What is the management plan for a patient with gastrointestinal bleeding, presented with melena (black, tarry stools), positive fecal occult blood test, and no bowel movement in 3 days?

Management of Gastrointestinal Bleeding with Melena and Constipation

This patient requires immediate hemodynamic assessment, resuscitation if unstable, and urgent upper endoscopy within 24 hours, as melena indicates an upper GI source until proven otherwise.

Immediate Assessment and Stabilization

Hemodynamic Evaluation

• Calculate the shock index (heart rate/systolic blood pressure) immediately—a value >1 indicates hemodynamic instability and predicts poor outcomes 1, 2
• Check for orthostatic hypotension, which indicates significant blood loss requiring ICU admission 1
• Perform digital rectal examination to confirm melena and exclude anorectal pathology 1

Risk Stratification

• For hemodynamically stable patients, calculate the Oakland score (includes age, gender, previous LGIB admission, digital rectal findings, heart rate, systolic BP, and hemoglobin) 1
• Oakland score ≤8 points: safe for urgent outpatient investigation 1
• Oakland score >8 points: requires hospital admission 1

Resuscitation Protocol

Fluid and Blood Product Management

• Initiate IV fluid resuscitation immediately with goal of normalizing blood pressure and heart rate 3
• Use restrictive transfusion thresholds: maintain hemoglobin >7 g/dL for patients without cardiovascular disease 1
• For patients with cardiovascular disease or massive bleeding, maintain hemoglobin >8-9 g/dL 3, 1

Coagulopathy Correction

• Transfuse fresh frozen plasma if INR >1.5 1, 2
• Transfuse platelets if platelet count <50,000/µL 1, 2

ICU Admission Criteria

Admit to ICU if any of the following are present 1:

• Orthostatic hypotension
• Hematocrit decrease ≥6%
• Transfusion requirement >2 units packed red blood cells
• Continuous active bleeding
• Persistent hemodynamic instability despite aggressive resuscitation

Diagnostic Approach

For Hemodynamically Unstable Patients (Shock Index >1)

• Perform CT angiography immediately—this provides the fastest, least invasive means to localize active bleeding 1, 2
• Following positive CTA, proceed to catheter angiography with embolization within 60 minutes 1
• Insert nasogastric tube to protect airway and decompress stomach 3

For Hemodynamically Stable Patients

• Perform upper endoscopy (esophagogastroduodenoscopy) first, as melena typically indicates upper GI bleeding 3, 4
• Upper endoscopy should be performed within 24 hours of presentation 5
• If upper endoscopy is negative and lower GI source suspected, proceed to sigmoidoscopy or colonoscopy 3

Management of Constipation Component

The 3-day absence of bowel movements is likely secondary to the melena itself (altered blood acting as a bowel irritant that has now passed) rather than a primary obstruction, but requires evaluation:

• Rule out fecal impaction during digital rectal examination 1
• Avoid aggressive bowel preparation if patient is actively bleeding or hemodynamically unstable 3
• Consider gentle laxatives only after hemodynamic stability is achieved and active bleeding is controlled

Anticoagulation/Antiplatelet Management

If Patient on Warfarin

• Interrupt warfarin immediately and reverse with prothrombin complex concentrate and vitamin K for unstable hemorrhage 1
• Restart warfarin 7 days after hemorrhage if patient has low thrombotic risk 1

If Patient on Aspirin

• Permanently discontinue aspirin if used for primary prophylaxis 1
• Do not routinely stop aspirin for secondary prevention; if stopped, restart as soon as hemostasis is achieved 1

Critical Pitfalls to Avoid

• Failure to consider upper GI source in patients presenting with melena and hemodynamic instability leads to delayed diagnosis—always perform upper endoscopy first 3, 2, 4
• Do not delay resuscitation to obtain imaging in unstable patients—stabilize first, then image 3, 6
• Mortality in GI bleeding relates more to comorbidities than exsanguination (3.4% overall, but 18% for inpatient-onset bleeding and 20% for patients requiring ≥4 units) 1
• If patient remains unstable despite aggressive resuscitation, proceed directly to surgery rather than pursuing further diagnostic studies 1