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Rectal exam no more article.
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Its not rectal exam no more, it’s hemoccult no more (or never). Heme testing is colon cancer screening only. We want to know is there: melena, maroon stool, BRB or brown stool (brown encompasses every other color: yellow, green, whatever). Heme testing brown stool is doing a poor crc screening test generally with no follow up. It’s just silly. I don’t even argue about it anymore, I just ignore it. Heme testing frank melena or BRB just confuses me more. But when I hear an ED physician tell me about a rectal exam with no heme test, I believe everything they say.
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Sometimes people ask why I don't do hemoccult testing. I explain there either is or isn't gross blood and they either should or should not be admitted to the hospital and if they need to go home either need to see GI or PCP who may likely refer to GI...and the occult heme, with all of its glorious false positives and negatives, doesn't really affect that decision.
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But the hemoccult can prove that the red stool that isn't quite the right color for BRB is beets or omnicef when the parents are freaking out because the poop is "bloody".
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As a doctor, I have literally never performed a FOBT, ever. Did it multiple times as a med student after being forced to by residents or attendings. Attendings in residency would sometimes get upset with me, but could never give me a clear way that an FOBT changed management. I would perform the rectal before telling the attending about the case, and then tell them what a saw. Most didn’t care about an FOBT, the ones that did I’d laugh and say “well I’m not gonna violate them a second time.” The number of debates or frank arguments I’ve had with colleagues is amazing regarding this completely useless test. It’s not a good cancer screen, it doesn’t rule in or out GI bleeds. A patient’s history is much more sensitive and specific for bleeding. I only perform a rectal to delineate potential need for expedited, definitive management.
I just don’t understand how people are still using this test, and amazingly become indignant when the hospital takes away the developers.
I just don’t understand how people are still using this test, and amazingly become indignant when the hospital takes away the developers.
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If it’s not red blood, you can tell the difference. If you can’t convince the patient, that’s really a terrible reason to order an incorrect test.
If they had an old UGIB, it will still be positive. Now you have a false positive screening test, which you will either ignore or subject the patient to an unnecessary colonoscopy. The NNH for colonoscopy is something like 1:300. That sounds trivial unless you do hundreds a year.
Look at it from a medicolegal perspective. You’ve ordered a screening test. Are you sure it was followed up? If not, once that patient gets cancer, that’s on you. Why not order a mammogram while you’re at it.
If they had an old UGIB, it will still be positive. Now you have a false positive screening test, which you will either ignore or subject the patient to an unnecessary colonoscopy. The NNH for colonoscopy is something like 1:300. That sounds trivial unless you do hundreds a year.
Look at it from a medicolegal perspective. You’ve ordered a screening test. Are you sure it was followed up? If not, once that patient gets cancer, that’s on you. Why not order a mammogram while you’re at it.
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Not really can be falsely positive by rectal exam also if you have gross bloody stool you should be anemic
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Man, some of you guys must have fantastic historians that can articulate their poop like Elon Musk describes a new Tesla. Mine can't tell me WHAT their poop looks like much less articulate anything that helps me rule in or out a GI bleed. I can't count the times I've had grandma with "generalized weakness", telling me everything is fine in the poop department and turned out to have frank melena. I feel like I damn near FOBT everyone these days.
Plus, my patient population will agree with everyone I ask them. If I ask them if they have bloody, tarry or maroon stools, they'll tell me they are having all three. And if they don't, at least one or two family members will tell me they "saw" bloody stools at least a week ago yet can't give me any more specifics. I'm damned if I do and damned if I don't.
Plus, my patient population will agree with everyone I ask them. If I ask them if they have bloody, tarry or maroon stools, they'll tell me they are having all three. And if they don't, at least one or two family members will tell me they "saw" bloody stools at least a week ago yet can't give me any more specifics. I'm damned if I do and damned if I don't.
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Ahem.
Does anyone have a link to the article?
Does anyone have a link to the article?
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First of all, it's weird there seems to be a GI doc in here trying to convince us to do stuff that's not standard of care. Presumably so he and his colleagues will have less work to do. He must either still be in training or work for an HMO or academic center.
Here are 9 reasons to do hemoccult testing at the bedside.
