What is the management approach for a patient presenting with melena (black, tarry stools) and intussusception (telescoping of the intestine), considering potential underlying causes such as gastrointestinal malignancy or bleeding ulcer?

Management of Melena and Intussusception

In adults presenting with both melena and intussusception, immediate surgical exploration with oncologic bowel resection is the recommended approach, as adult intussusception carries a 35% malignancy rate and requires resection without attempted reduction for colonic cases, while the melena indicates significant gastrointestinal bleeding requiring concurrent hemodynamic stabilization. 1, 2

Initial Resuscitation and Hemodynamic Stabilization

Before any diagnostic or surgical intervention, aggressive resuscitation takes absolute priority:

• Establish two large-bore IV lines in the anticubital fossae and begin aggressive fluid resuscitation with normal saline 3
• Assess hemodynamic stability: pulse >100 bpm and systolic BP <100 mmHg indicate severe bleeding requiring intensive monitoring 4, 3
• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL (or >9 g/dL in patients with massive bleeding, cardiovascular comorbidities, or significant ongoing hemorrhage) 4, 3
• Insert urinary catheter and monitor hourly urine output (target >30 mL/h) 3
• If shock persists after 2 liters of crystalloid, add plasma expanders as this indicates ≥20% blood volume loss 3

Diagnostic Approach

The combination of melena and intussusception in adults requires a different diagnostic pathway than either condition alone:

• CT imaging is typically diagnostic for adult intussusception and should be obtained in hemodynamically stable patients, with preoperative diagnosis achieved in 81% of cases 2
• Upper endoscopy (EGD) is generally not indicated before surgical exploration when intussusception is confirmed, as the intussusception itself requires operative management 1, 2
• In hemodynamically stable patients without confirmed intussusception, perform EGD within 24 hours to evaluate the melena source 4, 3

Surgical Management Strategy

Adult intussusception fundamentally differs from pediatric cases and requires surgical intervention:

For Colonic Intussusception:

• Perform immediate oncologic bowel resection without attempting reduction, as colonic intussusception has the highest malignancy rate (primary adenocarcinoma most common) 1, 2
• Resection with immediate anastomosis is the technique of choice in stable patients without perforation 2

For Small Bowel (Enteric) Intussusception:

• A more selective approach may be adopted, as small bowel intussusception is more likely to have benign lead points, though malignancy (often metastatic melanoma) still occurs 1, 5
• Resection remains the standard approach given that 100% of adult cases have an organic pathologic lead point 2
• Intraoperative assessment determines extent of resection 2

For Ileocolic Intussusception:

• Treat as colonic intussusception with oncologic resection without reduction, as malignancy rates approach those of colonic cases when a lead point is present 1

Critical Distinctions from Pediatric Management

This is not pediatric intussusception, which has fundamentally different management:

• Pediatric cases are 90% idiopathic and managed with pneumatic/hydrostatic reduction 6
• Adult intussusception has a pathologic lead point in 100% of symptomatic cases requiring surgery 2
• Laparotomy for uncomplicated pediatric intussusception carries 54% morbidity and 8% mortality, but adult cases are never "uncomplicated" due to the lead point pathology 7

Addressing the Melena Component

The melena in this clinical scenario likely originates from the intussusception lead point:

• Intussusception causes bowel edema, ischemia, and mucosal bleeding, producing melena or bloody stools 6, 5
• The surgical resection addresses both the intussusception and the bleeding source simultaneously 2, 5
• If hemodynamic instability persists despite resuscitation, proceed directly to surgery rather than endoscopy 4, 3

Risk Stratification and Timing

Surgical timing depends on hemodynamic status and peritoneal signs:

• Immediate surgery is required for: hemodynamic instability despite resuscitation, peritonitis, or evidence of perforation 4, 2
• Urgent surgery within 24 hours for: stable patients with confirmed intussusception and melena, as delay increases risk of bowel necrosis and perforation 6, 2
• Create a stoma only if peritonitis from perforation is present; otherwise perform primary anastomosis 2

Common Pitfalls to Avoid

• Do not attempt non-operative reduction in adults—this is appropriate only for pediatric idiopathic intussusception 6, 1, 2
• Do not delay surgery for extensive endoscopic evaluation when intussusception is confirmed on imaging, as the lead point requires resection regardless of endoscopic findings 1, 2
• Do not assume benign pathology—35% of adult intussusceptions are malignant, with higher rates in colonic and ileocolic locations 1, 2
• Do not perform endoscopy before adequate resuscitation—this critical error increases mortality in actively bleeding patients 3

Special Population Considerations

• Elderly patients (>65 years) with melena have significantly higher mortality rates and require more aggressive management with lower thresholds for transfusion and ICU admission 3, 8
• Patients with cirrhosis presenting with melena require specialized management as variceal bleeding carries 30% mortality versus 10% for nonvariceal sources 9
• Patients with significant cardiovascular, renal, or liver comorbidities have substantially higher mortality and require transfusion to maintain hemoglobin >9 g/dL 4