Can we give Racecadotril (acetorphan) to a patient with melena (upper gastrointestinal bleeding)?

Racecadotril Should NOT Be Given to Patients with Melena

Racecadotril is contraindicated in patients with melena (upper gastrointestinal bleeding) because it is an antidiarrheal agent designed to reduce intestinal secretions, not to manage bleeding, and its use could mask ongoing blood loss while delaying appropriate life-saving interventions.

Why Racecadotril is Inappropriate in This Context

Melena Indicates Upper GI Bleeding Requiring Urgent Management

• Melena is defined as the passage of black tarry stools and indicates upper gastrointestinal bleeding, typically from sources proximal to the ligament of Treitz 1
• Patients presenting with melena have significant bleeding that requires immediate resuscitation, risk stratification, and endoscopic intervention—not antidiarrheal therapy 1
• Upper GI bleeding carries a mortality of 2-10% and requires urgent medical management focused on hemodynamic stabilization 1, 2

Racecadotril's Mechanism is Irrelevant to Bleeding

• Racecadotril (acetorphan) is an enkephalinase inhibitor that reduces intestinal water and electrolyte secretion—it has no hemostatic properties whatsoever
• Using an antidiarrheal agent in a bleeding patient is fundamentally inappropriate as it addresses neither the source of bleeding nor the hemodynamic consequences
• The priority in melena is to stop the bleeding and restore circulating volume, not to alter stool consistency 1, 3

Appropriate Management of Melena

Immediate Resuscitation and Risk Stratification

• Administer intravenous fluids (normal saline or lactated Ringer solution) for hemodynamic stabilization 3, 2
• Transfuse red blood cells when hemoglobin falls below 70 g/L, targeting 70-100 g/L 1, 2
• Use prognostic scales (Blatchford score, Rockall score) for risk stratification to identify patients requiring urgent intervention 1

Pharmacologic Therapy That IS Appropriate

• Initiate high-dose proton pump inhibitors immediately upon presentation and continue for 72 hours post-endoscopy when rebleeding risk is highest 3, 2
• Consider erythromycin as a prokinetic agent before endoscopy 2
• In cases of suspected variceal bleeding with cirrhosis, administer vasoactive drugs (such as terlipressin) and antibiotics 1, 2
• Noradrenaline may be used for hemodynamic support if shock persists despite fluid resuscitation 4

Definitive Management

• Arrange urgent endoscopy within 24 hours of presentation (or sooner if hemodynamically unstable) for diagnosis and therapeutic intervention 1, 3, 2
• Endoscopic therapy is the cornerstone of treatment for both variceal and non-variceal bleeding 5, 6, 2

Critical Pitfall to Avoid

Never use antidiarrheal agents like racecadotril in patients with melena. This represents a fundamental misunderstanding of the pathophysiology—the patient is bleeding internally, not having infectious diarrhea. Using racecadotril could:

• Delay recognition of ongoing or recurrent bleeding
• Provide false reassurance by reducing stool frequency
• Waste precious time when urgent endoscopy and hemostatic therapy are needed 1, 3