A Physician's Perspective: Gastroenterology and the Bloodless Patient
An Interview of Robin Midian-Singh, M.D.
Gastroenterology is a sub-specialty of internal medicine that focuses on the gastrointestinal tract. A gastroenterologist diagnoses and treats conditions of the liver, gall bladder, pancreas, biliary tract, esophagus, stomach, small bowel and colon. Dr. Robin Midian-Singh, a gastroenterologist explained her role in caring for patients who refuse transfusions.
There are a number of procedures that a gastroenterologist performs. These include endoscopy, colonoscopy, ERCP (endoscopic retrograde cholangio pancreatography), EUS (endoscopic ultrasound) and liver biopsy. However, their work is far more than the performing of such procedures. Dr. Midian-Singh notes, “In assessing and treating disease we also take a cognitive focus with our patients. Our diagnosis is based on the presentation of symptoms and depends upon effective communication with our patients. My colleagues in the Gastroenterology department at Allegheny General Hospital diagnose and treat our patients, often without procedural intervention. Conditions of the gastrointestinal tract can cause much in the way of disruption and anxiety for patients. It is our privilege to help our patients to surmount these in a way which promotes their quality of life and respects their dignity.”
Patients who for religious reasons decline to have blood transfusions as part of their care are often treated by the Gastroenterology Group at Allegheny General Hopital. Dr. Midian-Singh notes: ‘We are pleased to work with our Bloodless Medicine Department to understand and then work in cooperation with these patients. I always bear in mind that I’m treating not a disease or condition, but a person. It is therefore important to understand and respect all aspects of that person including their cultural and religious traditions.’
For these patients who decline transfusions, an especially concerning problem is bleeding in the gastrointestinal tract. (Read Detecting a GI Bleed.) Treating this condition calls for good judgement, cooperation between physicians in differing departments and at times urgent intervention. For effective treatment of a GI bleed in such patients, the first responsibility lies with the patient himself. He must recognize the symptoms of a bleed and seek medical advice at first presentation. From this point the diagnostic skills of the doctor are tested as we need to determine what steps should be taken. Doctor Midian-Singh states that as many as 80% of GI bleeds stop on their own without any therapy. A patient’s history and presentation of symptoms are needed for us to diagnose the likely source of such bleeding. When active intervention is called for, endoscopy and colonoscopy may be utilized. A further tool is called capsule endoscopy which is the swallowing of a capsule which contains a camera that takes pictures every two seconds as it moves through the digestive system. This is often effective in finding occult (cannot be seen) blood loss.
For some of these bleeds, intervention may be done during the gastroenterology procedure to quell bleeding. For instance, a common source of GI bleeding is from a stomach ulcer. When an ulcer is observed, good judgement again must be used as some interventions in certain situations may actually increase the chances of bleeding. When bleeding is observed, procedures such as injection therapy, heat application and clipping can often be done to arrest bleeding.
Other sources of bleeding may call for follow-up intervention by interventional radiology or even surgery.
Dr. Midian-Singh notes, “The gastroenterology department at Allegheny General Hospital can proceed in the treatment of patients who refuse transfusions with a greater degree of confidence because we know that our partners in radiology, surgery and critical care medicine are also standing at the ready, willing to lend their expertise in the managing of such patients. No one department can effectively diagnose and treat the entire range of conditions and symptoms including various GI bleeds. But in coordination and in a culture of respect we can provide treatment that honors a person’s wishes.”
