

 

[Arcan57]

Unless the patient is blind or demented, I don't find melena to be a something that is occult prior to the rectal exam. I have a black Littman and I'll just point at it and ask if they have any stools that were the same color.

I am a believer in the pelvic exam in menstruating females with pain below the umbilicus. There are several docs in my group that do not do pelvics, and about once every couple of weeks I'll catch one of their bouncebacks coming in with PID after their cervicitis was untreated.

 

[takotsubo]

I agree with not doing a rectal and just asking the bleeding hx questions is enough.

How many people check a CBC before starting lovenox & coumadin say for a DVT?

No medical hx, say healthy truck driver.

 

[Apollyon]

I agree with not doing a rectal and just asking the bleeding hx questions is enough.

How many people check a CBC before starting lovenox & coumadin say for a DVT?

No medical hx, say healthy truck driver.

Since I'm checking coags, I also check the CBC. "Healthy truck driver?" Show me one - please. I've known a bunch, and "healthy" isn't a word I would apply. The polycythemic thrombocytopenic, those are good to know before putting on the anticoagulation.