What is the immediate management for a patient presenting with severe melena?

Immediate Management of Severe Melena

Patients presenting with severe melena require immediate hemodynamic resuscitation with large-bore IV access and aggressive fluid replacement, followed by urgent upper endoscopy within 24 hours, as melena indicates upper GI bleeding in 80% of cases and carries significant mortality risk, particularly in elderly patients with shock. 1, 2

Initial Resuscitation (First Priority)

Hemodynamic stabilization takes absolute priority over diagnostic procedures. 1, 2

• Establish two large-bore IV lines (ideally 14-16 gauge, or 8-Fr central access in adults) for rapid volume resuscitation 2
• Administer high-flow oxygen to ensure adequate tissue oxygenation 2
• Begin aggressive crystalloid resuscitation in patients with shock (pulse >100 bpm, systolic BP <100 mmHg) 3, 1
• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL in most patients, or >9 g/dL in those with massive bleeding, cardiovascular disease, or when endoscopy may be delayed 2
• Use O-negative blood if type-specific or cross-matched blood is not immediately available 2
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 2
• Insert a nasogastric tube to decompress the stomach, protect the airway, and assess ongoing bleeding 2

Risk Stratification

Use the Rockall score to identify high-risk patients who require intensive monitoring and urgent intervention. 3, 1

Independent predictors of mortality include:

• Age >60 years (30% mortality in patients >90 years vs. rare deaths in those <40 years) 3, 1
• Shock at presentation (pulse >100 bpm and systolic BP <100 mmHg) 3, 1
• Significant comorbidities, especially renal failure, liver disease, or disseminated cancer 3, 1
• Active bleeding or high-risk endoscopic stigmata (80% risk of continued bleeding or death in shocked patients with actively bleeding peptic ulcers) 3, 1

Laboratory Evaluation

Obtain immediate blood work: 1, 2

• Complete blood count (but do not rely on single hemoglobin measurements as they may not reflect acute blood loss) 1, 2
• Coagulation studies (PT, aPTT, INR, fibrinogen) 2
• Type and crossmatch for at least 4-6 units of packed red blood cells 1
• Serum lactate and base deficit to estimate and monitor the extent of bleeding and shock 1, 2
• Liver function tests 1

Correct coagulopathy (INR >1.5) with fresh frozen plasma and thrombocytopenia (<50,000/µL) with platelet transfusion before endoscopy. 3, 2

Endoscopic Management (Definitive Intervention)

Upper endoscopy is the primary diagnostic and therapeutic intervention and should be performed within 24 hours for most patients. 3, 1

Timing of Endoscopy:

• Emergency "out of hours" endoscopy is required for patients with ongoing hemodynamic instability despite adequate resuscitation 3, 1
• Hemodynamically stable patients can undergo early elective endoscopy (ideally the morning after admission) 3, 1
• Endoscopy should be performed by experienced endoscopists skilled in therapeutic interventions, available 24/7 3, 1
• Perform endoscopy in a fully equipped endoscopy unit or operating theatre with anesthetic support for unstable patients 3

Therapeutic Interventions:

• Apply endoscopic therapy when high-risk stigmata are identified: active bleeding, non-bleeding visible vessel, or adherent clot 1
• Use injection therapy, thermal coagulation, or combination approaches to reduce rebleeding 1

Pharmacologic Management

Administer high-dose proton pump inhibitor therapy after endoscopic treatment of bleeding ulcers: 1

• Omeprazole 80 mg IV bolus, followed by 8 mg/hour continuous infusion for 72 hours 1
• This regimen significantly reduces rebleeding in patients with major ulcer bleeding 1

Post-Endoscopy Monitoring

• Monitor continuously for signs of rebleeding: fresh hematemesis, recurrent melena, hypotension, tachycardia, or hemoglobin drop >20 g/L over 24 hours 1
• Hemodynamically stable patients can begin oral intake 4-6 hours after endoscopy 1, 4
• If rebleeding occurs, perform repeat endoscopy to confirm and attempt further endoscopic therapy 1

Surgical Consultation

Involve surgical gastroenterology early for high-risk patients. 1, 2

Indications for surgery:

• Uncontrolled hemorrhage despite endoscopic therapy 1, 2
• Rebleeding after one attempt at repeat endoscopic therapy 1
• Hemodynamic instability that cannot be stabilized with resuscitation and endoscopic intervention 1

Alternative Interventions When Endoscopy Fails

• Consider interventional radiology angiographic embolization when endoscopy is unsuccessful 2
• External-beam radiation therapy may be considered for chronic blood loss from gastric malignancy 2

Critical Pitfalls to Avoid

• Do not delay resuscitation for diagnostic studies—hemodynamic stabilization always comes first 1, 2
• Do not rely on blood pressure alone as an indicator of blood loss, as some patients compensate well despite significant hemorrhage 2
• Do not discharge patients with high-risk endoscopic findings (active bleeding, visible vessel, or adherent clot) prematurely, as they carry 50-80% rebleeding risk 1
• Do not perform routine repeat endoscopy in all patients—only indicated for clinical rebleeding or concern about suboptimal initial therapy 1
• Do not assume all black stools represent melena—obtain detailed medication and dietary history to exclude iron supplements or bismuth 4
• Do not delay endoscopy beyond 24 hours without clear contraindications, as therapeutic opportunities diminish with time 4

Disposition

• Admit high-risk patients to a critical care area for continuous monitoring 2
• Begin standard venous thromboprophylaxis as soon as bleeding is controlled 2
• Patients under 40 years with mild bleeding and no comorbidities can be fast-tracked toward discharge after successful endoscopic evaluation 3