1. Check for source of anemia.
2. When they develop metastatic colon cancer in the future and saw you for blood in stool 6 months ago, it will help you to show you were thorough and considered occult blood in your decision making. If you don't check, you either look lazy or incomplete.
3. Depending on if you work in an HMO or other health care system with good follow up, this information can be helpful for expedited referrals.
4. It's much easier to place blame or express negligence on someone for not doing something or withholding studies, especially if noninvasive.
5. Deviating from standard of care will get you into trouble, especially if you are doing it based off of one study that has not been validated yet.
6. It helps you to develop rapport with the patient.
7. It's easy. The rectal is the annoying part. The FOBT is easy.
8. A positive result can help you admit a patient without argument.
9. A negative result can help you discharge a patient. Let's face it, patients like objective studies.
Tip - double glove so you can touch the card and developer bottle with your undergloves once you've smeared the poop.
Here are 9 reasons to do hemoccult testing at the bedside.
1. Check for source of anemia.
2. When they develop metastatic colon cancer in the future and saw you for blood in stool 6 months ago, it will help you to show you were thorough and considered occult blood in your decision making. If you don't check, you either look lazy or incomplete.
3. Depending on if you work in an HMO or other health care system with good follow up, this information can be helpful for expedited referrals.
4. It's much easier to place blame or express negligence on someone for not doing something or withholding studies, especially if noninvasive.
5. Deviating from standard of care will get you into trouble, especially if you are doing it based off of one study that has not been validated yet.
6. It helps you to develop rapport with the patient.
7. It's easy. The rectal is the annoying part. The FOBT is easy.
8. A positive result can help you admit a patient without argument.
9. A negative result can help you discharge a patient. Let's face it, patients like objective studies.
Tip - double glove so you can touch the card and developer bottle with your undergloves once you've smeared the poop.
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The idea that a finger will cause bleeding and a false positive FOBT study is old school and not supported by the literature. Not only that, the post you are commenting on refers to using a negative result to offer reassurance to a patient or parent.
Also grossly bloody stool does not equal anemia.
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This is all assuming that FOBT performs well and is a good test to begin with but it isn't. False positive rate 5-10%. False negative 30-50% (Bangaru, 2016). Parkland was the hospital that got rid of it. https://www.bumc.bu.edu/emergencyme...liminating-In-Hospital-Fecal-Occult-Blood.pdf
Here are 9 reasons to do hemoccult testing at the bedside.
1. Check for source of anemia.
If negative this is falsely reassuring (example- intermittent bleeding ulcer or polyp). If positive but brown stool does a positive guiac matter? If a patient has new anemia and is symptomatic without a clear source they should be admitted anyways for scope.
2. When they develop metastatic colon cancer in the future and saw you for blood in stool 6 months ago, it will help you to show you were thorough and considered occult blood in your decision making. If you don't check, you either look lazy or incomplete.
If they had stool in their blood they should probably have a scope anyways. Or they can have FOBT performed as outpatient.
3. Depending on if you work in an HMO or other health care system with good follow up, this information can be helpful for expedited referrals.
This again assumes that the FOBT is a test that performs well. It doesn't.
4. It's much easier to place blame or express negligence on someone for not doing something or withholding studies, especially if noninvasive.
5. Deviating from standard of care will get you into trouble, especially if you are doing it based off of one study that has not been validated yet.
According to the American Gastroenterology Association's guidelines, fecal occult blood test (FOBT) should only be used in the context of colorectal cancer (CRC) screening.
6. It helps you to develop rapport with the patient.
7. It's easy. The rectal is the annoying part. The FOBT is easy.
The rectal is the only part that matters (masses, hemorrhoids, frank blood vs melena).
8. A positive result can help you admit a patient without argument.
And a negative result means that the specialists are less likely to take someone seriously who SHOULD be scoped.
9. A negative result can help you discharge a patient. Let's face it, patients like objective studies.
A negative result may make the patient feel like they don't need the scope that they should already get to begin with.
Here are 9 reasons to do hemoccult testing at the bedside.
1. Check for source of anemia.
If negative this is falsely reassuring (example- intermittent bleeding ulcer or polyp). If positive but brown stool does a positive guiac matter? If a patient has new anemia and is symptomatic without a clear source they should be admitted anyways for scope.
