The GCA consult

[bucknut101]

Does anyone else on this forum receive a ridiculous amount of consults for GCA? Over the last week at our VA we've received (and I'm not exaggerating) 8 consults to r/o GCA. And what is most frustrating about these is the nature of these consults. Here's usually how my intial conversation goes with the consulting NP or physician.

Them: "yeah, we have this guy who's been having severe headaches over the last few days and we think he has GCA"

Me: "OK, is he having any jaw/tongue claudication, fevers, weight loss, scalp tenderness, hip and shoulder pain, hx of polymalgia rhematica, etc ? Is he having problems with his vision?"

Them: "Uh, well I didn't ask about any of those things"
Me: "Well OK, then what's his ESR and CRP?"
Them: "We didn't check those"
Me "OK, well then what makes you think he has GCA?"
Them: "Well it's on the differential and we wanted you to do a TA biopsy to rule it out"
Me: "Uh no, we can't just go and biopsy somebody's artery based on the fact that they are just having headaches, I need more proof to be suspicious of GCA then this to do a biopsy"
Them: (getting annoyed)" Well can't you at at least just look at their eyes and diagnose it that way?"
Me: "No, you can't dx GCA that way. Please take the proper hx, obtain a stat CRP and ESR and let me know what these results are. If you are still concerned will be more than happy to help"

I mean is it that hard to do the proper workup for this disease? Do they honestly not know these things or are they just trying to dump the patient on someone else. But honestly it seems like if a patient comes in with a headache, "Uh oh must be GCA and we better call ophthalmology!"

Actually on one of these consults they actually did check the ESR and CRP. The problem was that both the labs were stone cold normal and the patient was 41 yo. Yet they still wanted us to do the TA biopsy. My staff said no, thankfully.

Wow it feels good to get that off my chest.

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[NR117]

I mean is it that hard to do the proper workup for this disease? Do they honestly not know these things or are they just trying to dump the patient on someone else.

They honestly don't know these things and are terrified of missing GCA. The problem is, you can have GCA without constitutional symptoms, or with normal labs; so people in other fields understandably do not feel comfortable ruling it out.
Having said that, asking you to do a TA bx in that 41 year-old is ridiculous...

 

[toulouselautrec]

Speaking of inappropriate consult requests...We should make a top-20 list or something.

I find the post-anethesiologist-ripping-tape-off-patient's-eyes-causing-corneal-abrasion consult really annoying.

But I agree with above, r/o GCA is unfortunately common. And fortunately, most of our workups are negative. Still, we've seen some very atypical presentations, delayed increase in ESR/CRP, etc. So you just never know.

 

[bucknut101]

I agree with both of you that GCA can present very atypically. The point of my post was that the consulting teams have usually done nothing to begin the process of diagnosing the disease. It is not difficult to take the proper history and check some labs.

I'm glad you brought up the post op corneal abrasions. Last year we would typically get these probably at least 3-4X a week. And what was interesting is that that of the 5 hospitals we cover it was only happening at one of them. We weren't quite sure what the hell they were doing at this hospital. This has not happened as much this year. I don't know if they finally woke up and realized they were doing something wrong.

During my OP rotation we did some combined surgeries with ENT, neursurgery, and OMFS. I was always amazed at the blatant disregard for the health of the eye during surgery. During all of our OP surgeries we have the corneal protectors on as much as possible, and are constantly aware that are hands, fingers, or instruments are not damaging the eye. I wish others did the same

 

[orbitsurgMD]

I agree with both of you that GCA can present very atypically. The point of my post was that the consulting teams have usually done nothing to begin the process of diagnosing the disease. It is not difficult to take the proper history and check some labs.

I'm glad you brought up the post op corneal abrasions. Last year we would typically get these probably at least 3-4X a week. And what was interesting is that that of the 5 hospitals we cover it was only happening at one of them. We weren't quite sure what the hell they were doing at this hospital. This has not happened as much this year. I don't know if they finally woke up and realized they were doing something wrong.

