What is the initial management for a patient presenting with melena (black tarry stool) in a ward setting?

Ward Management of Black Tarry Stool (Melena)

Immediately assess hemodynamic stability and initiate resuscitation while arranging urgent upper endoscopy within 24 hours, as melena indicates upper GI bleeding in the vast majority of cases, most commonly from peptic ulcer disease. 1

Immediate Assessment and Resuscitation

Hemodynamic Evaluation

• Check vital signs immediately and calculate shock index (heart rate ÷ systolic blood pressure)—a value >1 indicates hemodynamic instability requiring aggressive resuscitation 2
• Measure pulse, blood pressure, and assess for signs of shock (pulse >100 bpm, systolic BP <100 mmHg) 1
• Obtain hemoglobin/hematocrit, coagulation parameters, and blood type/cross-match immediately 2, 3

Resuscitation Protocol

• Begin IV fluid resuscitation immediately in unstable patients to normalize blood pressure and heart rate 2, 3
• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL (use 9 g/dL threshold if massive bleeding, cardiovascular disease, or anticipated delay in intervention) 2, 3
• Interrupt warfarin at presentation 2
• Insert large-bore IV access (two lines) and consider central venous pressure monitoring in severe cases 1

Specialist Involvement and Monitoring

• Transfer patient to gastroenterology service or ensure immediate gastroenterology consultation, as mortality is lower in specialist units due to adherence to protocols 1
• Place patient in high-dependency unit with nursing staff/patient ratio appropriate for critically ill patients 1
• Monitor continuously: pulse, blood pressure, urine output, and central venous pressure if available 1

Diagnostic Approach

Upper Endoscopy Timing

• Arrange urgent upper endoscopy within 24 hours as the primary diagnostic and therapeutic procedure 1
• The upper GI tract is the bleeding source in approximately 80% of melena cases, with peptic ulcer being most common (35-50%) 1
• Other common causes include gastroduodenal erosions (8-15%), esophagitis (5-15%), varices (5-10%), and Mallory-Weiss tears (15%) 1

Risk Stratification

• Patients with hematemesis plus melena have more severe bleeding than melena alone and require more aggressive monitoring 1
• Rebleeding is defined as: fresh hematemesis/melena with shock, CVP fall >5 mmHg, or hemoglobin drop >20 g/L over 24 hours 1

Medical Management

Proton Pump Inhibitor Therapy

• Administer high-dose omeprazole: 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours following endoscopic therapy in patients with major ulcer bleeding 1
• This regimen is recommended for all bleeding ulcer patients (duodenal, gastric, or stomal) 1

Post-Endoscopy Care

• Allow oral intake 4-6 hours after endoscopy if hemodynamically stable—prolonged fasting is unnecessary 1
• Continue close monitoring with frequent vital sign checks 1

Management of Rebleeding

Repeat Endoscopy Indications

• Perform repeat endoscopy to confirm rebleeding if fresh melena, hematemesis, falling BP, rising pulse, or falling CVP occurs 1
• Attempt endoscopic therapy once more if stigmata of hemorrhage persist on repeat endoscopy 1
• One trial showed repeat endoscopic therapy has outcomes at least as good as urgent surgery 1

Surgical Consultation

• Involve consultant surgeon early in management, as combined medical-surgical care is essential for critically ill bleeding patients 1
• Immediate surgery is indicated for: uncontrolled hemorrhage despite endoscopic therapy, or second rebleed after failed repeat endoscopic intervention 1
• Consider semi-urgent surgery for high-risk lesions (e.g., giant posterior duodenal ulcer with multiple bleeding points) even after first rebleed 1

Special Considerations

When Colonoscopy May Be Needed

• Colonoscopy has very low yield (4.8%) after non-diagnostic upper endoscopy for melena, but should be considered electively in stable patients due to increased colorectal cancer risk 4
• Melena can rarely originate from proximal small intestine—if upper endoscopy is negative and bleeding continues, consider capsule endoscopy 5

Critical Pitfalls to Avoid

• Do not delay endoscopy beyond 24 hours in stable patients—early endoscopy allows risk stratification and therapeutic intervention 1
• Do not assume bleeding has stopped based on stable vital signs alone—continue monitoring for at least 24 hours 1
• Do not perform routine repeat endoscopy after initial successful therapy—only repeat if clinical evidence of rebleeding 1
• Recognize that patients requiring ≥4 units transfusion have approximately 20% mortality risk and need intensive monitoring 2