2. When they develop metastatic colon cancer in the future and saw you for blood in stool 6 months ago, it will help you to show you were thorough and considered occult blood in your decision making. If you don't check, you either look lazy or incomplete.
If they had stool in their blood they should probably have a scope anyways. Or they can have FOBT performed as outpatient.
3. Depending on if you work in an HMO or other health care system with good follow up, this information can be helpful for expedited referrals.
This again assumes that the FOBT is a test that performs well. It doesn't.
4. It's much easier to place blame or express negligence on someone for not doing something or withholding studies, especially if noninvasive.
5. Deviating from standard of care will get you into trouble, especially if you are doing it based off of one study that has not been validated yet.
According to the American Gastroenterology Association's guidelines, fecal occult blood test (FOBT) should only be used in the context of colorectal cancer (CRC) screening.
6. It helps you to develop rapport with the patient.
7. It's easy. The rectal is the annoying part. The FOBT is easy.
The rectal is the only part that matters (masses, hemorrhoids, frank blood vs melena).
8. A positive result can help you admit a patient without argument.
And a negative result means that the specialists are less likely to take someone seriously who SHOULD be scoped.
9. A negative result can help you discharge a patient. Let's face it, patients like objective studies.
A negative result may make the patient feel like they don't need the scope that they should already get to begin with.
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Your thread got hijacked worse than a bunch of sorority girls in South America bro.
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There are numerous articles. Which one would you like?
Who Still Acutely Uses Fecal Occult Blood Tests?
If you trained or practiced in the last few decades, there’s no doubt you’ve performed hundreds, if not thousands, if not tens of thousands, of fecal occult blood tests. For many years,…
www.emlitofnote.com
Fecal occult blood testing in hospitalized patients with upper gastrointestinal bleeding
1Regions Hospital, HealthPartners, St. Paul, Minnesota; 2University of Minnesota Medical School, Minneapolis, Minnesota; 3University of Texas Health Sciences Center at San Antonio, San Antonio, Texas; 4South Texas Veterans Health Care System, San Antonio, Texas; 5University of California, San Fr...
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Inappropriate Use of Fecal Occult Blood Testing
This Teachable Moment describes the case of a 58-year-old man with bilateral knee osteoarthritis who presented to the emergency department with 1 week of dizziness and intermittent dark stools.
jamanetwork.com
Fecal occult blood testing as a diagnostic test in symptomatic patients is not useful: A retrospective chart review - PMC
Although the fecal occult blood test was designed primarily as a colorectal cancer screening tool for asymptomatic, nonhospitalized populations, it is being used for nonscreening purposes by some health care professionals, often without appropriate ...
www.ncbi.nlm.nih.gov
Inappropriate use of the faecal occult blood test in a... : European Journal of Gastroenterology & Hepatology
FOBT use are being followed in the Netherlands. Methods The frequency of reasons for ordering a FOBT in 15 hospitals over a time period of 1 year was determined and the consequences of the test result on the diagnostic workup were determined by a retrospective search of electronic hospital...
journals.lww.com
Diagnostic Fecal Occult Blood Testing in Hospitalized and Emergency Department Patients: Time for Change?
AbstractObjective. To examine the use of fecal occult blood testing in inpatients and in those presenting to the emergency department.Methods. We retrieved
academic.oup.com
An audit of the utility of in-patient fecal occult blood testing - PubMed
The FOBT, which is validated only for colorectal cancer screening, is often performed inappropriately in patients admitted to the hospital. This test should be restricted in hospital practice. It would be preferable to identify patients who are appropriate candidates for colorectal cancer...
www.ncbi.nlm.nih.gov
Inappropriate use of the faecal occult blood test outside of the National Health Service colorectal cancer screening programme - PubMed
Our study demonstrates significant misuse of the FOBT outside the NHS BCSP. Inappropriate use leads to false positives and exposes patients to unnecessary risk. False negatives provide reassurance to patients who may have symptoms that should be investigated. The FOBT should not be available to...
www.ncbi.nlm.nih.gov
....I guess what I am trying to say is, STOP DOING FOBTs. They are absolutely worthless in a patient with an acute GIB.
