25. The Coffee Grinder
Sometimes we have an idea of what we don’t know. But sometimes, we have no clue this unknown even exists. This is one of the many times I had no idea of what I should be looking for.
Mrs. Edith was with us for a few days. She was a lovely 75-year-old granny admitted due to lower GI bleeding and severe anemia. Her hemoglobin was 4 at admission, which was actually hard to believe since she was such an energetic person. Edith just loved to chat at the bedside. I enjoyed talking to her, but I was spending so much time there that I was getting behind schedule and arriving late for rounds. I honestly did not know how to interrupt her.
Edith had already received a blood transfusion and was waiting to undergo her second colonoscopy and endoscopy in that hospital stay. Her first ones came back clean but visualization was compromised due to inappropriate preparation. That and the fact that her melena persisted was enough for the GI team to suggest a new test to check for any lesions they might have missed.
‘Morning, Mrs. Edith! How was your night?’
'Oh, it was so nice! Nurses from the night were great, especially Anne. Do you know her? Anne. She said she takes the night shifts to be with her kids during the day. How cute is that?'
‘Mom, remember what we talked about? Dr. Diaz has other patients she needs to see.’ Her daughter spoke kindly to her mom and caressed her hand.
‘You’re right, you’re right.’ She let out a contagious laugh that reminded me of my own grandmother. ‘I’m sorry, Dr. Diaz. I am just not used to having so many people to talk to.’
Edith lived by herself. She was having melena for a few weeks before admission but it didn’t really concern her until her daughter noticed one day while visiting.
‘What do you guys think of doing rounds in the cafeteria today?’ Dr. Rivers suggested and Kate and I quickly accepted.
I decided to start with Mrs. Edith since she seemed like the most straightforward case: GI bleeding in the elderly, we were taking care of the anemia and the GI team was responsible for treating the intestines.
‘Ok, so coloscopy was clean. What else could be causing the bleeding?’ Dr. Rivers asked me.
‘Well, the GI team thinks they might have missed something. They suggested new endoscopies.’ I answered almost like a knee-jerk reflex and missing the real point of his question.
‘That seems appropriate, but it is also an easy way out, don’t you think?’ He smirked. ‘It’s easier to blame the test than actually finding another reason she is bleeding in the gut.’
‘You do have a point.’ I reconsidered.
‘Let’s pretend she really doesn’t have a lesion in the colon. What could be the reason she is bleeding?’ Dr. Rivers led the discussion.
‘Her coagulation panel is normal, so coagulation factors are probably okay.’ Kate began. ‘And platelet count is good too.’
‘But platelets could not be working for some reason, like uremia or genetic causes.’ I followed. ‘However, her renal function is good and she has no history of major bleeding to suggest a congenital cause.’ I sighed without any ideas.
‘Nice, I like where you guys are going. But there are other reasons why platelets don’t work. Any guesses?’
We were silent for a few seconds when suddenly Peter came from behind us and whispered to.
‘Drugs.’ I repeated for Dr. Rivers to hear. ‘NSAIDs and SSRIs for example can cause platelet dysfunction.’
‘True. Is she taking any of those?’ I shook my head no. ‘So, what else?’
I first thought he was just brainstorming but at that moment I began to suspect he had already figured out the diagnosis. Which meant I had already given some piece of information in my presentation that made the diagnosis clear.
I tried glancing at my notes to check what I was missing. But it’s like that saying, you don’t say hi to who you don’t know. I was never going to find it because I didn’t know what I was looking for.
‘Platelets can also be dysfunctional due to trauma.’ I guess this was supposed to be the a-ha moment but Kate and I were clueless. ‘Take a look at that.’
Dr. Rivers pointed to the big coffee grinder in the cafeteria. It was a huge funnel where the coffee beans were at the wide top and the powder was at the narrow bottom.
‘Where does that happen in the body?’
The missing information just clicked into place.
‘Aortic stenosis.’ I snapped my fingers. ‘Edith has a systolic heart murmur.’
‘That’s called Heyde Syndrome. As the blood flows through the stenotic valve, the platelets suffer conformational change which increases the breakdown of von Willebrand factor. This is associated with angiodysplasia of the GI tract, which can be missed in endoscopies. The bleeding usually resolves with aortic valve replacement.’ He bit a piece of his bagel. ‘Very fitting that we did rounds in the cafeteria today.’ He smiled satisfied with his new metaphor.
So I went to explain to Mrs. Edith and her daughter what we thought she had. It was quite a challenge to explain why a heart problem was causing GI bleeding, but the coffee grinder metaphor actually helped. Her new colonoscopy showed angiodysplasia and her melena stopped after Mrs. Edith underwent aortic valve replacement. At her discharge she was sad to leave, she wouldn’t have all those people to talk to at home. I did tell her though that she should come back to the clinic so we could catch up.
‘Sure thing, Dr. Diaz. I’ll bring you coffee next time.’ She winked.
…
Want to know more about Heyde Syndrome?
Want to read a real case of Heyde Syndrome?
https://journals.sagepub.com/doi/full/10.1177/2324709621997279
Clinical Board
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