During my OP rotation we did some combined surgeries with ENT, neursurgery, and OMFS. I was always amazed at the blatant disregard for the health of the eye during surgery. During all of our OP surgeries we have the corneal protectors on as much as possible, and are constantly aware that are hands, fingers, or instruments are not damaging the eye. I wish others did the same

Get used to it. GCA is a bogeyman for a lot of generalists. And finding someone willing to do a biopsy is not always that easy: the patients are often complicated, elderly and in poor health and have multiple reasons for having elevated ERSs and CRPs. Doing a good job at a biopsy, with a quality plastic-surgery closure, especially if you absolutely positively need a lot of specimen to be sure, can take the better part of an hour. And for that, Medicare pays you only couple hundred bucks--which makes it a money-losing public service. So no one is exactly lining up to do these.

If you are at an academic center, a presentation on GCA from the ophthalmic point of view might enable you to shape your referrals so as to avoid unnecessary and poorly thought-out requests.

Posting it on YouTube would be a good idea.

Another point: it seems that ophthalmology referral for anyone having headache complaints is becoming a primary-care standard. Most primary care docs are swamped, so a little polite and helpful guidance might help keep your referrals focused without antagonizing your otherwise willing referring doctors--after all, you still want them to send you other things, and once you are in practice, that goodwill is important, so you might as well get your professional relations skills in tune.

You might suggest that before the patient's appointment, determine
1. whether the patient has had sudden vision loss, recovered or not
2. headaches, fevers, malaise, night sweats, unexplained weight loss, jaw claudication or frequent dental pain, alopecia, scalp or "hair" pain or any symptoms of stroke
3. if there is an elevated erythrocyte sedimentation rate and C-reactive protein.

(I do lots of biopsies and have a reasonably high threshold for taking someone to the OR, and my rate of positives is still under 15%--go figure.)

When I have someone I suspect needs biopsy, I am sure to always list the reasons why I suspect they may have the disease and why making the diagnosis is important. I stress the fact that GCA is treatable when confirmed but which requires a rigorous course of medications that itself can cause significant side effects--ones that can even make them sick--but which will hopefully be able to be reduced in time to avoid the ugly trifecta of blindness, stroke and death.

 

[Mirror Form]

If the ER calls you about "ruling out GCA," you're pretty much screwed.

However, GCA is a clinical diagnosis that can present w/o eye findings. So no other service should ever consult you to "r/o" GCA. You can't rule it out (or even definitively rule it in) with an eye exam. So if it's their patient they need to treat the patient. Of course you'll be happy to put on your surgeon hat and do the biopsy, but that's it.

 

[bucknut101]

If the ER calls you about "ruling out GCA," you're pretty much screwed.

However, GCA is a clinical diagnosis that can present w/o eye findings. So no other service should ever consult you to "r/o" GCA. You can't rule it out (or even definitively rule it in) with an eye exam. So if it's their patient they need to treat the patient. Of course you'll be happy to put on your surgeon hat and do the biopsy, but that's it.

Exactly. Somehow at my institution the perception seems to be that GCA is purely an ophthalmic disease and we can diagnose it with an eye exam. I remember during intern year and during medical school if we suspected GCA we would do the work up and if we were still suspcious call in ophtho for the TA bx.

If a consulting doc has done the w/u, is still suspecting the dx, then calls me for a biopsy, I'm cool with that.

In many of our uveitis patients we suspect an underlying systemic disease and will go ahead and ask the proper questions and order the proper tests. If we find something or are still highly suspicous of a certain disease then we will consult rheumatology or the appropriate service. We could easily just refer all of our uveitis patients to rheum for the w/u but don't. However this is basically what medicine does to us when it comes to GCA.

 

[bucknut101]

Get used to it. GCA is a bogeyman for a lot of generalists. And finding someone willing to do a biopsy is not always that easy: the patients are often complicated, elderly and in poor health and have multiple reasons for having elevated ERSs and CRPs. Doing a good job at a biopsy, with a quality plastic-surgery closure, especially if you absolutely positively need a lot of specimen to be sure, can take the better part of an hour. And for that, Medicare pays you only couple hundred bucks--which makes it a money-losing public service. So no one is exactly lining up to do these.

If you are at an academic center, a presentation on GCA from the ophthalmic point of view might enable you to shape your referrals so as to avoid unnecessary and poorly thought-out requests.

Posting it on YouTube would be a good idea.

Another point: it seems that ophthalmology referral for anyone having headache complaints is becoming a primary-care standard. Most primary care docs are swamped, so a little polite and helpful guidance might help keep your referrals focused without antagonizing your otherwise willing referring doctors--after all, you still want them to send you other things, and once you are in practice, that goodwill is important, so you might as well get your professional relations skills in tune.

