Management of Occult GI Bleeding: A Clinical Guide (Clinical Gastroenterology) 3030714675, 9783030714673

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Clinical Gastroenterology Series Editor: George Y. Wu

Micheal Tadros George Y. Wu   Editors

Management of Occult GI Bleeding A Clinical Guide

Clinical Gastroenterology

Series Editor: George Y. Wu Division of Gastroenterology-Hepatology University of Connecticut School of Medicine Farmington, CT, USA

More information about this series at http://www.springer.com/series/7672

Micheal Tadros • George Y. Wu Editors

Management of Occult GI Bleeding A Clinical Guide

Editors Micheal Tadros Department of Gastroenterology and Hepatology Albany Medical Center Albany, NY USA

George Y. Wu Department of Internal Medicine, Division of Gastrenterology/Hepatology University of Connecticut Health Center Farmington, CT USA

ISSN 2197-7399     ISSN 2197-7704 (electronic) Clinical Gastroenterology ISBN 978-3-030-71467-3    ISBN 978-3-030-71468-0 (eBook) https://doi.org/10.1007/978-3-030-71468-0 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Humana imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

This book is dedicated to all our patients who have endured evaluations for obscure GI bleeding and to the physicians who so tirelessly have sought to determine and eliminate the causes, and to all the healthcare workers, who have persisted in being the guiding lights throughout the COVID-19 pandemic.

Preface

Occult gastrointestinal bleeding is a commonly encountered clinical problem in inpatient and outpatient practice. However, prompt delivery, accurate diagnoses, and effective therapy are often challenges. This textbook is designed to provide a comprehensive overview of the causes of occult GI bleeding, and an update on its management. The parts of the book are organized by organ and common causes of occult bleeding, prevalence, risk factors, typical presentations, diagnostic work up, advances on therapeutics, and pitfalls. Known genetic predispositions and special patient populations are discussed where data are available. Occult GI bleeding is common indication of referral to a gastroenterologist. It usually presents as iron deficiency/microscopic anemia and/or microscopic detection of blood in stool in standard heme occult cards or by fecal immunohistochemical testing. The usual challenge is to determine the cause of the occult bleeding. It is imperative to develop a proper differential diagnosis to avoid delay in diagnosis and management. A major concern with occult GI bleeding is diagnosing or ruling out an underlying GI malignancy. Accordingly, the approach to elderly patients is different from young and middle aged ones due to increased prevalence of particular diseases with age. In addition, the expanding number of patients on non-steroidal anti-inflammatory agents as well as antiplatelet and anticoagulants medications increases the risk for occult bleeding. The source of occult GI bleeding is usually identified with upper endoscopy and colonoscopy in 80–90% of patients. However, in the past, small bowel bleeding has been much more difficult to diagnose. However, advances in small bowel imaging and endoscopic modalities have led to enormous gains in diagnostic and therapeutic success rates in that organ. This book provides a unique, comprehensive yet concise resource which contains detailed information for adult/pediatric gastroenterologists, primary care, internists, family doctors, and hospitalists. At the same time, the text is written to be comprehensible to other allied healthcare workers including nurse practitioners, nurses, physician assistants, and students in healthcare fields.

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Preface

It is our hope that this volume will contribute to increasing awareness and prompt effective treatment that derives from understanding of the clinical problems and the modalities currently available to solve them. Albany, NY, USA Farmington, CT, USA

