Beware the Girl Scouts

The wonder of my job is that after fifteen years of having people tell me the intimate details of noted intestinal effluents I haven't lost an ounce of enthusiasm for these details. No doubt my social calendar reflects this trait since a dinner invitation is as frequent as a tall tree on the tundra.
Nonetheless, today I will limit my comments to the stated problem, "black stools". Those of us in the business know that this complaint occasionally means that the patient is bleeding internally. That is, blood is being coagulated by, lets say, stomach acid and produces the noted color and therefore the inquiry.

Not every person that presents with the complaint of black stool is bleeding to death. So what else can it be? Gee, a variety of food products and medicines produce this result. Iron supplement pills, vitamins with iron, Pepto Bismol(bismuth subsalycilate), charcoal tabs(for gas or as the universal antidote) are among some of the pills that can cause black stool. The food list is much longer and in no way complete. Organ meats (bloody, esp. spleen stuffed with kasha), beets(usually red stool), spinach(iron), licorice, some fruits(blueberries), and some purple foods come through color intact.

The hysteria produced when a person believes they are bleeding internally is not the topic of today's discourse. But rather a horde of seething greenish short individuals that are about during this time of year screaming for you to purchase and consume another suspicious foodstuff that can produce the symptom in question. Leprechauns? No, these are Girl Scouts. It has been noted recently in my practice as well as in the past that after consuming a quantity of 'chocolate sandwich cookies' a person may present with the complaint of black stool. Exhaustive elicitation of dietary history in patients presenting with dark stool should include information regarding consumption of Hydrox or Oreos or Mint Chocolate or Mystic Mints Need I say, "Got milk?".

To Quote Dr. S. Sulkes of Monroe County Developmental Disabilities Office in a letter to the New England Journal of Medicine, Jan. 5, 1984, (do references get more obscure?) "To this list should be added the colorings present in chocolate sandwich cookies". The author and several volunteers noted the presence of black stools 18-24 hours after eating 225 to 445 grams of cookies. 30 grams equal one ounce, so 240 grams is about 8 ounces or roughly half of a one pound box. (Who can eat less than half a box?) This was not noted after ingestion of other types of cookies (research-boring? never). He continues, "This phenomenon may be on the increase because of shifts in U.S. dietary habits". The lovable green scouts, found at the door of every retail establishment at this time of year, create a seasonal shift in our dietary habits. I'm not suggesting you change your choice of dietary indiscretion at this time of year but please include "cookie induced pseudomelena" or "Hydrox fecalis"(as Dr. Sulkes call it) in your differential diagnosis. I might suggest that you go out now and buy a few boxes to test the principle yourself.

Tony Dombroski R.N.
Gastroenterology Advice
Kaiser Permanente Medical Group
Oakland, California
Tony.Dombroski@nurseone.com

An 'Advice Nurse' is an expert available to patients for phone consultation. "Can I take the pink pills in the morning?", "I feel better. Why should I finish all the antibiotics?", "I've been using nasal spray three times a day for a month now. Why is my nose still stuffed up?". This is sort of like the 'Surf Doc' question and answer column in Surfing magazine but its live and in person, up close and personal. Mr. Dombroski has twenty years experience in practice, fifteen of which is as an advice nurse, ten in gastroenterology. He started surfing late in life (40) and is frequently seen on a boogy board at Ocean Beach, San Francisco (infectious disease research purposes only).