What are the next steps for a patient with a small amount of black stool (melena) and nausea, with vital signs that are stable (VSS - Vital Signs Stable)?

Management of Black Stool (Melena) with Nausea in a Hemodynamically Stable Patient

Begin immediate assessment with upper endoscopy (EGD) as the first-line diagnostic and therapeutic procedure, since melena typically indicates upper gastrointestinal bleeding, even in hemodynamically stable patients. 1, 2

Immediate Hemodynamic Assessment

• Calculate the shock index (heart rate ÷ systolic blood pressure) immediately—a value >1 indicates hemodynamic instability requiring urgent intervention rather than routine workup 1
• Check orthostatic vital signs, as orthostatic hypotension indicates significant blood loss requiring ICU admission 1
• Perform digital rectal examination to confirm melena and exclude anorectal pathology 1, 2
• Assess for signs of shock: pulse >100 beats/min and systolic BP <100 mmHg 2

Initial Laboratory and Risk Stratification

• Obtain complete blood count, BUN, creatinine, coagulation studies, and type and screen 2
• For hemodynamically stable patients, calculate the Oakland score (includes age, gender, previous GI bleeding admission, digital rectal findings, heart rate, systolic BP, and hemoglobin) to determine disposition 1
  • Oakland score ≤8 points: safe for urgent outpatient investigation 1
  • Oakland score >8 points: requires hospital admission 1
• Note that syncope, elevated BUN level, and elevated BUN/creatinine ratio predict need for endoscopic intervention 3

Resuscitation Protocol (If Needed)

• Initiate IV fluid resuscitation with goal of normalizing blood pressure and heart rate prior to endoscopic evaluation 2
• Use restrictive transfusion thresholds: maintain hemoglobin >7 g/dL for patients without cardiovascular disease 1, 2
• For patients with massive bleeding or significant cardiovascular comorbidities, maintain hemoglobin >8-9 g/dL 1, 2
• Transfuse fresh frozen plasma if INR >1.5 1
• Transfuse platelets if platelet count <50,000/µL 1

Diagnostic Approach

Since vital signs are stable, proceed with early elective upper endoscopy (EGD) ideally the morning after admission or within 24 hours. 2 This is the critical decision point:

• EGD is the initial procedure of choice as it has both diagnostic and therapeutic capabilities 2
• During EGD, identify the source of bleeding and apply appropriate endoscopic therapy if active bleeding, non-bleeding visible vessel, or adherent clot is found 2
• Common causes to look for include peptic ulcer disease, gastric erosions, esophagitis, Mallory-Weiss tears, and vascular malformations 2

If Upper Endoscopy is Negative

• Consider evaluation of the colon with colonoscopy, though melena typically indicates upper GI source 4
• If both upper and lower endoscopy are negative and bleeding persists, consider small bowel evaluation with video capsule endoscopy 5
• Consider Meckel's diverticulum in younger patients with unexplained bleeding 6

Medical Management

• Following successful endoscopic therapy for ulcer bleeding, initiate high-dose proton pump inhibitor therapy: omeprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours 2
• Address nausea with antiemetic therapy as needed 7
• Review and manage anticoagulation/antiplatelet medications: if on warfarin and unstable, reverse with prothrombin complex concentrate and vitamin K; if on aspirin for primary prevention only, permanently discontinue 1

Critical Pitfalls to Avoid

• Do not assume lower GI source based on "black stool" alone—melena indicates upper GI bleeding in the vast majority of cases, and failure to perform upper endoscopy first leads to delayed diagnosis 1, 2
• Do not delay endoscopy beyond 24 hours in patients with ongoing symptoms or signs of continued bleeding 2
• Do not use aggressive bowel preparation if patient shows any signs of hemodynamic instability 1
• Elderly patients (>65 years) and those with significant comorbidities (cardiovascular, renal, or liver disease) have significantly higher mortality rates and require more aggressive management 2

Indications for Urgent Surgery

Surgery is indicated if: 5

• Hypotension and shock persist despite aggressive resuscitation
• Blood transfusion requirement exceeds 6 units
• Severe bleeding recurs after initial control
• Endoscopic and angiographic therapies fail