Melena – Symptoms, 11 Interesting Facts, Diagnosis, Treatment and Prognosis

4 Interesting Facts of Melena

1. Melena is black tarry stool from gastrointestinal bleeding; on history and/or physical examination, it is a strong indicator of upper gastrointestinal tract bleeding
2. Initial evaluation should focus on hemodynamic stabilization, defining the significance of the bleeding, and identifying a possible underlying cause
3. Glasgow Blatchford score should be used to risk-stratify all patients for likelihood of adverse event and need for intervention
4. All patients should receive an urgent gastrointestinal evaluation
5. Melena is the most common presenting symptom of major gastrointestinal hemorrhage.
6. About 90% of quantitatively important gastrointestinal bleeding episodes occur from sites above the ligament of Treitz. Melena usually means bleeding from this location.
7. It takes 50 ml or more of blood in the stomach to turn stools black. One to two liters of blood administered orally will cause bloody or tarry stools for up to 5 days, the first such stool usually appearing within 4 to 20 hours after ingestion. 
8. Melena is black tarry stool from gastrointestinal bleeding; on history and/or physical examination, it is a strong indicator of upper gastrointestinal tract bleeding
9. Initial evaluation should focus on hemodynamic stabilization, defining the significance of the bleeding, and identifying a possible underlying cause
10. Glasgow Blatchford score should be used to risk-stratify all patients for likelihood of adverse event and need for intervention
11. All patients should receive an urgent gastrointestinal evaluation.

Classification

• Gastrointestinal bleeding
  • By patient presentation:
    • Melena: black tarry stool
    • Hematochezia: red blood or clots in stool
    • Hematemesis: blood in vomitus (either bright red or brown/coffee-ground appearance)
  • By location of bleeding source: 
    • Upper gastrointestinal tract bleed: source of bleeding is above ligament of Treitz
    • Lower gastrointestinal tract bleed: source of bleeding is below ligament of Treitz (includes small bowel and colon)
  • By visibility/apparent nature of bleeding:
    • Overt gastrointestinal bleeding: blood is visible in stool (ie, melena, hematochezia)
    • Occult gastrointestinal bleeding: stool appears normal despite detectable blood on fecal blood testing
    • Obscure gastrointestinal bleeding: source of bleeding remains unidentified after thorough evaluation with upper endoscopy and well-prepared colonoscopy
  • By variceal involvement:
    • Variceal bleeding: bleeding from esophageal or gastric varices (Related: Gastroesophageal varices)
    • Nonvariceal bleeding: bleeding from other sources (eg, peptic ulcer, angioectasia, erosive esophagitis, Mallory-Weiss tear) (Related: Peptic ulcer disease)

Clinical Presentation

Clinical presentation ranges from vague nonspecific symptoms to hemodynamic collapse

Symptoms of Melena

• Symptoms
  • Lightheadedness, dizziness, or loss of consciousness (Related: Syncope)
    • May be associated with vasovagal syndrome, anemia, or hypotension due to acute blood loss 
      • Should prompt urgent evaluation of hemodynamic status
        • Loss of consciousness is associated with 3-fold increased risk of death based on observational data (adjusted odds ratio, 3; 95% confidence interval, 1.3-7) 
  • Hematemesis or hematochezia
    • Estimated mortality rate is twice as high for patients who present with melena and hematemesis (9.9%) compared with melena alone (5.5%) 
  • Abdominal pain
    • Low sensitivity for upper gastrointestinal tract bleeding (sensitivity, 17%; specificity, 93%; positive likelihood ratio, 2.3 [1.2-4.4]) 
• Medical history:
  • Medications that predispose to upper gastrointestinal tract bleeding 
    • NSAIDs
    • Antiplatelet medications (eg, aspirin, clopidogrel, glycoprotein IIb/IIIa inhibitors)
    • Anticoagulants (eg, warfarin, direct oral anticoagulants, oral factor Xa inhibitors, heparin) 
    • Corticosteroids (particularly in combination with NSAIDs) 
  • Prior or underlying medical conditions
    • Predisposing gastrointestinal disorders
      • Peptic ulcer disease 
      • Cirrhosis
    • Medical conditions that increase the risk of angioectasias
      • Aortic stenosis (which can lead to Heyde syndrome)
      • End-stage renal disease
    • Malignancy of head and neck or upper gastrointestinal tract
    • Bleeding from upper airway 
      • Epistaxis (large volume)
      • Oropharyngeal bleeding (large volume)
    • Behavioral risk factors 
      • Alcohol use (Related: Alcohol use disorder)
      • Tobacco use (Related: Tobacco use disorder and smoking cessation)