Micheal Tadros George Y. Wu

Acknowledgments

Many thanks to those who worked exceptionally hard in the creation of this book. I would like to express my deepest appreciation to Dr. George Wu, the first physician I worked with pursuing a path in gastroenterology. His unwavering guidance and valuable advice still ring in my ears to this day. I could not have imagined a better advisor. Special thanks to all my medical students, who present me with passion and enthusiasm for teaching in the field of medicine. Each of my students has shown the qualities required to become skilled physicians in the future, and I aspire towards working with them and assisting them in every aspect of the way. I’m deeply appreciative to my division chief, Dr. James Litynski, for his continuous support, advice, and words of encouragement. Dr. Litynski is more of a friend and companion that leads with dedication and commitment. His guidance continues to help me in several aspects of my profession as a physician. I would also like to extend my sincerest gratitude to Dr. Henry Pohl, Dr. John Birk, Dr. Michael Karsiak, Dr. Helen Swede, Dr. Scott Wetstone, and several others, who assisted in developing my clinical and academic career. I offer my sincere appreciation for the learning opportunities provided by these individuals who have encouraged me to dream for the best. Without these people, I would be lacking the skill that I hold today. Thank you. Acknowledgments would be incomplete without offering recognition and gratitude to the souls of Dr. Cheryl Oncken, former chief of medicine at the University of Connecticut, and Dr. Thomas Devers, whose exceptional wisdom in the field of medicine continues to have an impact on me. These two prominent physicians have enabled me to become the physician I am today. Lastly, I would like to acknowledge with gratitude the support and love of my entire family, as well as H.G. Cosman. I wouldn’t be this successful without their inspiration and encouragement throughout my journey. They all kept me going, and their constant source of motivation is greatly appreciated (MT). The continued support of the Herman Lopata Chair in Hepatitis Research is gratefully acknowledged (GYW).

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Contents

Part I Introduction 1 An Introduction to the Clinical Approach and Management of Occult Gastrointestinal Bleeding��������������������������������    3 Jamie Horrigan, Micheal Tadros, and Jackcy Jacob 2 Non-Invasive Office Screening Methods������������������������������������������������   19 Edgar R. Naut and Gagandeep Singh 3 Endoscopic Detection������������������������������������������������������������������������������   29 Joseph M. Polito II and Caroline Polito 4 Radiologic Detection��������������������������������������������������������������������������������   47 Michael E. Schuster, Erik A. Jacobson, Anthony K. Sayegh, Victor N. Becerra, Robert P. F. Brooks, and Peter E. Kim Part II Localization 5 Esophagus ������������������������������������������������������������������������������������������������   65 Omar Tageldin, Virali Shah, Neeha Kalakota, Hwajeong Lee, Micheal Tadros, and James Litynski 6 Gastroduodenum��������������������������������������������������������������������������������������   87 Abbey Barnard, Hwajeong Lee, and Ethan Bortniker 7 Small Bowel����������������������������������������������������������������������������������������������  103 Perry K. Pratt and Haleh Vaziri 8 Lower GI��������������������������������������������������������������������������������������������������  131 Robert Smolic, Kristina Bojanic, Martina Smolić, Micheal Tadros, and George Y. Wu 9 Biliary- Pancreatic System����������������������������������������������������������������������  149 Cassidy Alexandre, Peter Ells, and Hwajeong Lee

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Part III Treatment Modalities 10 Bipolar and Monopolar Cautery, Clips, Bands, Spray, Injections, Embolization, and Minimally Invasive Surgery����������������  165 Enxhi Rrapi, Sunil Narayan, Gary Siskin, Steven C. Stain, Micheal Tadros, and Marcel Tafen Part IV Special Populations 11 Pediatric population��������������������������������������������������������������������������������  199 Jeremy P. Middleton and Craig A. McKinney 12 Premenopausal Women ��������������������������������������������������������������������������  215 Alicia Wiczulis and Katherine Kashinsky 13 Geriatric Population��������������������������������������������������������������������������������  225 Rebecca J. Stetzer, Julian Remouns, and Ali Hani Al-Tarbsheh 14 Patients with Native Cardiovascular Disease and Implantable Cardiac Devices������������������������������������������������������������������  237 Mark Hanscom and Deepika Devuni 15 Patients on NSAIDs/Anticoagulation ����������������������������������������������������  251 Asra Batool and Rosa T. Bui 16 Patients with Genetic Diseases����������������������������������������������������������������  265 Krishnakumar Hongalgi, Katherine Donovan, David Miller, and Nikki Allmendinger Index������������������������������������������������������������������������������������������������������������������  281