It is neither sensitive, nor specific. It neither rules in, nor rules out. I highly doubt anyone has ever been successfully sued for not performing an FOBT given that the test was only ever approved for screening purposes, and many hospitals across the country have forbidden its use outside of for screening purposes. If you want to use a well validated tool for ruling out life threatening upper GIBs, use the Glasgow-Blatchford Bleeding Score. For lower GIBs, just use common sense. Are they anemic? Is the rectal grossly bloody? Do they have a significant change from baseline hemoglobin? Are they on anticoagulation? Do they have multiple concerning co-morbidities? Etc.
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That response pretty much sums up why I don’t bother to have the discussion. Keep doing the voodoo that you do. Just don’t tell me
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This made me laugh way more than it should have
D
deleted547339
I wish I had you instead of some of my GI fellows when I was in fellowship.
Me: this patient is bleeding to death. They’re ghost white, have a crit of 3 and are sitting in a pool of melena with a SBP of 60 in spite of being on the Belmont. Call your team and come now.
GI fellow: But what’s the hemocult.
Me: I’m going to stab you.
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Sure, I occasionally do them on a baby.
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That I’m sure this is true makes me sad.
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I like 8 and 9
If I stick my finger in someone's butthole, I'll wipe the crap on a card and test it. I'm not doing the test for occult colon cancer. I do it at the bedside and show the patient "Look Ma! You have blood in your s*$t!"
Out of all the stupid, wasteful, meaningless things we do in the ED this is extremely low on the list.
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Yea man I get this all the time.
I'm surprised people don't look at their feces more often.
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I'll reply to my own post.
I don't mind not doing it anymore. But I'm not going to fight everyone in our system who wants it. So I'll continue to wipe the crap on a card.
I'd say about 1/25 cards I get I can't discern the result. Not sure. But I don't think there has been a bad outcome as a result of that.
D
deleted547339
Yea, I like our GI group now better than fellowship in spite of my fellowship program being “leaders in the field.” They come when we call.
IR on the other hand....
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An ED doc up there tried to argue with you about a GI topic..I was waiting for you to slap his ass down but instead you took the high road
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Agree. I haven't done a single one since I graduated residency.
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Getting my own place to do the right thing matters to me (and we do). Here I’ll share what every gastroenterologist knows is the evidence but I’m not going to convince the dogmatic who know better. At the plenary session of our recent national meeting, one of the guys who always talks about bleeding used ER FOBT as his joke to break the ice. I laughed but mostly out of the satisfaction in knowing that my ED is better than that.
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I’m glad. Academic depts don’t always understand the importance of the relationship with the ED. We also try to be of service when called. And our ED doesn’t call unless they need us. Bad calls are really infrequent in my practice. We also empower emergency physicians and hospitalists to prep the low risk lower bleeds that they’ve decided should stay (for whatever reason) and, if they prep, we scope. I’m almost never called late and when I am, it’s usually time to get dressed. We get the usual July uptick with new attendings but even that is pretty minimal and quickly solved.
Our EM group is a major factor in my partners QOL and happiness. When you take call for several days at a time, that 11p-6a protection is huge. It matters less to academic attendings cause the fellows take those calls and no one cares about them.
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If you can convince my admitting hospitalists that it’s not necessary you’d cut down on majority of my testing. I have only a few that don’t care about hemoccult results in patients with new onset anemia with brown stool. That said, every now and then (small percentage of the time as usually obvious per physical exam) I’m not sure if the black tarry stool is Melena or not (maybe once every few months) and sometimes it’s not obvious if the red stool is blood or not (had this happen 1 or 2 times in the last 10 years). A test with a 5% false positive rate is sometimes better than clinical judgment if you’re only 90% sure.
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I only call at night if I think the EGD needs to happen as soon as GI walks in the next morning or sooner. ...Or if the hospitalist insists I wake GI, but I always let them know that's why I'm calling.
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I hate that...when hospitalists demand you make a consult for them. I fight it, often, and sometimes I win and sometimes I don’t.
I have said more than once “the only reason why I calling you, Dr. Consult, is that I’m being forced to by our hospitalists so I can admit this patient. It’s a xx yo woman with a stable UGIB. I have no sp. ecific questions for you. Can I indicate that we spoke? And again...sorry for the call.”