Physical examination

• Targeted physical examination should evaluate hemodynamic status, severity of bleeding, and potential source of bleeding to determine need for hospitalization, transfusion, and urgent intervention 
• Vital signs: abnormalities can indicate severe blood loss
  • Tachycardia often precedes hypotension
    • Patients receiving β-blockers or other rate-controlling medications may not experience tachycardia
  • Normal vital signs may be present for blood loss of up to 1000 mL 
  • Mild tachycardia (heart rate of 100 to 120 beats per minute) is often associated with about 750 to 1500 mL of blood loss 
  • Systolic blood pressure less than 110 mm Hg is associated with 2-fold increased mortality compared with higher values (odds ratio, 2.1; 95% confidence interval, 1.2-3.9) 
  • Systolic blood pressure less than 90 mm Hg is associated with 10-fold increased mortality (odds ratio, 9.8; 95% confidence interval, 5.1-19) 
• Mental status: mentation/ability to protect airway
  • Altered mentation/inability to protect airway should prompt endotracheal intubation
• Head, eyes, ears, nose, throat: signs of severe anemia and cirrhosis
  • Conjunctival pallor, scleral icterus, oral mucosal icterus (eg, buccal icterus)
• Abdomen: cirrhosis, abnormal anatomy
  • Scars from prior surgery, ascites, shrunken/firm liver, or splenomegaly
  • Rectal examination: melena or fresh blood
    • Presence of melena on physical examination is associated with 25-fold likelihood of upper gastrointestinal tract bleed (likelihood ratio, 25; 95% confidence interval, 4-174) 
• Skin: hemodynamic status, signs of underlying comorbid conditions
  • Turgor, telangiectasias, purpura, petechiae, spider angiomas, or palmar erythema 
• Endocrine: signs of hypogonadism as might occur from long-standing cirrhosis
  • Gynecomastia or small testes

Blood loss (mL)	Less than 750	750-1000	1500-2000	More than 2000
Heart rate (beats per minute)	Less than 100	100-120	120-140	More than 140
Blood pressure	Normal	Normal	Decreased	Decreased

Citation: Data from American College of Surgeons: ATLS: Advanced Trauma Life Support for Doctors: Student Course Manual. 7th ed. American College of Surgeons; 2004.

Body system	Physical finding	Clinical correlation
Head, eyes, ears, nose, and throat
	Conjunctival pallor	Severe anemia
	Scleral/oral mucosal icterus	Cirrhosis
Abdomen
	Scars from prior surgery	Anatomic irregularity, adhesions
	Ascites, shrunken/firm liver, splenomegaly	Cirrhosis
Rectal examination
	Melena	Upper gastrointestinal tract source of bleeding
	Frank blood/hematochezia	Brisk upper gastrointestinal tract bleeding or lower gastrointestinal tract bleeding
Skin
	Reduced turgor	Volume depletion
	Telangiectasias on lips, oral mucosa, fingertips	Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
	Other cutaneous lesions	Kaposi sarcoma (violaceous plaques), Peutz-Jeghers syndrome (melanocytic macules), neurofibromatosis (café au lait spots)
	Purpura, petechiae, spider angiomas, palmar erythema	Cirrhosis
Endocrine
	Gynecomastia or small testes	Cirrhosis

Causes

• Upper gastrointestinal tract bleeding
  • Peptic ulcer disease
    • Peptic ulcer disease is the most common cause of upper gastrointestinal tract bleeding (followed by erosive gastrointestinal bleeding and gastroesophageal varices)
  • Erosive gastritis or esophagitis 
  • Gastroesophageal varices
  • Gastric cancer
  • Esophageal cancer
  • Crohn disease
  • Mallory-Weiss tear
  • Angioectasias 
  • Vascular tumors 
    • Hemangiomas, angiosarcoma, or Kaposi sarcoma
• Oropharyngeal bleeding
  • Head and neck cancer
  • Large-volume epistaxis

