Am I Dying

by Christopher Kelly

  Because that entire surface is covered in blood vessels, the GI tract is a common site for bleeding, which has only two possible exits. Blood in your stool is much more common than blood in your vomit. Both, however, can signal life-threatening problems.

  The effect of blood on your stool’s appearance depends on the location of the bleeding. Bleeding from the stomach usually turns your stool black and tarry, since the blood gets digested with your food. In contrast, bleeding from lower down the tract turns the stool maroon or bright red.

  If you see blood in your stool, should you just chalk it up to hemorrhoids and move on? Or do you need immediate medical attention?

  Take a Chill Pill

  You’re staying at a hotel and see blood on the paper after a few wipes. You know the television ad, with the bear family squeezing soft rolls of toilet paper? The rolls of paper in hotel and public bathrooms are about as gentle as the bear’s claws. You might as well wipe with a piece of plywood. The blood is likely from small traumatic injuries to the area around your anus. Next time, pack a roll from home. (Try explaining that to the TSA.)

  Your poop looks red, and you just enjoyed a delicious meal containing beets. Beets contain a strong pigment that turns everything it touches purple. It may look like there’s blood in your stool, but it has simply been stained by the remains of your lunch. Of note, the beet pigments can also get absorbed into your blood and then be deposited in your urine, which turns pink or purple.

  Make an Appointment

  One or two drops of blood come out after you defecate. Hemorrhoids are fragile, engorged blood vessels in and around the anus. They are more common later in life but can form during pregnancy (from the pressure on your pelvic veins) and in people with constipation (from the constant straining and squeezing, which wears the veins out). Hemorrhoids sometimes crack during defecation, coating the stool with a streak of blood or sending a few drops into the toilet. Your doctor can confirm the diagnosis with a rectal exam (sorry). Depending on your age, your doctor may also need to rule out cancer.

  Hemorrhoids require treatment only if they cause significant bleeding, itching, or pain. If you’re constipated, eat more fiber to soften your stool and relieve constipation, (see here) and increase your exercise to keep your guts active. Most people with hemorrhoids also get relief from sitting in a shallow bath of warm water. Finally, you can try an over-the-counter hemorrhoid cream that contains pain relievers. If all of that fails, you may need surgery to eliminate your hemorrhoids.

  You see bright red streaks of blood on your stool, but otherwise you feel fine. You may have hemorrhoids (just described) or a bleeding tumor or abnormal blood vessel in your colon. You may need a colonoscopy to make the diagnosis (see the Quick Consult).

  You have a sharp pain when you defecate, and there are streaks of bright red blood on your stool. You may have sustained an anal tear, also known as a fissure. The usual causes are chronic constipation (since large, firm stools are being forced through the anus); vaginal birth (which wreaks havoc on everything down there); and anal sex (next time, don’t skip the lube). Tears can bleed and cause intense pain during defecation. You may get relief by taking warm baths and eating fiber to soften your stool. Most doctors will prescribe a cream for the anus that increases blood flow to the tear and accelerates healing.

  You take a blood thinner. Blood thinners often cause spontaneous bleeding from minor abnormalities that aren’t dangerous and wouldn’t otherwise bleed. In some cases, however, blood thinners can increase bleeding from a tumor or another significant growth, leading to an early diagnosis. Your doctor will probably want to order a colonoscopy to make sure everything looks normal (see the Quick Consult). The major blood thinners include warfarin/Coumadin, apixaban/Eliquis, rivaroxaban/Xarelto, and dabigatran/Pradaxa.

  You have occasional crampy abdominal pain and diarrhea, which is sometimes streaked with bright red blood. You may have an intestinal infection or autoimmune disease, like inflammatory bowel disease (which includes both Crohn’s disease and ulcerative colitis). You should see your doctor as soon as possible for further testing. If the diarrhea and/or bleeding are severe, and you also feel lightheaded, go to the E.R.

