From the Guidelines
Given your history of melena with normal colonoscopy and endoscopy, and considering the latest guidelines, consulting a gastroenterologist about evaluating the small intestine is a reasonable next step, with capsule endoscopy being a recommended diagnostic tool for patients with overt, obscure GI bleeding and negative findings on high-quality EGD and colonoscopy, as stated in Statement 8 by 1. The small intestine is a potential source of bleeding that was not examined in your previous tests. Several factors will influence the decision to proceed with testing, including the severity of your original bleeding episode, current health status, age, family history, and any ongoing symptoms like anemia. Although you haven't had a recurrence in four years, which is reassuring, identifying the source of unexplained GI bleeding is ideal for preventing future complications. Small intestinal causes of bleeding can include small bowel tumors, Crohn's disease, angiodysplasias, or Meckel's diverticulum, among others. Capsule endoscopy is typically the first-line test for evaluating the small bowel, with other options including balloon-assisted enteroscopy or CT/MR enterography, as supported by the clinical practice guidelines for the use of video capsule endoscopy 1. It's also worth noting that recent guidelines, such as those from 2025, focus on the management of specific conditions like nonampullary duodenal lesions but do not directly address the necessity of small bowel investigation in patients with a history of melena and normal upper and lower endoscopy, making the 2017 guidelines on capsule endoscopy more relevant to your situation 1. However, the key consideration in your case remains the identification of the source of past bleeding and the prevention of future episodes, which aligns with the recommendation for capsule endoscopy in patients with overt, obscure GI bleeding, as per 1.
From the Research
Recurrence of Melena and Need for Small Intestine Check
- The patient had melena 4 years ago, but colonoscopy and endoscopy were normal, and there has been no recurrence since then.
- According to the study 2, obscure gastrointestinal bleeding is recurrent bleeding when the source remains unidentified after upper endoscopy and colonoscopic evaluation and is usually from the small intestine.
- The study 3 suggests that the presence of melena predicts bleeding in the proximal small intestine in patients with obscure gastrointestinal bleeding.
- However, the study 4 found that the diagnostic yield of colonoscopy to investigate melena after nondiagnostic EGD is low, and the need for therapeutic intervention during colonoscopy for this indication is very low.
- The study 5 found that further evaluation after nondiagnostic upper endoscopy reveals a potential source in 37% of patients with melena, with the right colon being the most likely location of pathology.
Evaluation of Patients with Melena
- The study 6 suggests that same-day upper and lower endoscopy can be useful in patients investigated for non-acute gastrointestinal bleeding, as a potential bleeding source could be missed if only one of these procedures is performed.
- The study 5 found that colonoscopy is the test of choice in patients with melena and nondiagnostic upper endoscopy.
- The study 3 recommends that deep enteroscopy, if performed before a capsule study, should begin with an antegrade approach in patients with melena and obscure gastrointestinal bleeding.
Need to Check the Small Intestine
- Based on the studies 2 and 3, it can be inferred that if the patient had melena and normal colonoscopy and endoscopy, and there is a recurrence, it may be necessary to check the small intestine to rule out obscure gastrointestinal bleeding.
- However, the decision to check the small intestine should be based on the individual patient's clinical presentation and medical history, as suggested by the study 4.