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D
deleted547339
So I’m both EM and MICU. I’m talking about in fellowship when I called from the ICU! Even worse. To add insult to injury, if I called anyone for anything (as opposed to my intern or resident), I would identify myself as the fellow and cut right to the point “guy bleeding to death, need you here now” - “got a STEMI, activate the lab” - “have dead gut, call the OR” etc.
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We don’t get the first thing in the morning FYI calls any more. They expect us to triage our consults and get to work. Our ED doesn’t call on behalf of others either (so that way the person who is calling is accountable for the request). That agreement really cut down those requests. It did take some discussion and having them feel like we could be trusted.
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I fight it, too and usually win, but when further fighting will be fruitless, I have a very similar approach to the phone call.
It's just a few of the hospitalists in general but more of them when they get busy.
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This is the crux of the matter for me. In a patient presenting with symptoms, you are utilizing a screening test as a diagnostic study - someone is presenting with symptoms. What are the test characteristics in acute GI bleeds? No one knows, because FOBT has not been studied as a diagnostic test.
If you read the Parkland article, you'll see it's a much larger cost (financial, opportunity) than you would anticipate.
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I think FOBT is BS unless it isn't.
Last shift.
* Older patient with new anemia and reported 3 days of dark stool -> admission without FOBT.
* Infant with reported infrequent dark flecks in stool, prior formula intolerance, still feeding well, benign abdomen -> FOBT -> see PCP in AM for repeat evaluation and possible formula change. Ultimately, the FOBT in this case only resolved ambiguity in my mind more than changed management.
Last shift.
* Older patient with new anemia and reported 3 days of dark stool -> admission without FOBT.
* Infant with reported infrequent dark flecks in stool, prior formula intolerance, still feeding well, benign abdomen -> FOBT -> see PCP in AM for repeat evaluation and possible formula change. Ultimately, the FOBT in this case only resolved ambiguity in my mind more than changed management.
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So this shouldn't be all that hard to test, or to design a study. Is the ultimate question
"Among patients who present to the ED with symptomatic anemia"
"one thing you want to know is if they are bleeding from the GI system?"
You can do any combination of the following:
- check labs (BUN, Cr, MCV, etc)
- look at the stool stool
- test the stool color FOBT
- and other stuff
which one performs best for important clinical outcomes? (i.e. need for admission, need for emergent transfusion, getting emergent upper/lower scope, always have to add in death)
I'm not good at study design....ultimately I think we are trying to figure out who needs admission and stuff done immediately vs who can go home and see PMD / GI within a week, right?
"Among patients who present to the ED with symptomatic anemia"
"one thing you want to know is if they are bleeding from the GI system?"
You can do any combination of the following:
- check labs (BUN, Cr, MCV, etc)
- look at the stool stool
- test the stool color FOBT
- and other stuff
which one performs best for important clinical outcomes? (i.e. need for admission, need for emergent transfusion, getting emergent upper/lower scope, always have to add in death)
I'm not good at study design....ultimately I think we are trying to figure out who needs admission and stuff done immediately vs who can go home and see PMD / GI within a week, right?
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I don’t need a FOBT to help me figure out if someone has stable chronic GI blood loss. IDA is almost alway gyn or GI. The patients don’t really overlap and those that do need to be assumed to have slow GI losses regardless. IDA is an indication for bidirectional endoscopy in the next few weeks versus now depending on severity and comorbid conditions. A neg FOBT won’t change that.
Can’t comment on pediatrics
Can’t comment on pediatrics
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is it even important to look at the stool then?
I'm talking about stable IDA (iron deficiency anemia)
Unstable anemia is different I suppose.
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Melena is important. If present, you know there was a significant UGIB in the last 24 hours. These require EGD for risk stratification and treatment to reduce the risk of rebleed. Patients can’t tell you if they have it but your finger won’t lie.
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I would not say that the test is worthless. It certainly has its place in evaluating anemic patients. Now if you're talking about performing occult blood testing in the patient with the active rectal bleed, you might be overdoing it.
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Man, forget this stuff for a second.
You know what You guys need to be able to do, to reach the pinnacle of your speciality?
A STAT, on demand, bi directional endoscopy. Going in from both ends at the same time, until the cameras meet in the middle. Then you can tell the patient ‘sir, I have explored you from mouth to anus, and didn’t find anything. Go home’
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OK @Gastrapathy here is one for you. My colleague had this patient today while on shift with me.
