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Teachable Moment
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December 2018

Inappropriate Use of Fecal Occult Blood Testing

Author Affiliations
  • 1Department of Internal Medicine, University Texas Southwestern Medical Center, Dallas
  • 2Digestive and Liver Specialists of Houston, Houston, Texas
  • 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

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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