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?
Vis a vis elevated white count and stress and viral infections. All of this is true. Add to the list generalized seizures (very brief... if a CBC is drawn immediately afterwards the results can tell you if the patient has actual seizures or pseudoseizures.) Also add to the list a big old dose of corticosteroids. Makes sense because methylprednisolone and such are artificial stress hormone.
So how can you determine whether the white count indicates bacterial infection or some of these other causes? It's called the "left shift". This consists of two clues. The first is a neutrophilia... the white count not only goes up, but the % of neutrophils in the count goes up. (I think above 70% is indicative...). The other clue that cinches the (medical) diagnosis is an elevation in bands. (also called "stabs" in some places.) Bands/stabs are immature forms of neutrophils. They should never exceed (I'm trying to remember the exact number) 3-7%. So "neutrophilia" and "bandemia" are hugely suggestive that there is a bacterial infection somewhere.
The mechanism of the change in differential is this: A bacterial infection produces inflammation that, in turn, results in the release of interleukins, cytokines, chemokines, complement... a veritable "soup" of signalling molecules. These reach the bone marrow where release of neutrophils goes gang-busters... in fact, the bone marrow is trying so hard to throw neutrophils into the warfare that it begins to release immature neutrophils (bands/stabs.)
A neutrophil is also called a "poly" or "PML" (just to confuse us) because it has a typical polymorphic nucleus... looks lumpy. A band is a neutrophil with a smooth nucleus. Last week one of my students took care of a man who'd been admitted to the hospital with a WBC of 22,000, and 39% bands. (An indoor record!)
That's good info about the differential, I knew a little about left shift and bands, but I like your explanation. Unfortunately, a diff was not done, so I am left to speculate. SO here's another question: WHY do you suppose no diff was done? Doc overlooked it? Or is a high WBC after acute GI bleed such an expected finding that they didn't need to do a diff? As I said, the docs- ER doc, hospitalist, GI doc, none of them ever addressed the high WBCs in their notes, and another CBC was not obtained before the patient was discharged. Thoughts on that?
I don't know why they didn't do a diff. I've seen it a lot and it honks me off. I wish it was a policy of the clinical laboratory services that any CBC with a WBC above (you pick the number) always has a diff done on it.
We as nurses are responsible for recognizing the atypical lab (not making the medical diagnosis... UTI, aspiration pneumonia, etc.) which provides us with some assessment data suggesting possible infection. Rolling that assessment into our plan of care, it's our job to be sentinels... on the look out for any other evidence of infection. (Fever being a big one.) Remember, the WBC is an important number, but it's just one datum. We treat the whole patient.
(Besides... when the patient is readmitted with a temp of 104... we can have the satisfaction of knowing we were right, even though we'd probably be upset on the patient's behalf.)
Yeah, I was watching his temp because it hovered right around 37 C. most of the time but I never saw it go up, and he didn't have any other noticeable signs of infection. He did have some LLQ pain at the beginning of my shift but it subsided because I was such an awesome SN. It just bothers me that they checked his hct a couple times a day initially but never rechecked a CBC or ran a diff. They didn't even recheck the hct on his last day before discharge. He was feeling relatively well though, so maybe that's why.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
repeating the labs isn't always necessary. If he recovered well after transfusion and there is no further bleeding there is no reason to check. The elevated white count is expected and depending on the differential in the beginning, if it showed no "left shift", there would be no reason to repeat.
Except there was no differential done in the beginning, or ever... So the elevated WBC is an expected result with GI bleed? That's what I am trying to figure out, and I can't find any references that say that.
His WBC was likely elevated from gastritis (vomiting that causes a tear is rarely a one time thing) and/or stress response/inflammatory changes from the body reparing the tear. It's not the bleed so much as the cause of the bleed.
GI bleeders run the gamut from your patient to ruptured esophageal varacies. The more you can figure out about any patient's true underlying pathophysiology, the better you can tailor their care.
I was just going on his reported prior history, since we don't have anything else to go on. He had a Mallory- Weiss tear (yeah I had to look it up too, it's not even in our textbooks), confirmed by EGD. He had been on NSAIDS (Mobic), which is a classic risk factor. But he did say he only vomited one time before the hematemesis began, and he seemed to be a reliable historian, consistently A&O x 4 and all that jazz.
So for lack of better info, like a diff, I'm thinking his high WBCs could be from a combination of the original gastritis (whatever caused the initial vomiting), inflammation, and emotional and physiological stress? Does that sound about right?
I think you're doing a fantastic job with this case.
He may well have only vomited once, especially with the NSAID use. Most of the Mallory Weiss tears I've seen as a ER nurse have been in pregnant women with hyperemesis--I share this as a reference point, not as an exclusive situation.
When I say stress response, I mean physical stress on the body that results in inflammatory processes. That's the bit with cytokines and such that someone much smarter than me explained up thread.
Make sure you can back up anything you put in your care plan. Your professor probably won't like gastritis with one episode of vomiting (not the typical presentation).
Thanks, I know I am overthinking it. She will definitely give me full credit for this answer, I guess I am just going for the gold star and the pat on the back. I am definitely planning on explaining the stress response, or trying to anyway.
Do you think risk of infection sounds reasonable? Not sure I have enough to go on for that though, besides the elevated WBC and a one-time temp of 37.4 (but that could be due to the blood transfusion). Also readiness for enhanced knowledge (he is afraid of it happening again and wants to know what kind of dietary/ other changes he can make to avoid it). For my 3rd, probably activity intolerance r/t acute blood los, AEB generalized weakness and SOB with ambulation. We need 3 diagnoses, but they don't have to be prioritized. I feel like I have less data for this guy than previous patients, probably because he really is pretty healthy otherwise.
His one and only WBC was 19.1. Period. That is all I have on the WBC. It was done in the ER, probably a couple hours after the first episode of hematemesis.
It just bothers me that they checked his hct a couple times a day initially but never rechecked a CBC or ran a diff. They didn't even recheck the hct on his last day before discharge. He was feeling relatively well though, so maybe that's why.
Episteme
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Vis a vis elevated white count and stress and viral infections. All of this is true. Add to the list generalized seizures (very brief... if a CBC is drawn immediately afterwards the results can tell you if the patient has actual seizures or pseudoseizures.) Also add to the list a big old dose of corticosteroids. Makes sense because methylprednisolone and such are artificial stress hormone.
So how can you determine whether the white count indicates bacterial infection or some of these other causes? It's called the "left shift". This consists of two clues. The first is a neutrophilia... the white count not only goes up, but the % of neutrophils in the count goes up. (I think above 70% is indicative...). The other clue that cinches the (medical) diagnosis is an elevation in bands. (also called "stabs" in some places.) Bands/stabs are immature forms of neutrophils. They should never exceed (I'm trying to remember the exact number) 3-7%. So "neutrophilia" and "bandemia" are hugely suggestive that there is a bacterial infection somewhere.
The mechanism of the change in differential is this: A bacterial infection produces inflammation that, in turn, results in the release of interleukins, cytokines, chemokines, complement... a veritable "soup" of signalling molecules. These reach the bone marrow where release of neutrophils goes gang-busters... in fact, the bone marrow is trying so hard to throw neutrophils into the warfare that it begins to release immature neutrophils (bands/stabs.)
A neutrophil is also called a "poly" or "PML" (just to confuse us) because it has a typical polymorphic nucleus... looks lumpy. A band is a neutrophil with a smooth nucleus. Last week one of my students took care of a man who'd been admitted to the hospital with a WBC of 22,000, and 39% bands. (An indoor record!)