What is the workup for a 17-year-old female (F) patient with Gastroesophageal Reflux Disease (GERD) presenting with melena (black tarry stool) in an outpatient Gastrointestinal (GI) setting?

Workup for a 17-Year-Old Female with GERD and Melena

Upper endoscopy (EGD) should be performed urgently as the first-line diagnostic procedure for a 17-year-old female with GERD presenting with melena. 1

Initial Assessment

When a 17-year-old female with GERD presents with melena (black tarry stool), this represents an alarm symptom that requires prompt evaluation:

• Melena indicates upper GI bleeding, which is a serious condition that can lead to significant morbidity and mortality
• The presence of this alarm symptom in a patient with GERD necessitates immediate diagnostic investigation
• Initial assessment should include:
  • Hemodynamic evaluation (vital signs, shock index calculation)
  • Laboratory tests: complete blood count, basic metabolic panel, coagulation profile 2
  • Digital rectal examination to confirm melena 2

Diagnostic Algorithm

Step 1: Upper Endoscopy (EGD)

• Upper endoscopy is clearly indicated in patients with GERD who present with alarm symptoms including bleeding 1
• This procedure should be performed urgently (within 24 hours) due to the presence of active bleeding 2, 3
• EGD serves both diagnostic and potentially therapeutic purposes:
  • Identifies the bleeding source
  • Allows for immediate intervention if an active bleeding site is found

Step 2: Based on EGD Findings

• If a bleeding source is identified (e.g., erosive esophagitis, peptic ulcer, varices):

  • Endoscopic therapy should be performed immediately for active bleeding 3
  • Appropriate medical therapy should be initiated (e.g., high-dose PPI therapy) 4, 3

• If no bleeding source is identified on upper endoscopy:

  • Consider colonoscopy to evaluate for lower GI sources that may present atypically
  • Consider video capsule endoscopy if small bowel bleeding is suspected 1

Specific Considerations

Medical Management During Workup

• Start high-dose proton pump inhibitor therapy immediately while awaiting endoscopy 4, 3
  • For a 17-year-old patient, appropriate PPI dosing would be 20-40 mg omeprazole or equivalent 4
  • This helps reduce the risk of continued bleeding and improves endoscopic visualization

Post-Endoscopic Management

• Follow-up endoscopy may be indicated based on initial findings:
  • For severe erosive esophagitis: repeat endoscopy after 8 weeks of PPI therapy to ensure healing and rule out Barrett's esophagus 1
  • For other findings: individualized follow-up based on the specific diagnosis

Common Pitfalls to Avoid

1. Delaying endoscopy: Melena is an alarm symptom that requires prompt evaluation, not watchful waiting 1, 2

2. Inadequate initial resuscitation: Ensure hemodynamic stability before endoscopic procedures 2

3. Focusing only on GERD: While the patient has known GERD, other causes of upper GI bleeding must be considered, including:

   • Peptic ulcer disease (most common cause in many populations) 5, 6
   • Esophageal or gastric varices 5
   • Mallory-Weiss tears 5
   • Gastritis or duodenitis 6

4. Overlooking medication history: NSAIDs and other medications can contribute to GI bleeding and should be discontinued if possible 2

By following this algorithm, clinicians can ensure appropriate and timely diagnosis and management of this potentially serious condition in a young patient with GERD presenting with melena.