What is the appropriate emergency management for a 79-year-old patient presenting with melena, abdominal pain, and generalized malaise?

Emergency Management of a 79-Year-Old with Melena, Abdominal Pain, and Malaise

This patient requires immediate hemodynamic assessment, aggressive resuscitation if unstable, and urgent upper endoscopy within 24 hours, as melena indicates upper gastrointestinal bleeding in the vast majority of cases. 1, 2

Immediate Hemodynamic Assessment

• Calculate the shock index immediately (heart rate ÷ systolic blood pressure); a value >1 indicates hemodynamic instability and predicts poor outcomes requiring ICU-level care 3, 4
• Assess for shock defined as pulse >100 beats/min AND systolic blood pressure <100 mmHg 1
• Perform digital rectal examination to confirm melena (black, tarry, sticky stool with distinctive odor) and exclude anorectal pathology 2, 4
• Check for orthostatic hypotension (drop in BP >20 mmHg or HR increase >20 bpm when standing), which indicates significant blood loss requiring ICU admission 2, 4

Risk Stratification Using the Rockall Score

• Age >79 years alone carries significant mortality risk; deaths are rare under age 40 but reach 30% in patients over 90 years 1
• Identify comorbidities immediately—advanced renal disease, liver disease, disseminated cancer, and cardiac/respiratory/CNS diseases are closely related to mortality 1
• The combination of shock (pulse >100, systolic BP <100) with active bleeding on endoscopy carries an 80% risk of continued bleeding or death 1

Immediate Resuscitation Protocol

• Place two large-bore IV catheters and begin aggressive crystalloid resuscitation (normal saline or Ringer's lactate) immediately with the goal of normalizing blood pressure and heart rate before any endoscopic evaluation 3, 2
• Use restrictive transfusion thresholds: maintain hemoglobin >70 g/L (7 g/dL) for patients without cardiovascular disease 3, 2
• For patients with cardiovascular disease (hypertension, coronary disease), maintain hemoglobin >80 g/L with a target of 100 g/L 3, 2, 4
• Correct coagulopathy immediately: transfuse fresh frozen plasma if INR >1.5 and platelets if platelet count <50 × 10⁹/µL 3, 2, 4

Anticoagulation Reversal (If Applicable)

• If the patient is on warfarin, interrupt immediately and reverse with 4-factor prothrombin complex concentrate PLUS low-dose vitamin K (<5 mg) for unstable hemorrhage—do NOT use fresh frozen plasma as first-line 3, 4
• If on direct oral anticoagulants (DOACs), interrupt immediately; for life-threatening hemorrhage, administer specific reversal agents (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) 3

Diagnostic Approach: Upper Endoscopy First

• Upper endoscopy (esophagogastroduodenoscopy) is the first-line diagnostic procedure for melena and should be performed within 24 hours of presentation 1, 2, 4
• In the majority of stable patients, endoscopy can be scheduled on an early elective list (ideally the morning after admission) 1
• For severely bleeding or shocked patients, emergency "out-of-hours" endoscopy must be available 24/7 1
• Endoscopy should be performed in a fully equipped endoscopy unit with trained nursing staff and cardiorespiratory monitoring equipment; in some institutions, emergency endoscopy may be safer in an operating theatre with anesthetic cover 1

Admission Level and Monitoring

• Admit to high-dependency unit or ICU if the patient has shock, significant comorbidity, or ongoing severe bleeding 1, 2
• Stable patients can be admitted to an acute general medical ward with staff experienced in gastrointestinal bleeding, but 24-hour observation and care must be available 1
• Experienced nursing staff should be available at a staff/patient ratio compatible with a high-dependency unit for critically ill patients 1

Common Causes to Consider

• Peptic ulcer disease accounts for 35–50% of upper GI bleeding, followed by gastroduodenal erosions (8–15%), esophagitis (5–15%), and varices (5–10%) 1
• In elderly patients with abdominal pain and melena, consider mesenteric ischemia—severe abdominal pain out of proportion to physical examination findings should be assumed to be acute mesenteric ischemia until disproven 1

Critical Pitfalls to Avoid

• Never delay resuscitation to obtain imaging or endoscopy in unstable patients—stabilize first, then proceed to diagnostics 2, 4
• Do not assume all black stool is melena—confirm with digital rectal examination to distinguish true melena from other causes of dark stool 2
• Mortality in upper GI bleeding is almost entirely restricted to patients with significant comorbid diseases; these conditions are decompensated by bleeding and must be aggressively managed 1
• If the patient remains unstable despite aggressive resuscitation, proceed directly to surgery rather than pursuing further diagnostic studies 2, 4
• In a 79-year-old with "not feeling well," consider that mortality is closely related to the number and severity of comorbid illnesses rather than exsanguination alone 1

If Upper Endoscopy Is Negative

• Consider CT angiography if bleeding continues despite negative upper endoscopy, as approximately 10–15% of severe hematochezia may originate from the upper GI tract 3
• Proceed to colonoscopy after adequate bowel preparation if upper endoscopy is negative and the patient is stable 2, 5