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

Immediate Management of Melena

Patients presenting with melena require immediate hemodynamic resuscitation, urgent risk stratification, and upper endoscopy within 24 hours, as melena indicates upper gastrointestinal bleeding in approximately 80% of cases and carries significant mortality risk. 1

Initial Resuscitation (Priority #1)

Hemodynamic stabilization takes absolute priority before any diagnostic procedures. 1

• Establish large-bore intravenous access (two lines minimum) immediately upon presentation 1
• Begin aggressive fluid resuscitation in patients showing signs of shock (pulse >100 bpm, systolic BP <100 mmHg) 1, 2
• Monitor vital signs continuously including pulse, blood pressure, and urine output 1
• Calculate the shock index (heart rate divided by systolic blood pressure); values <1 indicate hemodynamic stability 3

Immediate Laboratory Assessment

• Obtain complete blood count, coagulation studies, liver function tests, and type and crossmatch 1
• Transfuse packed red blood cells to maintain hemoglobin above 7 g/dL in most patients; use a threshold of 9 g/dL in patients with massive bleeding or significant cardiovascular comorbidities 2
• If the patient is on warfarin or antiplatelet agents, interrupt these medications immediately 3

Risk Stratification

Use the Rockall score to identify high-risk patients who require more aggressive management. 1

• Age >60 years, presence of shock, and significant comorbidities (especially renal disease, 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 (Primary Diagnostic and Therapeutic Intervention)

Upper endoscopy (esophagogastroduodenoscopy) should be performed within 24 hours for most patients, with emergency "out of hours" endoscopy required for patients with ongoing hemodynamic instability despite resuscitation. 1, 2

• The upper GI tract is the bleeding source in approximately 80% of melena cases, with peptic ulcer disease accounting for 35-50% 1
• Endoscopy must be performed by experienced endoscopists skilled in therapeutic interventions, available 24/7 1
• During endoscopy, identify the source and apply therapeutic intervention if active bleeding, non-bleeding visible vessel, or adherent clot is found 2
• Available therapeutic options include injection therapy, thermal coagulation, mechanical therapy (endoscopic clips), or combination approaches 1, 2

Common pitfall: Do not delay resuscitation for diagnostic studies—hemodynamic stabilization always comes first. 1

Pharmacologic Management Post-Endoscopy

High-dose proton pump inhibitor therapy is essential after endoscopic treatment of bleeding ulcers. 1, 2

• Administer omeprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours after successful endoscopic therapy 1, 2
• This regimen significantly reduces rebleeding in patients with major ulcer bleeding 1

Post-Endoscopy Monitoring

• 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
• Vital signs should be checked every 4-6 hours minimum 3
• Rebleeding requires repeat endoscopy to confirm and attempt further endoscopic therapy 1

Common pitfall: Do not discharge patients with high-risk endoscopic findings prematurely—active bleeding, visible vessel, or adherent clot carry 50-80% rebleeding risk. 1

Surgical Consultation

• Involve surgical gastroenterology early for high-risk patients 1
• 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

Alternative Diagnostic Considerations

If upper endoscopy is nondiagnostic (occurs in approximately 24% of cases), colonoscopy should be the next diagnostic step. 4, 5

• The right colon is the most likely location of pathology when upper endoscopy is nondiagnostic 4
• Colonoscopy reveals a suspected bleeding source in 4.8% of patients with melena and nondiagnostic EGD 5
• Small bowel capsule endoscopy may be useful in children or adults without upper gastrointestinal lesions 6
• The presence of melena doubles the odds of finding a bleeding site within the proximal small intestine in obscure GI bleeding 7

Common pitfall: Do not perform routine repeat endoscopy in all patients—only indicated for clinical rebleeding or concern about suboptimal initial therapy. 1

Special Populations

• 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 and mortality 2
• In children, the upper gastrointestinal tract is the most common bleeding source, with duodenal ulcer being the most frequent diagnosis 6