What are the next steps in the clinic for a patient presenting with melena (black, tarry stools)?

From the Guidelines

For a patient presenting with melena, the next steps in the clinic should include prompt endoscopic assessment to identify the source of bleeding and guide further management, as recommended by the NCCN clinical practice guidelines in oncology 1. The patient should undergo a thorough evaluation, including a complete blood count, coagulation studies, liver function tests, and blood typing and cross-matching. Key considerations in the management of melena include:

• Immediate assessment of hemodynamic stability
• Urgent upper endoscopy within 24 hours to diagnose and potentially treat the cause of bleeding
• Intravenous fluid resuscitation with crystalloids if there are signs of hypovolemia
• Consideration of proton pump inhibitor therapy to reduce the risk of bleeding, although definitive data supporting its use are lacking 1
• Correction of any coagulopathy with vitamin K, fresh frozen plasma, or platelet transfusion as needed
• Transfusion of packed red blood cells if hemoglobin is below 7 g/dL or if the patient is symptomatic
• Admission to a monitored setting for patients with significant bleeding These interventions are critical because melena typically indicates upper gastrointestinal bleeding, which can rapidly become life-threatening due to significant blood loss. The choice of endoscopic therapy, such as injection therapy, mechanical therapy, ablative therapy, or a combination of modalities, depends on the specific cause and location of the bleeding, as well as the availability of resources and expertise 1. In situations where endoscopy is not helpful, interventional radiology with angiographic embolization techniques or external beam radiation therapy may be considered as alternative management options 1.

From the Research

Next Steps in the Clinic for a Patient Presenting with Melena

The next steps in the clinic for a patient presenting with melena (black, tarry stools) involve several key actions:

• Stabilization of the patient's vital functions, including haemodynamics and airway and respiratory function 2
• Performance of an emergency upper GI endoscopy to identify the source of bleeding 2, 3
• Implementation of endoscopic techniques to control bleeding, such as injection of epinephrine around the ulcer crater 4
• Administration of proton pump inhibitors (PPIs) to decrease the rate of rebleeding, which can be given orally or intravenously 4
• Consideration of capsule endoscopy if the bleeding source is not identified by upper GI endoscopy, especially in cases of severe obscure-overt gastrointestinal bleeding 5
• Evaluation of the patient's overall condition, including assessment of cardiopulmonary function and hepatorenal capacity, particularly in elderly patients 6

Key Considerations

• The upper gastrointestinal tract is the most common source of bleeding in patients with melena 3
• Endoscopy is effective in identifying bleeding, but may not always identify the source of bleeding 3
• Patients with high-risk bleeding ulcers, such as those with active bleeding or non-bleeding visible vessels, require prompt and effective treatment to prevent rebleeding 4
• Capsule endoscopy can be useful in patients with severe obscure-overt gastrointestinal bleeding, providing positive findings in the majority of patients and guiding therapeutic procedures 5
• Elderly patients require special consideration due to the potential for decreased blood flow and function in various organs, making them more susceptible to severe bleeding and shock 6