Dear Dr. Roach: A colleague of mine recently had a pulmonary embolus at age 45. She is otherwise healthy. What must she be concerned about?
N.R.
A pulmonary embolus is a blood clot that travels to the lung. Although they can originate in any large vein, they most commonly come from the deep veins of the pelvis and thighs. The clots can break off with or without physical activity, and they usually travel through the right side of the heart into the lungs.
The symptoms of PE include shortness of breath, chest discomfort, fast heart rate and cough. Some people experience a sense of impending doom; others have no symptoms at all.
Once the diagnosis is made (now mostly by CT scan, but nuclear and dye studies still are done sometimes), treatment is begun immediately with injection drugs to stabilize the clot and allow the body to dissolve it. (In very rare instances, drugs to dissolve the clot are given, with extreme caution.) After four or so days on injection drugs, the person can be switched to oral medications, such as warfarin (Coumadin) or one of the new oral anticoagulant drugs.
The next issue for your colleague is determining why she got the PE, as that informs the decision about how long to continue anticoagulation. The list of possible causes is too long to review here, but her doctors will look for hereditary causes of blood clotting, such as deficiencies in the coagulation factors protein C and protein S; they鈥檒l evaluate her medications, if any, and perform a careful history and physical exam.
Undiagnosed cancer is a concern, and most authorities recommend appropriate screening 鈥� mammography, chest X-ray or other testing if indicated by the results of the initial evaluation.
The duration of anticoagulation depends, as I said, on the findings. If her clinicians cannot find a cause, many experts will give lifelong anticoagulation to people with a history of PE who also have a low risk of bleeding. A hematologist is usually the expert on deciding duration of anticoagulation.
听
Dear Dr. Roach: My husband is 74 and was just told by his doctor that he has blood in his stool. The doctor wants him to have a colonoscopy, since his last test was more than five years ago and it showed precancerous polyps. He refuses to have the test because his younger sister just died in November from colon cancer. He states that after seeing what she went through with all the treatment to no avail, he does not want to go through that: He just wants the illness to听run its course. What can he expect to happen? I am trying to听help him with his wishes since he will not have the test.
A.L.W.
I鈥檇 recommend he change his mind and get the test done. A positive stool test for blood is not a diagnosis of cancer. Only a minority of cases of blood in the stool turn out to be cancer; however, with his history of polyps, he is at higher risk.
Colon cancer grows slowly, and it is much, much more easily treated early. At this point, it's possible that the colonoscopy itself will be all he needs. If it is cancer, however, it will grow, and eventually may get to the point that it blocks the colon; that requires emergency surgery. Letting nature take its course is certainly a choice he can make, but having seen many people make that choice, I think it is very likely he will regret it.
Get the diagnosis first. Then, he will have more information to make his decision.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected].
听
