What is the management of melena?

Management of Melena

Melena requires immediate hemodynamic assessment and risk stratification, followed by urgent upper endoscopy as the primary diagnostic and therapeutic intervention, with timing determined by bleeding severity and patient stability. 1, 2

Initial Assessment and Stabilization

Rapidly assess hemodynamic status to categorize bleeding severity and mortality risk:

• Calculate the shock index (heart rate divided by systolic blood pressure) - a value <1 defines hemodynamic stability, while values ≥1 indicate instability requiring more aggressive intervention 2
• Identify shock parameters: pulse rate >100 beats/min AND systolic blood pressure <100 mmHg 3, 1
• Establish two large-bore IV lines in the antecubital fossae for fluid resuscitation and potential blood product administration 4
• Begin IV fluid resuscitation immediately if hemodynamically unstable, with the goal of normalizing blood pressure and heart rate prior to endoscopy 1

Risk stratification must incorporate the Rockall scoring system components: 3, 1

• Age: Mortality increases dramatically with age - deaths are rare under age 40 but reach 30% in patients over 90 years 3
• Comorbidities: Deaths are almost entirely restricted to patients with significant medical diseases, particularly advanced renal disease, liver disease, disseminated cancer, and cardiovascular/respiratory conditions 3, 1
• Shock status: As defined above 3
• Endoscopic findings: Will determine final risk assessment (discussed below) 3

Resuscitation Targets

Transfuse packed red blood cells using restrictive thresholds:

• Maintain hemoglobin >7 g/dL in most patients 1, 2
• Use a higher threshold of 8-9 g/dL in patients with massive active bleeding or significant cardiovascular comorbidities 1, 2
• Monitor transfusion requirements closely - patients requiring ≥4 units have significantly increased mortality risk 2

Common pitfall: Avoid over-transfusion, as restrictive strategies have been shown to improve outcomes in upper GI bleeding. 1, 2

Diagnostic Approach: Timing of Endoscopy

Upper endoscopy (EGD) is the initial procedure of choice as it provides both diagnostic and therapeutic capabilities. 1, 2

Timing depends on hemodynamic status and bleeding severity:

• Hemodynamically stable patients without active bleeding: Perform early elective endoscopy ideally the morning after admission (within 24 hours) 3, 1
• Hemodynamically unstable patients or those with ongoing bleeding: Perform emergency endoscopy within 24 hours, potentially requiring out-of-hours service 3, 1
• Severely shocked or actively bleeding patients: May require endoscopy in an operating theatre environment with anesthetic support available 3

Endoscopy should be performed in a fully equipped endoscopy unit with trained nursing staff, cardiorespiratory monitoring equipment, and access to therapeutic accessories. 3

Endoscopic Management and Findings

During endoscopy, identify the bleeding source and apply appropriate therapy based on findings: 1, 4

High-risk endoscopic findings requiring intervention:

• Active bleeding from a peptic ulcer - carries an 80% risk of continued bleeding or death in shocked patients 3
• Non-bleeding visible vessel - associated with 50% risk of rebleeding 3
• Adherent clot - requires therapeutic intervention 1

Low-risk endoscopic findings:

• Clean-based ulcer, Mallory-Weiss tear, or normal endoscopy - associated with very low risk of rebleeding and death 3

Therapeutic endoscopic options include: 1, 4

• Combination therapy: Epinephrine injection plus thermal coagulation or mechanical clips (preferred approach) 4
• Hemostatic clips for large visible vessels 4
• Injection therapy, mechanical therapy, or ablative therapy (argon plasma coagulation) 1

Post-Endoscopic Medical Management

Following successful endoscopic hemostasis for ulcer bleeding:

• Administer high-dose proton pump inhibitor therapy: Omeprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours 1, 4
• Continue maintenance PPI therapy to prevent rebleeding 4

Management of Refractory or Recurrent Bleeding

If endoscopic therapy fails or bleeding recurs: 1, 4

• Angiographic embolization should be considered as the next intervention 3, 1
• External beam radiation therapy can effectively manage both acute and chronic GI bleeding when endoscopic and interventional approaches fail 1
• Surgical intervention may be necessary in cases of uncontrolled bleeding despite endoscopic and angiographic attempts 3

Ongoing Monitoring and Rebleeding Recognition

Continuous monitoring is essential even after successful initial management: 2, 4

• Monitor vital signs every 4-6 hours minimum 2
• Immediate medical team notification required for: Fresh melena, hematemesis, drop in blood pressure, rise in pulse rate, or hemoglobin decrease 2, 4
• Rebleeding is defined as: Fresh hematemesis and/or melena with development of shock, fall in central venous pressure, or reduction in hemoglobin 4

Special Considerations

Anticoagulation management: 2

• Interrupt warfarin immediately at presentation with GI bleeding 2
• Document all antiplatelet and anticoagulant medications as they affect bleeding risk and procedural planning 2

High-risk populations requiring more aggressive management: 3, 1

• Elderly patients (>65 years) have significantly higher mortality rates 1
• Patients with multiple comorbidities (cardiovascular, renal, liver disease) are at higher risk for complications and death 3, 1
• Consider high-dependency unit management for elderly patients with multiple comorbidities and serious hemorrhage 3

Common pitfall: Do not minimize the significance of melena - mortality for hospitalized patients who develop GI bleeding can reach 18%, primarily related to underlying comorbidities. 2