From the Guidelines
Management of a patient with melena requires prompt evaluation and treatment of gastrointestinal bleeding, with a focus on hemodynamic stabilization and endoscopy within 24 hours, as recommended by the most recent guidelines 1. The initial assessment should focus on hemodynamic stabilization with intravenous access using two large-bore catheters (16-18 gauge), fluid resuscitation with crystalloids, and blood transfusion if hemoglobin is below 7 g/dL or if the patient is hemodynamically unstable.
- Vital signs, including orthostatic measurements, should be monitored frequently.
- Laboratory tests should include complete blood count, coagulation studies, comprehensive metabolic panel, and type and cross-match. After stabilization, endoscopy should be performed within 24 hours, with urgent endoscopy (within 12 hours) for patients with hemodynamic instability or signs of ongoing bleeding.
- If upper GI bleeding is suspected, proton pump inhibitors should be started immediately (e.g., pantoprazole 80 mg IV bolus followed by 8 mg/hour infusion for 72 hours) 1.
- For patients on anticoagulants, reversal should be considered based on bleeding severity and underlying indication.
- Patients with suspected variceal bleeding should receive octreotide (50 mcg IV bolus followed by 50 mcg/hour infusion) and prophylactic antibiotics (ceftriaxone 1g IV daily). Following acute management, identifying and treating the underlying cause is essential, which may include H. pylori eradication, discontinuation of NSAIDs, or management of portal hypertension, as suggested by previous guidelines 1. This comprehensive approach addresses both the immediate bleeding crisis and prevents recurrence by targeting the underlying etiology.
From the Research
Melena Management Approach
The management approach for a patient with melena involves several steps, including:
- Diagnosis: identifying the underlying cause of melena, which can be due to various factors such as peptic ulcer disease, varices, or Helicobacter pylori infection 2
- Treatment: depending on the underlying cause, treatment may involve medications such as proton pump inhibitors, antibiotics, or endoscopic therapy 2, 3, 4
- Supportive care: providing supportive care to manage symptoms and prevent complications, such as blood transfusions or fluid replacement 2
Helicobacter pylori Eradication
For patients with melena due to Helicobacter pylori infection, eradication therapy is recommended, which typically involves a combination of antibiotics and a proton pump inhibitor 3, 4. The choice of antibiotics and proton pump inhibitor may depend on various factors, including the patient's CYP2C19 genotype status 5.
Proton Pump Inhibitors
Proton pump inhibitors, such as omeprazole, have been shown to be effective in inhibiting acid survival of Helicobacter pylori by a urease-independent mechanism 6. They are often used in combination with antibiotics to eradicate Helicobacter pylori infection 3, 4.
Endoscopic Therapy
For patients with melena due to peptic ulcer disease or varices, endoscopic therapy may be necessary to control bleeding and prevent re-bleeding 2. This can involve various techniques, such as injection therapy, thermal coagulation, or endoclips.
Repeat Endoscopic Therapy or Operative Surgery
In some cases, repeat endoscopic therapy or operative surgery may be required if bleeding recurs 2. The decision to proceed with repeat endoscopic therapy or operative surgery depends on various factors, including the patient's overall health status and the severity of the bleeding.