Contributors

Cassidy Alexandre, MD  Department of Medicine, Division of Gastroenterology, Albany Medical Center, Albany, NY, USA Nikki Allmendinger, MD  Albany Medical Center, Albany, NY, USA Ali Hani Al-Tarbsheh, MD  Albany Medical College, Albany, NY, USA Asra Batool, MD  Albany Medical Center, Gastroenterology, Albany, NY, USA Abbey  Barnard, MD  Veterans Affairs San Diego Healthcare System, San Diego, CA, USA University of California-San Diego, Division of Gastroenterology, La Jolla, CA, USA Victor  N.  Becerra, MD  Albany Medical College Diagnostic Radiology, Albany, NY, USA Kristina Bojanic, MD, PhD  Department of Biophysics and Radiology, Faculty of Dental Medicine and Health Osijek, J.  J. Strossmayer University of Osijek, Osijek, Croatia Department of Biophysics and Radiology, Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek, Croatia Department of Radiology, Health Center Osijek, Osijek, Croatia Ethan  Bortniker, MD  Veterans Affairs San Diego Healthcare System, San Diego, CA, USA University of California-San Diego, Division of Gastroenterology, La Jolla, CA, USA Robert  P.F.  Brooks, MD  Albany Medical College Diagnostic Radiology, Albany, NY, USA Rosa T. Bui, MD  Albany Medical Center, Gastroenterology, Albany, NY, USA Deepika Devuni, MD  Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA, USA Katherine Donovan, MS  Albany Medical Center, Albany, NY, USA xiii

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Contributors

Peter  Ells, MD  Department of Medicine, Division of Gastroenterology, Albany Medical Center, Albany, NY, USA Mark Hanscom, MD  Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA, USA Krishnakumar Hongalgi, MD  Albany Medical Center, Albany, NY, USA Jamie  Horrigan, MD  Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA Jackcy  Jacob, MD, FACP, FAAP  Department of Internal Medicine, Albany Medical Center, Albany, NY, USA Erik  A.  Jacobson, MD  Albany Medical College Diagnostic Radiology, Albany, NY, USA Neeha  Kalakota, MD  Division of Gastroenterology, Albany Medical Center, Albany, NY, USA Katherine Kashinsky, MD  Albany Medical Center, Albany, NY, USA Peter  E.  Kim, Albany, NY, USA

MD  Albany

Medical

College

Diagnostic

Radiology,

Hwajeong Lee, MD  Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA James Litynski, MD, FACG  Division of Gastroenterology, Albany Medical Center, Albany, NY, USA Craig A. McKinney, MD  Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Virginia Children’s Hospital, Charlottesville, VA, USA Jeremy  P.  Middleton, MD  Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Virginia Children’s Hospital, Charlottesville, VA, USA David Miller, MS  Albany Medical Center, Albany, NY, USA Sunil  Narayan, MD  Vascular and Interventional Radiology, Albany Medical College, Albany, NY, USA Edgar  R.  Naut, MD, FACP, FHM  Department of Medicine, Saint Francis Hospital and Medical Center, Hartford, CT, USA Joseph M. Polito II, MD  Albany Medical Center, Medicine, Albany, NY, USA Caroline Polito, BS  Stony Brook University Medical Center, Renaissance School of Medicine, Stony Brook, NY, USA Perry K. Pratt, MD  University of Connecticut Health, Division of Gastroenterology & Hepatology, Farmington, CT, USA Julian Remouns, MD  Albany Medical College, Albany, NY, USA