  Your poop sometimes looks jet black, but otherwise you feel fine. If you’re taking iron supplements, they’re probably the culprit. Black licorice, blueberries, and Pepto-Bismol can also turn your stool dark. If you haven’t taken any of these, you might be bleeding from your stomach. Remember that the blood in the stomach gets digested as it winds through the colon, turning it (and your stool) black. Bring a stool sample to your doctor (and don’t use that Tupperware again!). A simple test can determine if the stool contains blood or not. If it does, you’ll probably need a procedure known as an endoscopy, in which a camera is inserted into the stomach to look for bleeding.

  You have a family history of colon cancer, or you’re also losing weight. You definitely need to be checked for colon cancer, even if you just see one or two drops of blood in your stool, since your risk is much higher than the average. You’ll need a colonoscopy (see the Quick Consult).

  You also have frequent nosebleeds or bruising for no clear reason. You could have a disorder of your clotting system, or abnormally low levels of platelets (the cells that help form clots). These conditions increase your risk of bleeding from many different locations, including the lining of your intestines. See your doctor as soon as possible to undergo further evaluation. Of note, you should seek urgent attention if the bleeding is very frequent or profuse.

  Get to the E.R.

  You feel lightheaded, especially when standing. If you see blood in your stool and feel lightheaded, there’s probably a lot more blood coming down your pipeline. The lightheadedness is a sign that your bleeding has already become critical. You need to get to the E.R. for an urgent assessment and possibly a blood transfusion.

  You sit down to defecate, and bright red blood pours out. You can easily bleed to death through your anus. If the floodgates have opened and you don’t rush to the emergency room, your bleeding may stop at the same time as your heart.

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  Quick Consult

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  Your Colon’s Hollywood Moment

  Early life is all about the milestone years. Sixteen years old, and you can drive. Twenty-one years old, and you can finally use your real ID at a bar. Unfortunately, later life isn’t as sweet. Fifty years old . . . and you’re finally due for your first colonoscopy. (At least you’re just a few years away from discounted movie tickets and Social Security checks.)

  During a colonoscopy, a doctor snakes a camera through the colon to look for abnormal growths or sources of bleeding. Anything funny-looking is biopsied and checked for cancer. The camera is at the end of a long, narrow tube (about as wide as your finger), which is inserted into your anus with a hefty amount of lube. Although this process may sound roughly as enjoyable as having your fingernails pried off, you’ll receive plenty of medications to help you chill out. Also, the whole thing takes only about thirty minutes.

  The worst part is usually not the procedure itself, since you’re kind of sleeping, but rather the preparation starting the evening before. Your doctor will prescribe a large bottle of clear fluid to guzzle that night and early the next morning. Alas, this fluid is specifically designed to cause profuse diarrhea, since you’ll need to flush the poop from your system. (It’s hard to see tumors when the walls of the colon are slathered with thick feces.)

  Most adults can wait until age fifty for their first colonoscopy; however, some guidelines recommend routine screening start even earlier, at age forty-five. If you have a strong family history of colon cancer, you’ll need to schedule yours even earlier. You may also need an urgent colonoscopy if you have signs of possible colon cancer, like blood in your stool or unexplained anemia (low blood cell count). Colonoscopies are usually repeated every ten years, or sooner if polyps (noncancerous growths) are found.

  We strongly recommend you stick with the
colonoscopy schedule, even if the idea grosses you out. If Katie Couric could have one performed on national television, we know you can handle it too. If you remain adamantly opposed, however, there are alternatives. For example, you can use a special kit to periodically check your stool for blood or for genetic evidence of a tumor (DNA traces consistent with cancer). Unfortunately, the kit isn’t as good at detecting cancer as a colonoscopy is, and if you do find evidence of a possible tumor, you’ll need a colonoscopy anyway.

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  Part 7

  Arms and Legs

  Leg Pain and Cramps

  EDITED BY NICHOLAS MORRISSEY, M.D.

  Do your painful legs cramp your style? Although leg pain can be used as an excuse to skip the gym and just kick up your legs on the coffee table, it can also interfere with normal function and, in rare cases, be a sign of a broader problem.

