How should I manage a patient who develops melena after undergoing esophageal dilation with biopsies?

Management of Melena After Esophageal Dilation and Biopsies

Immediately assess for esophageal perforation first, as this is a life-threatening emergency that takes priority over bleeding management, then evaluate the source and severity of gastrointestinal bleeding. 1, 2

Immediate Assessment for Perforation (First Priority)

Suspect perforation if the patient develops persistent chest pain, breathlessness, fever, or tachycardia—these symptoms mandate urgent imaging even when bleeding is present. 1, 2

• Perform a CT scan with oral contrast immediately if any concerning symptoms develop, as this is the gold standard and superior to conventional contrast studies for detecting perforation 2
• Chest X-ray alone is insufficient—normal findings do not exclude perforation, though it may show pneumomediastinum, pneumothorax, subcutaneous emphysema, or pleural effusion 1, 2
• Major bleeding is uncommon following esophageal dilation (perforation is the more serious complication), but bleeding risk is higher in patients with coagulopathy or on anticoagulants 1

If perforation is confirmed: Keep the patient NPO, initiate broad-spectrum antibiotics immediately, and obtain urgent consultation with experienced gastroenterology and surgical teams for management options including surgical repair, endoscopic stent placement, or conservative management 2

Bleeding Assessment and Management (Second Priority)

Clinical Evaluation

• Document hemodynamic stability: check blood pressure (including orthostatic vitals), heart rate, and signs of hypovolemia 3
• Melena after esophageal procedures can originate from trauma to the esophageal mucosa during dilation, biopsy sites, or pre-existing esophageal ulceration 4, 5
• Patients with esophageal ulcers commonly present with melena (40%) or melena with hematemesis (40%), with 50% having orthostatic hypotension and 80% requiring transfusions 4

Laboratory and Resuscitation

• Obtain complete blood count, basic metabolic panel, coagulation panel, liver tests, and type and crossmatch 3
• Rapidly infuse normal saline or lactated Ringer solution to correct hypovolemia and maintain blood pressure 3
• Transfuse blood when hemoglobin is less than 7 g/dL 3
• Initiate high-dose proton pump inhibitor therapy immediately upon presentation 3

Endoscopic Re-evaluation

Perform urgent repeat endoscopy within 24 hours if the patient is hemodynamically unstable or has signs of ongoing bleeding. 3

• Endoscopic stigmata in esophageal ulcers typically include oozing blood (35%) and adherent clot (25%) 4
• Endoscopic hemostasis can be attempted, though rebleeding is common in esophageal sources—initial control may be successful but recurrence is typical 6, 4
• If endoscopic hemostasis fails, attempt transcatheter arterial embolization, then proceed to surgery if hemostasis is not obtained 3

Risk Stratification

• Use clinical prediction guides such as the Glasgow-Blatchford bleeding score for risk stratification and to determine therapy 3
• Malignant strictures carry greater perforation and bleeding risk compared to benign disease 1, 7
• GI bleeding is often the initial presenting symptom of malignancy in 77% of patients with GI tumors 6

Post-Procedure Monitoring Protocol

Monitor patients for at least 2 hours in the recovery room with regular vital signs (pulse, blood pressure, temperature). 1

• Continue high-dose proton pump inhibitor treatment for the first 72 hours post-endoscopy, as this is when rebleeding risk is highest 3
• Ensure the patient is well and tolerating water before discharge 1
• Provide written instructions with contact information for the on-call team should they experience chest pain, breathlessness, or become unwell 1

Colonoscopy Consideration

If upper endoscopy is nondiagnostic and melena persists, consider colonoscopy, though the diagnostic yield is low (4.8%) and therapeutic intervention rate is very low (1.7%). 8

• Colonoscopy can be performed electively in stable patients without continued bleeding, as this population has increased risk of colorectal cancer 8
• Right-sided arteriovenous malformations, colitis, large polyps (≥20 mm), tumors, or ulcers are potential lower GI sources 8

Critical Pitfalls to Avoid

• Never assume melena is simply from minor mucosal trauma—always rule out perforation first when symptoms are concerning 1, 2
• Do not delay imaging if persistent chest pain develops, as transient chest pain is common but persistent pain indicates possible perforation 1
• Avoid discharging patients before they tolerate oral fluids and have stable vital signs for at least 2 hours 1
• Do not restart anticoagulation without careful consideration of bleeding risk versus thrombotic risk, though specific timing data are limited 3