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 CT angiography (CTA) or catheter-based arteriography to identify the source of bleeding, as these tests are considered appropriate for obscure upper GI bleeding 1.
Rationale
- The patient's presentation with melena suggests upper GI bleeding, but the normal upper GI endoscopy and colonoscopy results indicate that the source of bleeding is not in the upper GI tract or colon 1.
- In cases of obscure upper GI bleeding, where the source of bleeding is unknown despite complete GI tract imaging and endoscopic evaluation, CTA or catheter-based arteriography are considered appropriate next steps 1.
- These tests can help identify the source of bleeding, such as a small bowel source, and guide further management 1.
- The American College of Radiology guidelines recommend CTA or catheter-based arteriography as equivalent diagnostic tests for identifying the bleeding source in cases of obscure upper GI bleeding 1.
Key Points
- CT angiography (CTA): a non-invasive test that uses CT scans to visualize the blood vessels and identify the source of bleeding.
- Catheter-based arteriography: an invasive test that uses a catheter to inject contrast material into the blood vessels and visualize the source of bleeding.
- Obscure upper GI bleeding: bleeding with unknown source despite complete GI tract imaging and endoscopic evaluation.
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 involves further investigation to identify the source of bleeding.
- Consider using capsule endoscopy to visualize the small intestine, as it is a well-established investigation for iron deficiency anemia and melena, especially after negative upper and lower endoscopy 2.
- Earlier use of capsule endoscopy in inpatients with melena or severe iron deficiency anemia can reduce the need for colonoscopy and shorten hospital stay 2.
- If capsule endoscopy indicates possible jejunal bleeding, anterograde enteroscopy, such as single balloon enteroscopy, can be used to identify and mark the lesion prior to minimally invasive surgery 3.
- Re-examination with standard upper endoscopes by experienced physicians can also identify culprit lesions in a substantial proportion of patients with obscure gastrointestinal bleeding 4.
- The diagnostic yield of colonoscopy to investigate melena after a nondiagnostic EGD is low, but it can still be useful in detecting colorectal cancer, especially in patients who are at increased risk 5.
Investigation Options
- Capsule endoscopy: to visualize the small intestine and identify potential sources of bleeding 3, 2.
- Anterograde enteroscopy: to identify and mark the lesion prior to minimally invasive surgery 3.
- Re-examination with standard upper endoscopes: to identify culprit lesions in patients with obscure gastrointestinal bleeding 4.
- Colonoscopy: to detect colorectal cancer, especially in patients who are at increased risk 5.
Considerations
- The choice of investigation depends on the patient's clinical presentation, medical history, and the availability of resources.
- A multidisciplinary approach, involving gastroenterologists, surgeons, and radiologists, may be necessary to manage patients with melena and normal upper GI endoscopy and colonoscopy results 3, 4, 6.