From the Guidelines
Melena is primarily caused by upper gastrointestinal bleeding, which can lead to anemia due to acute or chronic blood loss, with the most common etiologies being duodenal ulcer, gastric erosions, gastric ulcer, varices, Mallory-Weiss tears, esophagitis, duodenitis, and neoplasm, as reported in the study by Singh-Bhinder et al 1. The primary causes of melena include peptic ulcer disease, gastritis, esophageal varices, Mallory-Weiss tears, gastric cancer, and use of medications like NSAIDs and anticoagulants.
- Key causes of upper gastrointestinal bleeding leading to melena and anemia include:
- Peptic ulcer disease
- Gastritis
- Esophageal varices
- Mallory-Weiss tears
- Gastric cancer
- Use of medications like NSAIDs and anticoagulants
- Other less common causes such as Dieulafoy lesion, aortoenteric fistula, and hemobilia According to the study by Singh-Bhinder et al 1, ulcer disease is a common etiology of UGIB, and an underrecognized but serious cause of UGIB is Dieulafoy lesion, which accounts for 1% to 2% of acute bleeding. Management of melena-induced anemia typically involves addressing the underlying cause, such as proton pump inhibitors (like omeprazole 40mg daily) for ulcers, endoscopic interventions for active bleeding, or discontinuation of offending medications, as well as blood transfusions for severe anemia (hemoglobin <7 g/dL) and iron supplementation (ferrous sulfate 325mg three times daily) for several months to replenish iron stores, as suggested by guidelines for the management of iron deficiency anaemia 1. It is essential to seek immediate medical attention for proper diagnosis and treatment of melena and anemia, as the connection between melena and anemia is direct, with ongoing blood loss depleting red blood cells faster than the bone marrow can produce them, leading to symptomatic anemia with fatigue, weakness, and shortness of breath. In patients presenting with substantial UGIB, aggressive volume resuscitation and maintenance of hemodynamic stability are the first priorities, followed by an attempt to identify and treat the source of hemorrhage, as recommended by Singh-Bhinder et al 1. The diagnostic approach may involve upper endoscopy, video capsule endoscopy, and other investigations to identify the underlying cause of melena and anemia, with the goal of preventing further bleeding, managing anemia, and improving quality of life.
From the Research
Causes of Melena Leading to Anemia
- Melena, or tarry black stool, can be caused by various factors, including upper gastrointestinal tract bleeding, which can lead to anemia 2
- The most common causes of melena in children are duodenal ulcers, gastric ulcers, esophagitis, and esophageal varices, with the upper gastrointestinal tract being the most common source of bleeding 2
- Helicobacter pylori infection is a significant cause of peptic ulcers, which can lead to melena and anemia 3, 4, 5
- Other causes of melena include nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal damage, which can also lead to anemia 5
- Earlier use of capsule endoscopy in patients with melena or severe iron deficiency anemia can reduce the need for colonoscopy and shorten hospital stays, highlighting the importance of prompt diagnosis and treatment 6
Diagnostic and Management Strategies
- The "test-and-treat" strategy is recommended for managing Helicobacter pylori infection, with the choice of testing method depending on patient age, symptoms, and medication use 4
- Treatment regimens for H. pylori infection include dual therapy, triple therapy, and quadruple therapy, with proton pump inhibitor (PPI)-based triple therapy regimens being effective in eradicating the bacterium in about 90% of patients 3, 5
- Omeprazole is a well-studied proton pump inhibitor that can be used in combination with antibacterial agents to treat H. pylori infection and prevent NSAID-induced gastrointestinal damage 5