Contributors

xv

Enxhi Rrapi, BA  Albany Medical College, Albany, NY, USA Anthony  K.  Sayegh, MD  Albany Medical College Diagnostic Radiology, Albany, NY, USA Michael  E.  Schuster, MD  Albany Medical College Diagnostic Radiology, Albany, NY, USA Virali Shah, MBA  Albany Medical College, Albany, NY, USA Gagandeep  Singh, MD, FHM  Department of Medicine, Saint Francis Hospital and Medical Center, Hartford, CT, USA Gary Siskin, MD  Vascular and Interventional Radiology, Albany Medical College, Albany, NY, USA Robert  Smolic, MD, PhD  Department of Pathophysiology, Physiology and Immunology, Faculty of Dental Medicine and Health Osijek, J.  J. Strossmayer University of Osijek, Osijek, Croatia Department of Pathophysiology, Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek, Croatia Department of Medicine, Division of Gastroenterology/Hepatology, University Hospital Osijek, Osijek, Croatia Martina  Smolić, MD, PhD  Department of Pharmacology and Biochemistry, Faculty of Dental Medicine and Health Osijek, J.  J. Strossmayer University of Osijek, Osijek, Croatia Department of Pharmacology, Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek, Croatia Steven  C.  Stain, MD  Department of Surgery, Albany Medical College, Albany, NY, USA Rebecca J. Stetzer, MD  Albany Medical College, Albany, NY, USA Micheal  Tadros, MD, MPH, FACG  Department of Gastroenterology and Hepatology, Albany Medical Center, Albany, NY, USA Marcel Tafen, MD  Division of Trauma and Surgical Critical Care, Albany Medical College, Albany, NY, USA Omar Tageldin, MD  Department of Internal Medicine, Albany Medical Center, Albany, NY, USA Haleh Vaziri, MD  University of Connecticut Health, Division of Gastroenterology & Hepatology, Farmington, CT, USA Alicia Wiczulis, MD  Albany Medical Center, Albany, NY, USA George  Y.  Wu, MD, PhD  Department of Internal Medicine, Division of Gastrenterology/Hepatology, University of Connecticut Health Center, Farmington, CT, USA

Part I

Introduction

Chapter 1

An Introduction to the Clinical Approach and Management of Occult Gastrointestinal Bleeding Jamie Horrigan, Micheal Tadros, and Jackcy Jacob

Introduction and Definitions The clinical presentation GI blood loss depends on the location of the bleeding as well as the volume and rate of the bleeding. Minuscule blood loss of 0.5–1.5 mL per day in the GI tract is normal and not visualized, whereas larger blood volumes of 100–200 mL or greater produce visible blood in the stool [3]. Visible bleeding is defined as overt GI bleeding which most commonly presents in one of the following ways: (1) hematemesis – coffee-ground colored emesis typically from an upper GI source, (2) hematochezia – bright red blood or clots typically from a location in the distal GI tract or less commonly a briskly bleeding upper GI source, or (3) melena – tarry, black or maroon colored stool typically from an upper GI source or from degradation of blood in slow transit from the proximal colon [4]. Occult GI bleeding is not visible to the naked eye and is defined by a positive fecal occult blood test (FOBT) with or without iron deficiency anemia (IDA) [2]. When enough blood is lost over time and not adequately replaced by the body, iron deficiency can develop and eventually manifests as IDA. Chronic GI blood loss as little as 5–10 ml/day can lead to IDA [5]. In most instances, the cause of overt or occult bleeding is readily identified by esophagogastroduodenoscopy (EGD) and/or colonoscopy. However, when EGD J. Horrigan Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA e-mail: [email protected] M. Tadros (*) Department of Gastroenterology and Hepatology, Albany Medical Center, Albany, NY, USA e-mail: [email protected] J. Jacob Department of Internal Medicine, Albany Medical Center, Albany, NY, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 M. Tadros, G. Y. Wu (eds.), Management of Occult GI Bleeding, Clinical Gastroenterology, https://doi.org/10.1007/978-3-030-71468-0_1

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J. Horrigan et al.

Table 1.1  Definitions of gastrointestinal bleeding Gastrointestinal bleeding Overta: Bleeding is visible

Occult: Bleeding is invisible

Typical manifestation Hematemesis Melena Hematochezia Iron deficiency anemia (IDA) and/ or Positive fecal occult blood test (FOBT)

Obscure: Bleeding is visible or invisible

a

Definition Vomiting of bright red blood or dark colored “coffee-grounds” Black, tarry, foul smelling stool Bright red or maroon, bloody stool Hemoglobin