Cause	Incidence (%)
Peptic ulcer disease	20-67
Erosive disease	4-31
Bleeding varices	4-20
Esophagitis	3-12
Mallory-Weiss tear	4-12
Malignancy	2-8
Vascular lesions	2-8
Esophageal ulcers	2-6
Idiopathic/unknown cause	3-19

Citation: From Tielleman T et al: Epidemiology and risk factors for upper gastrointestinal bleeding. Gastrointest Endosc Clin N Am. 25(3):415-28, 2015, Table 2.

Upper gastrointestinal tract bleeding
	Nose, pharynx, or lungs (swallowed)
	Esophagogastric mucosal tear (Mallory-Weiss tear)
	Esophageal rupture (Boerhaave syndrome)
	Erosions (eg, esophagitis, gastritis, duodenitis)
	Ulcer (eg, esophagus, stomach, duodenum, anastomosis)
	Dieulafoy lesion (ruptured mucosal artery)
	Angiomas
	Varices (eg, esophagus, stomach, duodenum)
	Neoplasm (eg, carcinoma, lymphoma, leiomyosarcoma, polyps)
	Hemobilia
	Vascular-enteric fistula (usually aortic aneurysm or graft)
“Middle” gastrointestinal tract bleeding
	Presents as either upper or lower GI bleeding
	Results from small-bowel lesions such as:
	• Tumors, Crohn disease, vascular-enteric fistulas
	• Ulcers (eg, esophagus, stomach, duodenum, anastomosis)

Citation: Data from Eastwood GL: Gastrointestinal bleeding. In: Mushlin SB et al, eds: Decision Making in Medicine: An Algorithmic Approach. 3rd ed. Mosby; 2010, Table 1.

Risk factors of Melena

Patients with history of earlier gastrointestinal bleeding are at greatest risk of future gastrointestinal bleeding (relative risk, 13.5) 

Underlying chronic and acute medical conditions and some medications (eg, NSAIDs, antiplatelet therapy, anticoagulants, systemic steroids) also increase risk for gastrointestinal bleeding

Other risk factors/associations 

• Medical history of predisposing conditions:
  • Portal hypertension
  • Cirrhosis
  • Helicobacter pylori infection 
  • Gastroesophageal reflux disease
  • Zollinger-Ellison syndrome
  • End-stage renal disease 
    • Risk is greater during first year of dialysis owing to platelet dysfunction and other coagulation abnormalities
  • Conditions associated with acquired angioectasias (eg, aortic stenosis with Heyde syndrome) or congenital angioectasias (eg, Peutz-Jeghers syndrome, hemorrhagic telangiectasia)
• Acute illness 
  • Shock
  • Respiratory failure
  • Thermal injury (causing Curling ulcer)
    • Gastric erosion due to ischemia and sloughing of gastric mucosa
  • Increased intracranial pressure (causing Cushing ulcers)
    • Gastric, duodenal, and/or esophageal ulcers due to overstimulation of vagus nerve leading to increased gastric acid secretion
      • Associated with gastric, duodenal, or esophageal ulcers
• Medications that predispose to upper gastrointestinal tract bleeding 
  • NSAIDs 
    • Synergistic risk when combined with other risk factors
    • Risk is higher when high-dose NSAIDs are used (relative risk, 5.8)
  • Antiplatelet medications (eg, aspirin, clopidogrel, glycoprotein IIb/IIIa inhibitors) 
  • Anticoagulants (eg, warfarin, direct oral anticoagulants, oral factor Xa inhibitors, heparin) (relative risk, 12.7) 
  • Corticosteroids (particularly in combination with NSAIDs) 
• Devices 
  • Mechanical ventilation
  • Renal replacement therapy
  • Extracorporeal life support
  • Left ventricular assist device 
• Behavioral risk factors
  • Alcohol use
  • Tobacco use

How is Melena diagnosed?

