High WBCs with acute GI bleed?

[suzw]

My patient, a 70-something male, was admitted for GI bleed due to Mallory-Weiss tear. He had been feeling nauseous in the morning and vomited his coffee, and felt a little better (no hematemesis at that time). Many hours later in the day he started feeling worse, and that is when he vomited large amounts of blood. I suspect the MW tear happened during the first vomiting episode (though this is not known for sure) thus causing the subsequent hematemesis. His hct hit a low of 22 (down from 39) before transfusion the next day.

The thing that is perplexing me the most though is his WBC. He had a WBC of 19 later that evening (PRIOR to transfusion). He has no other risk factors to account for this. No known infections, no other illnesses besides whatever made him vomit, no significant leukocytosis inducing meds. No diff was done, and the physician didn't address the high WBCs in any of his notes. Could whatever caused the patient to vomit in the first place (before the tear happened) be what caused the high WBCs? I.e. could a virus or gastritis be enough to make the WBC that high? Maybe the virus/ bacterial illness plus the physical and psychological stress of being acutely ill? I can't find anywhere what the expected values would be for these conditions, but 19 is higher than what my septic patient the previous week had.

I don't have to come up with an answer for my clinical paper, but I would like to be able to explain this better. Thoughts? Would a WBC be this highly elevated due to a simple stomach virus or bacterial infection?

[suzw]

Oh, and he has no known underlying illnesses, besides BPH, hyperlipidemia, and hypertension, for which he was taking atenolol, simvastatin, and 2 or 3 different BPH meds.

[Episteme]

Well... leukocytosis only tells you that there is an inflammatory process going on. Most often it's an infection, but it doesn't have to be. When his esophagus tore, could some blood have spilled out of the GI system into the peritoneum just under the diaphragm? If I were that guy's nurse "risk for infection" would make my list and I would follow his temp and CBC w/diff very closely. But there may be blood where it doesn't belong and the body has to take care of it on its own.

[smf0903]

I will be curious to see what the RNs on here say :) My thought would be that any GI tear would cause a marked increase in WBC because the gut is chock full of bacteria. I would think any compromise of GI integrity would be like party central for the immune system.

[suzw]

Yeah, I was perplexed as to why he was discharged before having a repeat CBC, and no diff was ever done. He was feelong well on discharge though, with no fever. He never had a temp higher than 37.2 or so.

So smf0903 are you thinking that bacteria from the gut got into his bloodstream via the tear?

[suzw]

By the way, my clinical instructor is new, but she's an experienced nurse and couldn't quite figure it out either.

[RescueNinjaKy]

Are you sure it was coffee and not blood. If he had a gi bleed that comes into contact with the gastric acid it turns the blood into coffee colored emesis. Perhaps he has ulceration/fistulas and that is the origin of the bleed, also it can lead to abscess which can account for the elevated wbc.

[RescueNinjaKy]

And if he already had gi problems, drinking coffee can irritate/exacerbate it

[suzw]

Well he said it happened right after drinking his morning coffee and he threw up his coffee. He had an upper GI that showed a Mallory Weiss tear, not abscesses, ulcerations or fistulas.

[Esme12, ASN, BSN, RN]

The irritation for the tear and gastritis/esophagitis is inflammatory and accompanies this will cause an elevation of the WBC's.

It is the bodies inflammatory response to trauma/injury/invasion.

[suzw]

Ok thanks Esme! I didn't realize inflammation could raise WBCs that much.

[Guest 360983]

A doc once told me viral illnesses raise WBCs higher than most bacterial infections. I don't have any evidence for this, so take it with a grain (or a shaker) of salt.

Like Esme said, don't underestimate the body's stress response.