  For most people, leg pains are from cramps in the calves. These cramps occur because of strong contractions of the leg muscles, which happen when the nerves to the muscles become overexcitable. Common causes include low levels of electrolytes like magnesium, potassium, or calcium; a local buildup of acid; and dehydration. Failure to adequately stretch after exercise can also lead to cramping.

  But is your leg pain a cramp? Or is it actually pain from poor circulation, a blood clot, or an inflamed muscle, nerve, or joint?

  Take a Chill Pill

  You just bench-pressed a Buick. We recommend an active lifestyle that includes exercise, but take care not to overdo it. An overly vigorous workout can lead to muscle fatigue, dehydration, and exercise-related injuries like shin splints, tendinitis, and hairline fractures. Stay hydrated using rehydration solutions rather than just water, and stretch before and after your workouts. Also make sure you have comfortable, properly fitting sneakers. You should have room to wiggle your toes, but your foot should not slide around in your sneaker. If you notice pain after exercising, treat your muscles with stretching, massage, and medications like acetaminophen/Tylenol or ibuprofen/Advil/Motrin until the pain resolves.

  You wake up with painful leg cramps at night. Half of adults over the age of fifty experience painful nighttime cramps in the calf or foot. The pain improves after getting out of bed and stretching the affected muscle. To prevent cramps, stretch at least three to four times per day, including right before bed. If that doesn’t help, try taking vitamin B complex capsules. If you’re still cramping up, speak with your doctor about trying medications to relax your muscles. Some doctors recommend a glass of tonic water before bed, as it contains a chemical known as quinine that can relieve cramps. Unfortunately, quinine can also have serious side effects, including rash, headache, nausea, ringing in the ears, abnormal heart rhythm, and low platelets, so don’t try it without a doctor’s supervision.

  Your weight has increased during the past nine months. Leg cramps are common during pregnancy—though they are a mere taste of the physical pain to come during motherhood. The pain occurs in part because of the extra weight on your legs. In addition, women in their third trimester have relatively low blood calcium and magnesium levels. If you’re chugging along in the final stretch and have leg cramps, try taking calcium and/or magnesium supplements, which may provide relief and are usually safe for your growing baby. (But check with your obstetrician first just to be safe, in case you or your baby have some rare issue that would make these supplements problematic.) Unfortunately, blood clots are also more common in pregnancy, so if one of your legs is especially red, swollen, and/or painful, you should notify your doctor right away.

  Make an Appointment

  Your legs feel restless at night, like you need to move them around. Restless legs syndrome doesn’t usually cause leg pain, but rather an uncomfortable tingling sensation in both legs that improves with movement. The symptoms are most prominent while you’re resting or trying to sleep, and they get better early in the morning. About one in ten adults has this disorder; if you’re pacing around your room instead of sleeping comfortably, you could be one of them. In some cases, restless legs syndrome is a side effect of medications like antihistamines, antidepressants, and antinausea drugs like metoclopramide/Reglan. (Please don’t stop taking these medications without speaking to your doctor.) In other cases, restless legs syndrome may be a sign of a medical condition such as iron deficiency, kidney disease, neuropathy, multiple sclerosis, or even pregnancy. You can try stretching your legs before bed to reduce your symptoms. Hot showers can also help. Regardless, you should see your doctor for a thorough evaluation.

  Your socks leave deep marks on your legs, and your favorite shoes don’t fit anymore. Your legs may be swollen with fluid, which can cause painful stretching of the skin. There are many causes of leg swelling (see here), and a thorough evaluation may be required to check for kidney, liver, or heart disease.

  You have numbness, tingling, burning, and/or weakness in one or both legs. A herniated disc in your lower spine or a narrowed spinal canal can compress the nerves to the leg, producing pain, loss of normal sensation, and/or weakness. If your symptoms improve when you lean forward, you likely have a narrowed area around the nerve (known as spinal stenosis), which opens up slightly as your spine bends. Anti-inflammatory medications (like ibuprofen/Advil/Motrin) can reduce pressure on the nerve and help relieve your symptoms. If these fail, doctors may inject steroids around the nerve to further suppress inflammation or perform surgery to relieve the nerve compression. You may experience similar symptoms if you have neuropathy, a form of nerve damage that can occur if you have diabetes, longstanding alcohol abuse, vitamin deficiencies, and certain autoimmune diseases. The exact treatment depends on the cause; however, medications like gabapentin/Neurontin and pregabalin/Lyrica often help relieve symptoms.

