What is the initial emergency management of a patient presenting with melena due to an acute upper gastrointestinal bleed?

Initial Emergency Management of Melena

Immediately assess hemodynamic status by calculating the shock index (heart rate divided by systolic blood pressure)—a value >1 indicates hemodynamic instability requiring ICU admission and aggressive resuscitation. 1, 2

Immediate Assessment and Resuscitation

Hemodynamic evaluation:

• Check vital signs including orthostatic blood pressure (drop >20 mmHg or heart rate increase >20 bpm when standing indicates significant blood loss requiring ICU admission) 1
• Perform digital rectal examination to confirm melena (black, tarry, sticky stool with distinctive odor) and exclude anorectal pathology 3, 1
• Assess for shock: pulse >100 beats/min and systolic BP <100 mmHg 3, 4

Resuscitation protocol for unstable patients:

• Initiate intravenous fluid resuscitation immediately with goal of normalizing blood pressure and heart rate before endoscopic evaluation 3, 1, 4
• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL for most patients 3, 1, 5
• Use higher threshold of 8-9 g/dL for patients with cardiovascular disease, massive bleeding, or significant comorbidities 3, 1, 4
• Correct coagulopathy with fresh frozen plasma if INR >1.5 1, 2
• Transfuse platelets if platelet count <50,000/µL 1, 2

Risk Stratification

For hemodynamically stable patients, calculate the Oakland score (includes age, gender, previous lower GI bleeding admission, digital rectal findings, heart rate, systolic BP, and hemoglobin) 1, 2:

• Score ≤8 points: safe for urgent outpatient investigation 1, 2
• Score >8 points: requires hospital admission 2

High-risk features requiring aggressive management:

• Age >65 years 1, 4
• Shock or hemodynamic instability 1, 4
• Significant comorbidities (especially cardiovascular, renal, or liver disease) 4
• Low initial hemoglobin 1

Diagnostic Approach Based on Stability

For hemodynamically unstable patients (shock index >1):

• Perform CT angiography immediately to localize active bleeding 1, 2
• Following positive CTA, proceed to catheter angiography with embolization within 60 minutes 2

For hemodynamically stable patients:

• Perform upper endoscopy (esophagogastroduodenoscopy) within 24 hours as the initial diagnostic procedure, since melena typically indicates upper GI bleeding 3, 1, 4, 5
• Most patients can be safely endoscoped on an early elective list (ideally the morning after admission) 3, 4
• Emergency "out of hours" endoscopy should be available 24/7 for severely bleeding patients 3

Admission and Monitoring

Admit patients to appropriate level of care:

• Severely ill patients should be admitted to high dependency unit or intensive care unit 3
• Other patients can be admitted to acute general medical ward with experienced staff 3
• All units must have round-the-clock expertise including emergency endoscopy 3

Medication Management

Proton pump inhibitors:

• May be administered after resuscitation is initiated 5
• Following successful endoscopic therapy for ulcer bleeding, give high-dose omeprazole (80 mg stat followed by infusion of 8 mg hourly for 72 hours) 4

Anticoagulation/antiplatelet management:

• If on warfarin, interrupt immediately and reverse with prothrombin complex concentrate and vitamin K for unstable hemorrhage 2
• If on aspirin for primary prophylaxis, permanently discontinue 1, 2
• If on aspirin for secondary prevention, do not routinely stop; restart as soon as hemostasis is achieved 2

For suspected variceal bleeding:

• Administer antibiotics and vasoactive drugs 5, 6
• Consider prokinetic agent erythromycin before endoscopy 5

Critical Pitfalls to Avoid

• Never delay endoscopy or resuscitation to obtain stool studies—melena is a clinical diagnosis based on visual inspection and digital rectal examination 1
• Always consider upper GI source first in patients with melena and hemodynamic instability; perform upper endoscopy before colonoscopy 1, 2, 4
• Mortality relates more to comorbidities than exsanguination (overall 3.4%, but 18% for inpatient-onset bleeding), so aggressively manage underlying conditions 1, 2
• Do not perform aggressive bowel preparation if patient is actively bleeding or hemodynamically unstable 2
• If patient remains unstable despite aggressive resuscitation, proceed directly to surgery rather than pursuing further diagnostic studies 2