What is the immediate management for a patient presenting with melena?

Immediate Management of Melena

Patients presenting with melena require urgent resuscitation, risk stratification, and upper endoscopy within 24 hours, as melena indicates upper gastrointestinal bleeding in the vast majority of cases and carries significant mortality risk, particularly in elderly patients with comorbidities. 1

Initial Resuscitation and Assessment

Hemodynamic stabilization takes absolute priority:

• Establish large-bore intravenous access (two lines) and begin aggressive fluid resuscitation in patients with shock (pulse >100 bpm, systolic BP <100 mmHg) 1
• Monitor vital signs continuously, including pulse, blood pressure, and urine output 1
• Obtain immediate blood work: complete blood count, coagulation studies, liver function tests, and type and crossmatch 1
• Transfuse blood products as needed to maintain hemodynamic stability 1

Risk stratification using the Rockall score identifies high-risk patients:

• Age >60 years, presence of shock, and significant comorbidity (especially renal, liver disease, or disseminated cancer) independently predict mortality 1
• Patients under 40 years rarely die from upper GI bleeding, while those over 90 have 30% mortality 1
• Shocked patients with active bleeding from peptic ulcers have an 80% risk of continued bleeding or death 1

Endoscopic Evaluation

Upper endoscopy (esophagogastroduodenoscopy) is the primary diagnostic and therapeutic intervention:

• Perform endoscopy within 24 hours of presentation for most patients 1
• Emergency "out of hours" endoscopy is required for patients with ongoing hemodynamic instability despite resuscitation 1
• The upper GI tract is the bleeding source in approximately 80% of melena cases, with peptic ulcer disease accounting for 35-50% 1
• Endoscopy should be performed by experienced endoscopists skilled in therapeutic interventions, available 24/7 1

Therapeutic endoscopic interventions should be performed when high-risk stigmata are identified:

• Active bleeding, non-bleeding visible vessel, or adherent clot warrant immediate endoscopic therapy 1
• Injection therapy, thermal coagulation, or combination approaches reduce rebleeding rates 1

Pharmacologic Management

High-dose proton pump inhibitor therapy is essential after endoscopic treatment of bleeding ulcers:

• Administer omeprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours after successful endoscopic therapy 1
• This regimen significantly reduces rebleeding in patients with major ulcer bleeding 1

Post-Endoscopy Monitoring

Close observation is mandatory following endoscopy:

• Hemodynamically stable patients can begin oral intake 4-6 hours after endoscopy 1
• Continue monitoring for rebleeding (fresh hematemesis, melena, hypotension, tachycardia, or hemoglobin drop >20 g/L over 24 hours) 1
• Rebleeding requires repeat endoscopy to confirm and attempt further endoscopic therapy 1

When Upper Endoscopy is Nondiagnostic

If upper endoscopy reveals no bleeding source (occurs in approximately 24% of melena cases), proceed with colonoscopy:

• The right colon is the most common lower GI source when upper endoscopy is negative 2, 3
• Colonoscopy identifies a bleeding source in 37% of patients with melena and nondiagnostic upper endoscopy 2
• Melena doubles the odds of finding a bleeding site in the proximal small intestine, so consider capsule endoscopy if colonoscopy is also negative 4

Surgical Consultation

Involve surgical gastroenterology early for high-risk patients:

• Uncontrolled hemorrhage despite endoscopic therapy requires urgent surgery 1
• Patients who rebleed after one attempt at repeat endoscopic therapy should be considered for surgery 1
• Combined medical-surgical care is essential for critically ill bleeding patients 1

Critical Pitfalls to Avoid

• Do not delay resuscitation for diagnostic studies - hemodynamic stabilization always comes first 1
• Do not assume melena always originates from the upper GI tract - while most common, right colon and small bowel sources occur in up to 24% of cases when upper endoscopy is negative 2, 3
• Do not perform routine repeat endoscopy in all patients - only indicated for clinical rebleeding or concern about suboptimal initial therapy 1
• Do not discharge patients with high-risk endoscopic findings prematurely - active bleeding, visible vessel, or adherent clot carry 50-80% rebleeding risk 1