  You feel pain while walking that improves when you rest. You may have narrowing of the arteries that supply blood to one or both of your legs. As a result, your muscles aren’t able to get enough blood when they’re really working hard, resulting in pain. This phenomenon is called claudication. People who smoke or have a history of high blood pressure, high cholesterol, or diabetes are at greatest risk. The treatment is quitting smoking (duh); controlling your blood pressure, cholesterol, and diabetes; and undertaking a progressive walking routine. The goal is to push yourself just a little further each day, since the strain will prompt your legs to develop new, unobstructed blood vessels. If your symptoms are really disabling, your doctor may start you on a medication to increase blood flow to your legs or, alternatively, suggest a procedure to open up or bypass the blockage. If you note that one leg has rapidly worsening symptoms or pain that occurs at rest, that leg may not be getting any blood flow at all—an emergency that requires an E.R. trip.

  You recently started a new medication. Some of the medications that may contribute to leg pain and cramping include diuretics (water pills that rid the body of extra fluid and salt, sometimes causing dehydration and electrolyte deficiency), albuterol inhalers (used for asthma), oral contraceptives, raloxifene/Evista (for osteoporosis), and statins (for cholesterol). Don’t stop any medications without first speaking to your doctor.

  One of your legs is red, warm, and painful to the touch. You could have a skin infection, known as cellulitis, especially if you had a recent injury to that area that broke the skin. You could also have a blood clot in one of the superficial veins in your legs, which usually isn’t dangerous but can cause painful swelling. Call your doctor for a same-day appointment. If you can’t get one, or if you also have fever and chills, just head over to the E.R.

  Get to the E.R.

  You have painful swelling in only one leg, and you recently had a long bus/train/plane ride or a leg injury. You could have a blood clot in one of the deep veins in your leg, which causes painful swelling and can travel to other parts of the body, like the lungs. Such clots are more common in people who have recently immobilized their legs (long ride in a car/bus/airplane, cast for a broken bone, and so on), take oral contraceptives, or have ca
ncer. The diagnosis is confirmed using ultrasound. The treatment is blood thinners for at least three months.

  One of your legs is painful, cold, and numb (and you’re not sitting in a freezer). You could have a sudden, complete blockage of one of the arteries in your leg. You’ll need medications and a procedure to restore blood flow to the leg before irreversible complications occur, such as gangrene. If you’d like to keep that leg attached to your body, get to the E.R. right away.

  Swollen Feet

  Upset that your favorite stilettos suddenly don’t fit? Not sure why, you look down and notice that . . . What the hell? . . . I have cankles?!

  Foot swelling, also called pedal or peripheral edema, occurs when fluid accumulates in and beneath the skin. As the edema becomes more severe, you may notice it in your calves or even thighs, and pressing your finger into your skin may leave a lasting indentation.

  It’s unsightly, sure, but is it serious? Thankfully, most of the time you’re just dealing with an unfortunate cosmetic situation. Sometimes, however, the swelling can be painful. In rare cases, edema indicates a serious problem with the heart, kidneys, or other key organs that requires immediate attention.

  So which is it—a lifetime of socks or a trip to the emergency room?

  Take a Chill Pill

  You’ve been binging on salty foods. We like takeout Chinese food as much as anyone. Hell, it got both of us through medical school. Sadly, General Tso’s chicken is not a beauty food. (If only . . . ) Lots of salt causes your body to hang on to extra water, so your blood doesn’t turn salty like the Dead Sea. Gravity causes that fluid to track down into your feet. Cut back on takeout, packaged soups and canned goods, and other foods with high salt loads.