Melena Requires Immediate Hospital Evaluation
Melena (black, tarry stools) is a definite indication to seek immediate hospital evaluation as it signifies significant gastrointestinal bleeding that can lead to hemodynamic instability and increased mortality if not promptly addressed. 1, 2
Understanding Melena and Its Significance
- Melena is defined as the passage of black tarry stools, indicating digested blood in the gastrointestinal tract 1
- It typically represents significant bleeding from the upper gastrointestinal tract (proximal to the ligament of Treitz), though occasionally can originate from the small intestine or even the colon 3, 4
- Melena generally indicates more severe bleeding than isolated hematemesis and requires prompt medical attention 1
- Common causes include peptic ulcers (35-50%), gastroduodenal erosions (8-15%), esophagitis (5-15%), varices (5-10%), and Mallory-Weiss tears (15%) 1
Reasons Hospital Evaluation is Necessary
- Mortality rates for patients admitted with gastrointestinal bleeding are significant (11%), highlighting the potential severity 1
- Melena can indicate substantial blood loss requiring urgent resuscitation and transfusion 2
- Early specialist intervention in a hospital setting reduces mortality compared to delayed treatment 1
- Hospital admission allows for:
- Immediate hemodynamic assessment to identify shock (pulse >100 beats/min, systolic BP <100 mmHg) 2
- Prompt intravenous fluid resuscitation if needed 2
- Blood transfusion to maintain hemoglobin above 7g/dL (or 9g/dL in patients with massive bleeding or cardiovascular comorbidities) 2
- Urgent endoscopic diagnosis and potential therapeutic intervention 2
Diagnostic Approach in Hospital Setting
- Esophagogastroduodenoscopy (EGD) is the initial procedure of choice as it has both diagnostic and therapeutic capabilities 2
- For hemodynamically stable patients, early elective endoscopy (ideally within 24 hours of admission) is appropriate 2
- For unstable patients or those with ongoing bleeding, emergency endoscopy should be performed more urgently 2
- If upper endoscopy is non-diagnostic, colonoscopy may be indicated, though the diagnostic yield is relatively low (4.8%) 5
- In cases where standard endoscopy doesn't identify a source, small bowel evaluation may be necessary, particularly if melena persists 6, 3
Special Considerations
- Elderly patients (>65 years) have significantly higher mortality rates and require more aggressive management 2
- Patients with significant comorbidities (especially cardiovascular, renal, or liver disease) are at higher risk for complications 2
- Rare causes of melena should be considered when common sources are ruled out, including gastrointestinal stromal tumors (GISTs) 7 and, rarely, severe colitis 4
- Following successful endoscopic therapy in patients with ulcer bleeding, high-dose proton pump inhibitor therapy is recommended 1, 2