What is the treatment protocol for patients with melena, hematemesis, or hematochezia (passage of black, tarry stools, vomiting blood, or passage of fresh blood per rectum) in an intrahospital setting?

Intrahospital Treatment Protocol for Melena, Hematemesis, and Hematochezia

Initial Resuscitation and Stabilization

The immediate management of patients with gastrointestinal bleeding (melena, hematemesis, or hematochezia) requires aggressive resuscitation, hemodynamic stabilization, and prompt endoscopic evaluation to reduce mortality. 1

Hemodynamic Assessment and Stabilization

• Place two large-bore venous cannulae (16-18G) in the antecubital fossae 2
• Initiate fluid resuscitation:
  • Start with 1-2 liters of normal saline for initial volume replacement 2
  • If patient remains shocked after initial fluid resuscitation, administer plasma expanders 2
  • Target hemodynamic parameters:
    • Mean arterial pressure > 65 mmHg
    • Urine output > 30 ml/hour
    • Central venous pressure 5-10 cm H₂O 2

Blood Transfusion Criteria

• Transfuse packed red blood cells when:
  • Hemoglobin < 7 g/dL in most patients 2
  • Hemoglobin < 9 g/dL in patients with:
    • Massive bleeding
    • Significant cardiovascular comorbidities
    • Anticipated delay in therapeutic interventions 2
  • Active hematemesis with shock 2

Monitoring

• Continuous vital sign monitoring (automated BP, pulse)
• Insert urinary catheter and monitor hourly urine output
• Consider central venous pressure monitoring in patients with significant cardiac disease 2

Diagnostic Approach

Endoscopic Evaluation

• Upper and lower GI endoscopy should be the initial diagnostic procedures for nearly all stable patients presenting with acute gastrointestinal bleeding 2
• For hemodynamically stable patients:
  • Perform sigmoidoscopy and esophagogastroduodenoscopy (EGD) to identify bleeding source 2
  • Upper endoscopy should be performed urgently within 24 hours in patients with high-risk features or ongoing bleeding 2

Imaging Studies

• Computed tomography angiography (CTA) should be performed in patients with ongoing bleeding who are hemodynamically stable after resuscitation 2
• Consider full colonoscopy when:
  • Lower GI bleeding is suspected
  • Risk factors for colorectal cancer are present
  • Suspicion of a concomitant proximal source of bleeding 2

Specific Treatment Protocols

Non-Variceal Upper GI Bleeding

Medical Management

• Administer high-dose proton pump inhibitor:
  • Omeprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours 2
  • Alternative: Pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion

Endoscopic Management

• Endoscopic therapy options for bleeding ulcers:
  • Injection therapy with epinephrine
  • Thermal coagulation
  • Mechanical therapy (hemoclips)
  • Combination therapy is superior to single modality 2

Management of Rebleeding

• For rebleeding after initial endoscopic therapy:
  • Attempt repeat endoscopic therapy once 2
  • Consider surgery if second rebleeding occurs or if endoscopic therapy fails 2

Anorectal Variceal Bleeding

Medical Management

• Intravenous fluid replacement
• Blood transfusion as needed
• Correction of coagulopathy
• Optimal medication for portal hypertension 2

Endoscopic Management

• Local procedures for bleeding control:
  • Endoscopic variceal ligation
  • Endoscopic band ligation
  • Sclerotherapy
  • EUS-guided glue injection 2, 3
• Consider endorectal placement of a compression tube as a bridging maneuver 2

Severe Lower GI Bleeding

Management Approach

• For hemodynamically unstable patients with severe bleeding:
  • Immediate surgery if unresponsive to resuscitation 2
  • For inflammatory bowel disease patients with refractory hemorrhage, perform subtotal colectomy with ileostomy 2

Special Considerations

Patients with Liver Disease

• Early involvement of hepatology specialist team 2
• Multidisciplinary management focusing on optimal control of comorbid conditions 2
• Avoid fluid overload in patients with cirrhosis 2

Post-Endoscopic Management

• Allow patients who are hemodynamically stable 4-6 hours after endoscopy to drink and start a light diet 2
• Continue close monitoring with frequent vital sign checks
• Watch for signs of rebleeding:
  • Fresh melena or hematemesis
  • Fall in blood pressure
  • Rise in pulse rate
  • Fall in central venous pressure 2

Common Pitfalls to Avoid

• Delaying endoscopy in patients with high-risk features
• Failing to identify upper GI sources in patients presenting with hematochezia (occurs in up to 15% of cases) 2
• Inadequate initial resuscitation before endoscopic intervention
• Neglecting to correct coagulopathy
• Overlooking potential colorectal cancer in patients with rectal bleeding (risk ranges from 2.4% to 11%) 2

By following this structured approach to the management of gastrointestinal bleeding, clinicians can effectively stabilize patients, identify bleeding sources, and implement appropriate therapeutic interventions to reduce morbidity and mortality.