60 yo guy comes in saying he’s pooping blood for 1 week (painless hematochezia). No other major symptoms. ESRD for 1 year on dialysis. On warfarin (i can’t remember why). Said had a c-scope 3 years ago and had “polyps” but doesn’t know anything else about it, and we don’t have a record of it.
Exam: HR 75, BP 150/90. Non-focal physical exam. Doesn’t even look particularly pale. Abd non-tender. Stool is unequivocally brown.
Labs today:
Cr 6.8
BUN 30
LFTs normal
Rest of chemistries I recall we’re normal but don’t know them off hand.
WBC nrml
Hg 7.1
Platelets nrml
INR 1.2
MCV 83
3 years ago
Cr 3.0 (Cr slowly went up over last three years and started dialysis 1 yr ago)
Hg 9.1
We did a FOBT but I won’t tell you the results for purposes of this conversation. If the ER called you at 11:00 PM Thu for you opinion or recs, what would you say?
A couple of other things:
- he doesn’t appear to have symptomatic anemia, and if he does it’s not really his complaint. He is walking and not SOB
- he appears to be relatively reliable.
- he had a PMD but I’ve never heard of his/her name, and in general in this community it’s difficult to get quick follow-up for most specialties especially GI.
- I don’t know if he’s on a PPI and not sure if it’s germaine to this conversation.
So....he says he’s pooping blood. Vitals are normal. Brown stool, and hg went from 9.1 three years ago to 7.1 now. And he’s also allegedly supposed to be on warfarin, but his INR is 1.2.
Does he need emergency, with 24 hr repeat scope(s)? Does he need urgent 1-2 week repeat scope(s)? Think he needs to be admitted? Or is he OK to go home?
Clearly he is not critically ill.
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- Attending Physician
I'm glad you didn't tell us the FOBT because the results wouldn't matter. Hgb 7.1, drop in hemoglobin from previous, multiple severe chronic medical comorbidities, reporting multiple bloody BMs, and supposedly on coumadin. Why the heck would you even FOBT this guy? The ONLY thing it would do in this situation is potentially talk you into doing the wrong thing for the patient. This is a slam dunk admit 100% of the time. They can obs and do serial hemoglobins, or the can just scope him, makes no difference to me. I really hope this story doesn't end w/ "the FOBT was negative so we sent him home".
There is the argument that you might feel a mass in the rectum or prostate. Not emergent but nice to know.
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Obs/admit, prep, scope. He doesn’t have “nml” platelets, he might have a normal number but has ESRD. I don’t get that call, he’s just prepped and waiting for me in the am. I’m not sending him home over the phone. Now, whoever did the FOBT, the patient saw blood. So it’s beyond me why it matters.
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Rectal exam is very useful information. Its wiping the poop on a magic card that doesn't matter
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I very rarely do a hemoccult these days. Old person with change in hemoglobin that's unexplained? Get's admitted. I wouldn't seriously send them home.
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Maybe he saw blood earlier...and he wasn't bleeding at the time of the DRE.
If he showed up to your office with all of this information (including labs), would you send him to the ER or directly admit him? (as the ER can't really help you in this case).
Basically it sounds like you would not handle this as an outpatient.
I think this case is perhaps mildly more interesting than others think here...as the ESRD is highly likely playing a role in his new anemia drop.
Pt was admitted...I'll log-in in to see how he was doing.
This was pretty cut and dry because ultimately his Hg was 7.1. But would everyone think the same way if his Hg went from 10.8 to 9.3? Or 12.5 to 10.9? We get this stuff all the time. Depending on the characteristics of the poop...I might send home the 12.5 to 10.9 with strict return precautions (or maybe not if he's been pooping "blood" for 7 days...why don't I see blood now....and his drop occurred possibly over 3 years in setting of ESRD.)
Problem is some ER docs would want to admit anyone popping blood for any reason. But this guy is more interesting because clearly he isn't taking his coumadin, but if he restarts it is he gonna bleed? So at 7.1 you have no room for error, but if his Hg was 11? 12? I dunno.
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And motherf******$ act like they forgot about DRE...
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Nowadays e'rebody wanna talk like they got sumthin' to say
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