What is the initial management of melena in the emergency department?

Initial Management of Melena in the Emergency Department

Immediate Hemodynamic Assessment and Resuscitation

Begin with immediate evaluation of hemodynamic status, measuring pulse rate and blood pressure to identify shock (defined as pulse >100 beats/min and systolic BP <100 mmHg), and initiate aggressive IV fluid resuscitation in unstable patients with the goal of normalizing vital signs before endoscopy. 1, 2

Resuscitation Protocol

• Establish large-bore IV access and begin crystalloid resuscitation immediately in hemodynamically unstable patients (those with shock parameters or ongoing bleeding) 1, 2, 3

• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL in most patients; however, use a higher threshold of 9 g/dL for patients with massive bleeding, significant cardiovascular comorbidities (especially coronary disease), or anticipated delays in therapeutic intervention 4, 1, 2

• Correct coagulopathy if INR >1.5 with fresh frozen plasma and vitamin K, and transfuse platelets if count <50,000/µL 1

Risk Stratification

Immediately stratify patients into low-risk versus high-risk categories using validated clinical scoring systems (Blatchford or Rockall scores) to guide disposition and urgency of endoscopy 4, 1

High-Risk Clinical Predictors

Identify patients at increased risk for rebleeding and mortality based on:

• Age >65 years, presence of shock, poor overall health status, and significant comorbid illnesses (especially cardiovascular, renal, or hepatic disease) 4, 1, 2

• Laboratory findings including low initial hemoglobin, elevated blood urea nitrogen, elevated creatinine, or elevated aminotransferases 4, 1

• Clinical presentation with fresh red blood on rectal examination, in emesis, or nasogastric aspirate, plus transfusion requirement 4, 1

Diagnostic Approach

Perform esophagogastroduodenoscopy (EGD) as the initial diagnostic procedure of choice because it provides both diagnostic and therapeutic capabilities in a single intervention. 4, 1, 2

Timing of Endoscopy

• Emergency endoscopy within 24 hours is indicated for hemodynamically unstable patients or those with evidence of ongoing active bleeding 1, 2

• Early elective endoscopy (ideally the morning after admission) is appropriate for hemodynamically stable patients without signs of active bleeding 1, 2

Endoscopic Therapeutic Intervention

• During EGD, identify the bleeding source and apply endoscopic therapy if active bleeding, non-bleeding visible vessel, or adherent clot is identified 1, 2

• Following successful endoscopic hemostasis in ulcer bleeding, initiate high-dose proton pump inhibitor therapy (80 mg bolus followed by continuous infusion of 8 mg/hour for 72 hours) 1, 2

Management of Non-Diagnostic EGD

If EGD fails to identify a bleeding source, proceed with CT angiography (which can detect bleeding rates as low as 0.3 mL/min) in patients with ongoing bleeding 1

• Consider colonoscopy after non-diagnostic EGD, though the diagnostic yield is relatively low (4.8%) and therapeutic intervention rate is only 1.7%; however, this population has increased risk of colorectal malignancy (OR 2.87) 5

• Melena predicts proximal small bowel bleeding in obscure GI bleeding cases, with 56.1% of melena patients having bleeding sources in the proximal 2/3 of small intestine (OR 1.97), suggesting antegrade deep enteroscopy or capsule endoscopy as next steps if upper endoscopy is negative 6

• Angiography with therapeutic embolization should be considered for active bleeding not amenable to endoscopic control 1

Special Populations Requiring Aggressive Management

Elderly patients (>65 years) have significantly higher mortality rates and require more intensive monitoring and earlier intervention. 1, 2

Patients with cardiovascular disease, renal failure, or liver disease are at substantially higher risk for complications and death, necessitating lower thresholds for transfusion and ICU admission 1, 2

Critical Pitfalls to Avoid

• Do not delay resuscitation to obtain endoscopy—stabilize hemodynamics first with the goal of normalizing blood pressure and heart rate before proceeding to diagnostic procedures 4, 1, 2

• Do not under-transfuse patients with cardiovascular disease or massive bleeding—these populations require hemoglobin maintained at 9 g/dL rather than the standard 7 g/dL threshold 4, 1, 2

• Do not assume melena always indicates upper GI bleeding—approximately 5% of cases originate from colonic sources, and small bowel bleeding accounts for a significant proportion of obscure cases 6, 5