How should I manage an elderly male with one week of dark, loose stools (melena) and anemia (low hemoglobin) who is hemodynamically stable?

Management of Hemodynamically Stable Elderly Male with Melena and Anemia

This elderly male with one week of dark, loose stools (melena) and known anemia who is hemodynamically stable requires bidirectional endoscopy—both upper endoscopy with duodenal biopsies and colonoscopy—because dual pathology occurs in 10-15% of cases and coeliac disease accounts for 2-3% of iron deficiency anemia presentations. 1

Immediate Assessment and Risk Stratification

Confirm Hemodynamic Stability

• Calculate the shock index (heart rate ÷ systolic blood pressure); a value >1 indicates instability and would mandate immediate CT angiography rather than endoscopy 2
• Since blood pressure is normal and assessment is "good," this patient appears stable for elective endoscopic evaluation 1
• Melena strongly suggests an upper GI source, though 10-15% of patients with severe hematochezia may have upper GI bleeding, and small bowel sources can also present with melena 3, 2

Laboratory Evaluation

• Obtain complete blood count, coagulation profile (PT/INR), and type-and-cross 2
• Correct any coagulopathy before endoscopy: transfuse fresh frozen plasma if INR >1.5 and platelets if count <50 × 10⁹/L 2, 1
• Measure serum ferritin (most powerful test for iron deficiency) and transferrin saturation 1

Diagnostic Algorithm

Upper Endoscopy First (Priority Investigation)

Upper GI endoscopy should be performed first because melena indicates upper GI or proximal small bowel bleeding 3, 1

• Schedule on the next available elective list (ideally morning after admission for stable patients) rather than emergency out-of-hours endoscopy 1
• Upper endoscopy reveals a cause in 30-50% of patients with iron deficiency anemia 1
• Obtain duodenal biopsies during upper endoscopy because 2-3% of patients with iron deficiency anemia have coeliac disease, even without typical symptoms 1
• Common upper GI causes include peptic ulcer, erosive gastritis/duodenitis, oesophagitis, and malignancy 1

Lower GI Evaluation (Mandatory Second Step)

All patients must undergo examination of the lower GI tract unless upper endoscopy reveals carcinoma or coeliac disease, because dual pathology occurs in 10-15% of cases 1

• Do not accept oesophagitis, erosions, or peptic ulcer as the sole cause without completing lower GI evaluation 1
• Colonoscopy is preferred over barium enema because it demonstrates angiodysplasia and allows biopsy 1
• In elderly patients, colorectal cancer accounts for 6-27% of lower GI bleeding cases, and approximately 40% of rectal carcinomas are palpable on digital rectal examination 4
• Bidirectional endoscopy (upper and lower at the same session) is an efficient approach 1

Age-Specific Considerations in the Elderly

High-Risk Features

• Advanced age is the strongest risk factor for lower GI bleeding, with diverticulosis and angiodysplasia increasing dramatically after age 60-70 4
• Diverticulosis accounts for 21-41% of lower GI bleeding in elderly patients 4
• Iron deficiency in the elderly is often multifactorial: poor diet, reduced absorption, occult blood loss, medications (aspirin/NSAIDs), and chronic disease 1

Investigation Threshold

• Confirmed iron deficiency anemia warrants the same investigational algorithm in elderly men as in younger patients 1
• The yield of GI pathology is high: elderly patients with iron deficiency should undergo endoscopic examination irrespective of hemoglobin level 5
• In one study, 49% of anemic elderly patients and 56% of non-anemic iron-deficient patients had upper GI lesions; 32% of anemic patients had lower GI lesions 5
• Synchronous colonic tumors were found in 9.5% of patients with benign upper GI lesions 5

Balancing Risks and Benefits

• The risks and benefits of invasive endoscopy must be carefully weighed in those with major comorbidities or limited performance status 1
• However, the presence of GI symptoms, positive fecal occult blood, and NSAID use are of limited value in guiding whether to investigate—investigation is still warranted 5
• CT colonography may be a more attractive alternative to colonoscopy for frail older individuals 1

Transfusion Management

• Use restrictive transfusion thresholds: hemoglobin trigger 70 g/L (target 70-90 g/L) for patients without cardiovascular disease 2
• For patients with cardiovascular disease: hemoglobin trigger 80 g/L (target 100 g/L) 2
• Prudent transfusion practices maintaining hemoglobin 9-10 g/dL are indicated in elderly patients with comorbidities 6

Anticoagulation and Antiplatelet Management

If on Warfarin

• Interrupt warfarin immediately at presentation 2
• For unstable hemorrhage, reverse with prothrombin complex concentrate AND vitamin K 2
• Restart warfarin at 7 days after hemorrhage for patients with low thrombotic risk 2

If on Aspirin

• Aspirin for primary prophylaxis should be permanently discontinued 2
• Aspirin for secondary prevention should not be routinely stopped; if stopped, restart as soon as hemostasis is achieved 2

Further Evaluation if Initial Workup is Negative

• Further small bowel visualization is not necessary unless the anemia is transfusion-dependent or there has been visible blood loss 1
• Follow-up studies show this approach is safe provided dietary deficiency is corrected, NSAIDs are stopped, and hemoglobin is monitored 1
• Small bowel radiology is rarely useful unless history suggests Crohn's disease 1
• Enteroscopy may be helpful to detect and treat small bowel angiodysplasia if iron deficiency anemia is transfusion-dependent 1

Critical Pitfalls to Avoid

• Never skip lower GI evaluation even if upper endoscopy reveals a lesion (except carcinoma or coeliac disease), because dual pathology occurs in 10-15% 1
• Do not omit duodenal biopsies during upper endoscopy—coeliac disease is found in 2-3% of iron deficiency anemia cases 1
• Do not assume symptoms, fecal occult blood, or NSAID use predict findings—elderly patients with iron deficiency require investigation regardless 5
• In elderly patients with reduced physical activity and without severe cardiopulmonary disease, symptoms of severe anemia may go unnoticed until hemoglobin reaches life-threatening levels 7
• Anemia in the elderly is often multifactorial (nutritional deficiency, chronic disease, unexplained anemia), affecting >20% of those over 85 years 1, 8