Does a patient with stable vital signs and melena (black, tarry stools) meet the requirement for hospital admission?

Management of Stable Patients with Melena

Patients with stable vital signs and melena should be admitted to the hospital for further evaluation and management, as melena indicates a major bleed requiring inpatient care according to the British Society of Gastroenterology guidelines. 1

Risk Assessment and Classification

The presence of melena (black, tarry stools) requires careful evaluation even in hemodynamically stable patients:

• Use the Oakland score to stratify risk 1:

  • Scores >8 points classify the bleeding as "major" and require hospital admission
  • Scores ≤8 points may be suitable for outpatient management if no other indications for admission exist

• Key components of the Oakland score 1:

  • Age (higher points for older patients)
  • Gender (male = higher risk)
  • Previous lower GI bleeding admission
  • Digital rectal exam findings (blood present)
  • Vital signs (heart rate, systolic blood pressure)
  • Hemoglobin level (lower values = higher points)

• Important to note: Melena typically indicates an upper GI source of bleeding or proximal small bowel bleeding 2, which carries higher risk than distal lower GI bleeding.

Diagnostic Approach for Stable Patients with Melena

1. Initial assessment:

   • Complete blood count to assess hemoglobin level
   • Coagulation studies
   • Type and cross-match if significant blood loss
   • Digital rectal examination to confirm melena

2. Endoscopic evaluation:

   • Upper endoscopy (gastroscopy) should be the first investigation as melena most commonly indicates an upper GI source 1, 3
   • If upper endoscopy is negative, colonoscopy should follow

3. Imaging considerations:

   • CT angiography if active bleeding is suspected despite stable vitals 1, 4
   • For stable patients with melena, endoscopy is preferred over radiological investigation initially

Treatment Considerations

• Blood transfusion thresholds 1, 4:

  • Use restrictive transfusion strategy with hemoglobin trigger of 70 g/L
  • Target hemoglobin of 70-90 g/L after transfusion
  • Higher threshold (80 g/L) and target (100 g/L) for patients with cardiovascular disease

• Medication management:

  • Consider temporary discontinuation of anticoagulants/antiplatelets if appropriate
  • Initiate proton pump inhibitor therapy, especially if upper GI source is suspected

Special Considerations

• Recurrent bleeding risk: Patients with melena have higher transfusion requirements and worse outcomes compared to those with other presentations of GI bleeding 5

• Comorbidities: Assess for underlying conditions that may increase bleeding risk or complicate management

• Pitfalls to avoid:

  • Do not assume stable vital signs mean the bleeding is minor - melena represents significant blood loss
  • Do not discharge patients with melena without proper risk stratification using validated tools like the Oakland score
  • Do not delay endoscopic evaluation in patients with melena, even if hemodynamically stable

Follow-up

For patients admitted with melena:

• Monitor vital signs and hemoglobin levels
• Perform endoscopic evaluation within 24 hours
• Consider outpatient follow-up only after the source of bleeding has been identified and controlled

Remember that the presence of melena doubles the odds of finding a bleeding site within the proximal small intestine among patients with obscure GI bleeding 2, emphasizing the importance of thorough upper GI evaluation.