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Dear Dr. Slowtwitch - Upper GI Bleed
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I have been training for a middle distance race, things have been going well but this week I started feeling weak and light headed. I had a deep black stool, was getting really bad head rushes when standing up and was out of breath climbing the stairs.

This isn't my first experience of this, in fact I've had it about 5-6 times now. I know I had an upper GI bleed, thus the black stool. I went to my doctor and they tested my blood (results on Monday), but it's the same old story, I'll need to take Iron tablets to get my HGB back up, I have decided to take an OTC proton pump inhibitor just as a precaution until I get my results.

Anyway, I can still train, but my paces are way down. As a reference I ran 7km before work yesterday, my pace was 17 seconds/km slower than last time I ran the route last week, and my heart rate was 10bpm higher this time.

How would you go about training? Should I just rest, or just do some easy training, or can I train properly but just slower than normal?
I went for a 2h30 ride this morning, hills aren't much fun, but otherwise I feel ok, though obviously my speed is lower than normal.
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Re: Dear Dr. Slowtwitch - Upper GI Bleed [NUFCrichard] [ In reply to ]
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More questions firstly (and more may come)!
Declaration: medical doctor but not a GP or gastro-enterologist.

1. Have you ever had a gastroscopy to investigate this previously? If so, what has it shown?
2. Do you know what your current haemoglobin and ferritin are?
3. Are you or have you recently been taking any anti-inflammatories, aspirin or medications that can increase bleeding (ie warfarin)?
4. Do you get any symptoms of heart burn, reflux or gastritis?
5. Just the one black stool or more since then?

If this is not the first time like you describe and you have not previously had a scope, then that should be part of the investigations performed.
If you are iron deficient because of this, even if your haemoglobin is decent, an IV iron infusion may be a better option than oral iron, newer preparations are well tolerated with a good safety profile and far nicer/convenient than oral preparations.
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Re: Dear Dr. Slowtwitch - Upper GI Bleed [pbnz] [ In reply to ]
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1) Yes, last time I was scoped top and bottom (thank god for propofol!) but they didn't find anything.
2) I get my results on Monday, I know my normal HGB value is 15.5-15.8 and in the past it has fallen to 9-13 afterwards (9 wasn't pleasant).
3) I very rarely take painkillers, I haven't taken a single NSAID for weeks. No blood thinners either.
4) No, I do have lots of stomach/digestive issues when I run and some issues when I ride.
5) 1 real deep black one, not so bad since, but I take iron tablets as soon as I have any worry of an issue, so it isn't always so clear if it comes from iron or blood.

I expect that my HGB will be a bit low, maybe 13 or so. I hope they look for an ulcer again, it'd be nice to find the reason why this happens so often. It messes up my training, but my biggest worry is that sometime it won't stop after a day or 2 and will cause me some real problems.

I'd prefer to get IV Iron, but I don't think it is offered here (Germany) unless you have lots of side effects from the tablets.
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Re: Dear Dr. Slowtwitch - Upper GI Bleed [NUFCrichard] [ In reply to ]
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1) Yes, last time I was scoped top and bottom (thank god for propofol!) but they didn't find anything.
Good. Does not always rule out a GI bleed but good to know.

2) I get my results on Monday, I know my normal HGB value is 15.5-15.8 and in the past it has fallen to 9-13 afterwards (9 wasn't pleasant).
Let us know your results when they come through. Your iron stores (ferritin) are pretty important in this. If they are low (<30 depending on reference ranges it confirmed iron deficiency and as an endurance athlete you may benefit from IV iron even if not anaemic by the topics definitions. Also, given those Hb results, I am presuming you are male?

3) I very rarely take painkillers, I haven't taken a single NSAID for weeks. No blood thinners either.
Traditional, non selective NSAIDs can be nasty on the gut and cause GI bleeding. COX2 selective agents may be a better choice if you have a need for them (celecoxib)

4) No, I do have lots of stomach/digestive issues when I run and some issues when I ride.
Sorry, was meaning more in day to day life.

5) 1 real deep black one, not so bad since, but I take iron tablets as soon as I have any worry of an issue, so it isn't always so clear if it comes from iron or blood.
Well the digested blood causes a lovely, distinctive smelling stool called melaena, one of the reasons I never wanted to set foot on an acute medical ward unless I had to.

I expect that my HGB will be a bit low, maybe 13 or so. I hope they look for an ulcer again, it'd be nice to find the reason why this happens so often. It messes up my training, but my biggest worry is that sometime it won't stop after a day or 2 and will cause me some real problems.
Sounds like another scope is in order.

I'd prefer to get IV Iron, but I don't think it is offered here (Germany) unless you have lots of side effects from the tablets.
Sorry can't help you on that front, suffice to say we have pretty liberal use of it in Australia, even in non anaemic but iron deficient endurance athletes. I am sure there is likely to be a way, just need to find a doctor on your side.
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Re: Dear Dr. Slowtwitch - Upper GI Bleed [pbnz] [ In reply to ]
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Results are in and almost exactly as expected:
Haemoglobin is 13.2
Ferritin is 23.2

As my doc is on holiday, they say I should just wait until he is back next week to decide what we want to do. Pretty useless really. I'll keep on with the PPI and Iron and hopefully will recover quite quickly..
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Re: Dear Dr. Slowtwitch - Upper GI Bleed [NUFCrichard] [ In reply to ]
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That is definitely a decent drop and your ferritin confirms iron deficiency.
This needs proper investigation which will almost certainly involve a gastroscopy.
IV iron will restore your levels to normal more rapidly, I would really push for where you can get this done.


NUFCrichard wrote:
Results are in and almost exactly as expected:
Haemoglobin is 13.2
Ferritin is 23.2

As my doc is on holiday, they say I should just wait until he is back next week to decide what we want to do. Pretty useless really. I'll keep on with the PPI and Iron and hopefully will recover quite quickly..
Last edited by: pbnz: Jul 30, 18 7:12
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Re: Dear Dr. Slowtwitch - Upper GI Bleed [pbnz] [ In reply to ]
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Further, if EGD/COLO are unrevealing, your gastroenterologist may want to consider a video capsule endoscopy to visualize the remaining small bowel that can't normally be reached via standard endoscopic procedures, particularly given the visualized melena and this being a repeat event.

Any recent NSAID use?
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Re: Dear Dr. Slowtwitch - Upper GI Bleed [NUFCrichard] [ In reply to ]
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GO TO THE DOCTOR, NOW! I had bleeding in my stool, with very dark poop and finally went to the gastroenterologist and got a colonoscopy. they found that I had colorectal cancer. luckily for me and my family, despite it being stage 3, it was localized and dealt with. I'm now 7 years clear. colorectal cancer is one of the deadliest ones out there but its also curable if caught early enough. please get yourself checked out, if you want to talk about it, PM me.

Greg
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Re: Dear Dr. Slowtwitch - Upper GI Bleed [ In reply to ]
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So I have all my results now finally.

Erosive Gastritis Type b. I have several small ulcers and lots of redness in the Antrum.

Apparently my histology was all fine and negative (inc H.Pylori). I don't know what I am supposed to do now, just wait until it happens again?
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