Strange Stool Color and Fatigue in a Man With COPD and Atrial Fibrillation

Asim Kichloo, MD; Dushyant Singh Dahiya, MD; Farah Wani, MD; Khalil Kanjwal, MD


April 12, 2021


Acute GI bleeding can be classified into the two following subtypes, according to the location of the bleeding and the presentation of the symptoms:

  • Upper GI bleeding usually presents with hematemesis or melena. Massive upper GI bleeding may present with hematochezia.

  • Lower GI bleeding typically presents with hematochezia. Rarely, patients with right-sided colonic bleeding may present with melena.

In this case, the patient presented to the ED with acute, sudden-onset worsening shortness of breath upon exertion, fatigue, and dark stools. Upon examination, he had tachycardia, hypotension, weak peripheral pulses, and cold and pale extremities. Laboratory investigations revealed low hemoglobin levels, and the fecal occult blood test was positive. These characteristic signs, symptoms, and test results favor a diagnosis of acute blood loss anemia from a GI source, which was later visualized on colonoscopy. In addition, the patient was taking aspirin, clopidogrel, and apixaban, which are known to increase the risk for GI bleeding.

Although this patient had a history of COPD and presented with worsening shortness of breath, he did not have increased cough, wheezing, or sputum production. Moreover, he did not require home oxygen and had no triggering factors. These findings make a diagnosis of acute exacerbation of COPD less likely.

Congestive heart failure was ruled out by the absence of orthopnea (no increase in the number of pillows to help relieve shortness of breath while lying down), paroxysmal nocturnal dyspnea, and peripheral edema. In addition, the echocardiogram showed a normal left ventricular ejection fraction.

In-stent restenosis has been reported in 3%-20% of patients who undergo PCI with stent placement and depends on the drug-eluting stent used.[1] It can occur within 3-12 months of the stent placement and may present with features of recurrent angina or myocardial infarction (MI). This patient did not have clinical features suggestive of angina or MI, and the ECG findings were unremarkable; thus, in-stent restenosis was unlikely.

Finally, although a positive family history of IBD predisposes the patient to IBD and requires aggressive screening, the results of his colonoscopy 2 years earlier were unremarkable. In addition, the findings on his most recent colonoscopy do not support a diagnosis of IBD.

The initial assessment and treatment of a patient who presents to the ED with suspected acute GI bleeding should focus on hemodynamic stability; however, other investigations should also occur in parallel. The goals are to determine the location of the bleeding (upper or lower GI tract), assess the severity of the bleeding, triage the patient to an appropriate setting, provide general supportive measures, and initiate resuscitation if necessary.


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