Over the past month my hemoglobin (Hb) level dropped unexpectedly from a powerful and red-blooded 13 g/L to a feeble and anaemic 8.5 g/L over a three week period. The big question was: why?
The first thing that occurs to most medicos is that the drop has been caused by blood loss, if not from some obvious wound, then maybe for somewhere more subtle, like the bowel or intestines. Blood loss via the bowel may not be in liquid form, but rather (not to put too fine a point on it) in the form of black poo. “No black poo here” I said. Still, there may be a leak somewhere else, so just to be sure, it was deemed time for both a gastroscopy and a colonoscopy.
A gastroscopy is an examination of the inside of the oesophagus, stomach and duodenum. The oesophagus is the tube connecting the back of the throat to the stomach, also called gullet – which is a great word: “Snow White’s poorly chewed apple stuck in her gullet” – who doesn’t feel that in the back of their throat?). The duodenum is a chamber at the base of the stomach where semi digested food from the stomach enters the intestines to complete digestion.
The gastroscopy is performed using a thin, flexible plastic tube with a tiny digital camera and light at one end. The tube is passed through the mouth and allows the doctor to see if there is any damage to the lining of the oesophagus or stomach, and whether there are any ulcers in the stomach or duodenum.
A colonoscopy is an examination of the large bowel and part of the small bowel.
The colonoscopy is performed using a long, firm and flexible plastic tube with a tiny digital camera and light at one end passed through the anus. As well as looking for sources of blood loss, it can be used to look for colon polyps (growths on the lining of the colon) or cancer of the colon, and to help diagnose symptoms such as unexplained diarrhoea or abdominal pain
In both cases, the gastroenterologist carefully guides each instrument in the appropriate direction (from the top down or the bottom up), to look around inside. The picture from the camera appears on a monitor to provide a clear, magnified view.
For both procedures preparation is required, one a little more dramatic than the other (detailed prep instructions are usually provided when you book in for the procedure).
For the gastroscopy, I was told not to eat or drink anything for up to eight hours before the test, so that my stomach was empty to allow the doc to see the entire area and to decrease the possibility of food or fluid being vomited into the lungs while I was under sedation (called aspiration). That seemed pretty simple.
For the colonoscopy things are a little messier. For this procedure, I had to completely empty my bowels. This cannot be done without help, usually in the form of a purgative (a dose of salts and chemicals that evacuates the bowels). The difficulty is that the purgative reduces everything to fluid using the water I usually carry in my body, to the extent that I could lose 1-2 litres of fluid in a few hours.
This is bad for everyone, because if this fluid is not replaced as it is lost, we can become dehydrated, often without realising it. Symptoms can range from mild to major, starting with confusion, headaches, dizziness and weakness, getting progressively worse, to coma, organ failure, and even death. Dehydration during prep is more common than you imagine. I know several people who were put on drips as soon as they arrived for the test because they arrived dehydrated.
For us BigD-ers, there is an added danger: even mild dehydration can cause our fistula to clot.
So the trick is to balance fluid loss with intake. Normally I try not to get more than 1.5 to 2 kg over my base weight. That means I can drink 1 – 2 litres of fluid between dialysis sessions and keep well. During the last day before the procedure I was losing at least that much in a few hours, so I needed way to replace the fluid lost each time I went to the loo (which was often). This is where my bathroom scales came in handy. As I dashed to the toilet, I would jump on the scales and weigh myself. After the action blew over, I would weigh myself again, work out the difference, and then drink at least that amount of fluid. eg, if I lost .25 a kilo, I would drink 250 -330ml of water; half a kilo, 500-plus ml and so on.
The result of this Toilet-Scale Dance was that I weighed about a kilo above my base weight when I was wheeled into the theatre, which I think was just right. All went well. My body was well prepared; I slept like a baby (I quite like that feeling of unconsciousness rolling over me as the anaesthetic takes over!). I woke up about 90 minutes later, feeling fine.
A little later the gastroenterologist arrived and told me they had found nothing untoward. Though as a final test, I will be asked to swallow a camera pill to check out the so far unexplored central regions between my duodenum and the small bowel. I’m looking forward to that experience.
My thinking on the matter is that I am just over-sensitive to changes in Aranesp (synthetic erythropoietin – EPO) used to increase my red blood cell levels). My doctor stopped my Aranesp as soon as my Hb was found to be 13, and maybe it was stopped for too long. This may well be the answer, especially if pill-cam comes up clean (so to speak).
In the meantime, if you have a colonoscopy scheduled, get ready to learn the steps of the Toilet-Scale Dance and stay well.