From the Guidelines
The next step in management for a 50-year-old man with melena and normal upper GI endoscopy and colonoscopy results is to perform a video capsule endoscopy or CT enterography to investigate the small bowel as a potential source of bleeding, as the bleeding site is suspected to be below the ligament of Treitz 1.
Diagnostic Approach
- The patient's presentation with melena and normal upper GI endoscopy and colonoscopy results suggests obscure gastrointestinal bleeding (OGIB), which is defined as bleeding with an unknown source despite complete GI tract imaging and endoscopic evaluation 1.
- In cases of OGIB, video capsule endoscopy is a useful diagnostic tool to visualize the small bowel, which is not accessible by standard upper endoscopy or colonoscopy 1.
- Alternatively, CT enterography may be used to identify the source of bleeding in the small bowel, especially if the bleeding is intermittent 1.
Rationale
- The American College of Gastroenterology practice guidelines and the American Gastroenterological Association expert statement recommend esophagogastroduodenoscopy as the first-line diagnostic and therapeutic investigation for nonvariceal upper GI bleeding 1.
- However, in cases where the bleeding site is suspected to be below the ligament of Treitz, video capsule endoscopy or CT enterography may be necessary to investigate the small bowel 1.
- The choice of diagnostic modality depends on the clinical presentation, patient factors, and institutional availability 1.
Management
- The patient should be closely monitored for signs of ongoing bleeding, and aggressive volume resuscitation should be performed as needed to maintain hemodynamic stability 1.
- Once the source of bleeding is identified, targeted therapy can be initiated to control the bleeding and prevent recurrence 1.
From the Research
Next Steps in Management
The next step in management for a 50-year-old man with melena and normal upper GI endoscopy and colonoscopy results would involve further investigation to identify the source of bleeding.
- Consideration of capsule endoscopy or enteroscopy to visualize the small intestine, as the bleeding source may be located in this area 2, 3.
- Re-examination with standard upper endoscopes by experienced physicians may also identify culprit lesions in the proximal jejunum 4.
- In some cases, laparoscopic evaluation or surgical exploration may be necessary to diagnose and treat the underlying cause of bleeding, such as a jejunal tumor or neurofibroma 2, 5.
Diagnostic Considerations
- The use of capsule endoscopy earlier in the investigative pathway may reduce the need for colonoscopy and shorten hospital stay 3.
- A normal upper GI endoscopy does not exclude the possibility of a bleeding source in the small intestine or proximal jejunum 4, 5.
- Repeat endoscopy or other diagnostic tests may be necessary to identify the source of bleeding, especially if the initial tests are inconclusive 6.