You might suggest that before the patient's appointment, determine
1. whether the patient has had sudden vision loss, recovered or not
2. headaches, fevers, malaise, night sweats, unexplained weight loss, jaw claudication or frequent dental pain, alopecia, scalp or "hair" pain or any symptoms of stroke
3. if there is an elevated erythrocyte sedimentation rate and C-reactive protein.

(I do lots of biopsies and have a reasonably high threshold for taking someone to the OR, and my rate of positives is still under 15%--go figure.)

When I have someone I suspect needs biopsy, I am sure to always list the reasons why I suspect they may have the disease and why making the diagnosis is important. I stress the fact that GCA is treatable when confirmed but which requires a rigorous course of medications that itself can cause significant side effects--ones that can even make them sick--but which will hopefully be able to be reduced in time to avoid the ugly trifecta of blindness, stroke and death.

Great idea on informing other services about GCA from an ophthalmic point of view. I think getting the word out on a few other common consults would be worth while too.

I've also noticed the increasing number of patients referred for HA's by their PCP's. Usually I find these patients are told by the referring doctor that maybe there glasses aren't correct and eyestrain is causing the HA's.

I've also seen several patients that were sent back to our varous clinics because the PCP felt the cause of their headaches was their POAG. The patients were told that their pressures must be too high and resulting in headaches.

 

[toulouselautrec]

Another point: it seems that ophthalmology referral for anyone having headache complaints is becoming a primary-care standard. Most primary care docs are swamped, so a little polite and helpful guidance might help keep your referrals focused without antagonizing your otherwise willing referring doctors--after all, you still want them to send you other things, and once you are in practice, that goodwill is important, so you might as well get your professional relations skills in tune.

We get a lot of referrals for migraine headache from PCPs before the migraine has been even diagnosed or the headache has been systemically worked up. So we often end up diagnosing the migraine ourselves, and then pass the patient back to the PCP because we don't treat/manage migraines. It is kind of frustrating, but as you pointed out, you don't want to antagonize your referring docs, plus it gets the patient plugged in (many of these patients need a comprehensive eye exam anyways for other reasons.)

to bucknut101: I understand your frustration about consulting services not starting a workup properly. This happens to us a lot too. I was called once to evaluate for pseudotumor cerebri, except--1) they didn't have imaging results, 2) they had done 2 LPs, both under fluoro, mind you, and no opening pressure for either LP. And there was already another known underlying neurologic process that could explain the headache. Frustrating, no?

 

[Wolverine98]

Actually on one of these consults they actually did check the ESR and CRP. The problem was that both the labs were stone cold normal and the patient was 41 yo. Yet they still wanted us to do the TA biopsy. My staff said no, thankfully.

First I'll say that I agree that there are a fair number of inappropriate r/o GCA issues. However...

I thought I'd give one little word of warning on this. In this situation, I agree that in a 41yo, it's not GCA. However, I've seen two patients in the 6 weeks who walked into my clinic (which is a glaucoma clinic, but I was the only one available that day) who had normal or near-normal labs and florid GCA on biopsy. They both had suspicious enough symptoms that I was comfortable making the call for a TAB anyway. Keep this in mind: ESR and CRP are about 97% sensitive, so, by definition, getting those two labs will miss 3 out of every 100 cases. There's some evidence that increased platelets (over 450,000) increases the sensitivity, since they are acute-phase reactants.

In addition to the clinical importance here, the rumor is that in past years that's been something very popular on oral boards, where they'll nail you with a patient who has normal labs but ends up having GCA.

Also, consider what you'd rather be dealing with between these two options: (1)A patient referral from a non-ophthalmologist that may not be GCA, but they're worried about it, or (2) a referral from a non-ophthalmologist after they missed GCA and the patient is bilaterally blind (also something our department has seen in the last 2 months). I know which one I feel is worse.

Dave

 

[Andrew_Doan]

I agree with Dave and many others who posted above. As an ocular pathologist, I see about a 10-20% positive biopsy rate; however, because GCA can be devastating, we have to biopsy a bunch to catch the few real ones as the screening tools we have are not perfect.

On the other hand, look at these types of consults (e.g., GCA and rule-out fungal ball) as providing job security for ophthalmologists. It's good to be needed! I understand as a resident, it can be painful to deal with consults, but I know you'll welcome it as a young (and later as a senior) practicing ophthalmologist when you're paid for each consult.