Diagnostic Procedures

Melena is a clinical diagnosis based on presence of black tarry stool on examination

Goal of diagnostic work-up is to estimate the extent of bleeding and to identify its source 

After diagnosis of melena, management should include laboratory studies, gastroenterology evaluation, and possibly, additional procedures and imaging 

• Laboratory evaluation 
  • Order basic laboratory tests for all patients, including CBC, basic metabolic panel, coagulation studies, and type and screen
• Gastroenterology evaluation
  • Should be performed for all patients
    • Upper endoscopy should be considered to determine cause of bleeding 
    • If upper endoscopy findings are negative, consider colonoscopy to evaluate for proximal colon bleeding, followed by capsule endoscopy or other modalities to evaluate small-bowel bleeding if source remains unclear
• Nasogastric lavage
  • Not routinely done, but may help to clear gastric blood for better endoscopic visualization
• Imaging
  • Generally not indicated in initial work-up but may be considered if upper endoscopy is not possible or if source of bleeding is not identified with endoscopy
  • Possible studies include:
    • CT enterography/angiography 
    • Technetium 99m–labeled RBC scan (no indication for this scan in acute work-up for melena 

• CBC 
  • Patients with melena are twice as likely to present with mild anemia (ie, hemoglobin level less than 10 g/dL) and significant anemia (ie, 8 g/dL or lower) compared with patients with bloody emesis (eg, coffee-ground emesis) 
  • Hemoglobin level less than 8 g/dL is associated with 3.8-fold increased mortality compared with a level greater than 10 g/dL
  • Initial hemoglobin/hematocrit may not accurately reflect acute blood loss
    • Normocytic anemia may indicate acute gastrointestinal bleeding
    • Microcytic anemia may indicate chronic gastrointestinal bleeding and/or iron deficiency anemia
  • Serial CBC should be monitored periodically in the inpatient setting
• Chemistry profile
  • Elevated BUN level is associated with absorption of blood products in small intestine
  • BUN/creatinine ratio more than 30 is associated with 7.5-fold increased likelihood of upper gastrointestinal tract bleeding 
  • BUN level of 8 to 24.9 is associated with 5.5-fold increase in fatality; BUN level of 25 or more is associated with 18-fold increase in fatality
• Type and screen
• Coagulation panel (prothrombin time with INR, partial thromboplastin time)

• CT enterography/angiography 
  • May be considered if upper endoscopy is not possible or if source of bleeding is not identified with endoscopy 
    • Hemodynamic status must be stable 
  • May be indicated if bleeding of small bowel is suspected
• No indication for technetium 99m–labeled RBC scan in acute work-up for melena 

Procedures

Nasogastric or orogastric aspiration or lavage

General explanation

• Historically has been used to localize bleeding to upper gastrointestinal tract 

Indication

• Not routinely indicated in acute upper gastrointestinal tract bleeding 
• May help to clear gastric blood for better endoscopic visualization

Complications

• Traumatic abrasions to oropharynx/esophagus, epistaxis, displacement of tube into lungs

Interpretation of results

• Aspiration of blood or coffee-ground emesis for localizing source of upper gastrointestinal tract bleeding has low sensitivity (44%; 95% confidence interval, 39-48) but high specificity (95%; 95% confidence interval, 90-98) 
  • False-positives may occur owing to trauma from tube insertion
• Nasogastric lavage with blood or coffee-ground emesis is associated with 9.6-fold increased likelihood of upper (versus lower) gastrointestinal tract bleeding 

Upper endoscopy

General explanation

• Direct visualization of upper gastrointestinal tract using video gastroscope
• Primary diagnostic and therapeutic procedure for evaluation and management of upper gastrointestinal tract bleeding
• Goal is to identify (and potentially treat) source of bleeding 
• Should be performed in first 24 hours for nonvariceal upper gastrointestinal tract bleeding and within 12 hours for suspected variceal bleeding

Indication

• Evidence of upper gastrointestinal tract being the source of bleeding (eg, melena, hematemesis)

Contraindications

• Relative contraindications include hemodynamic instability and unstable comorbid conditions 
• Risk-benefit profile of procedure should guide medical decision making for each patient and clinical scenario

Complications

• Perforation
• Bleeding
• Adverse reaction to anesthesia

Differential Diagnosis

Most common

Evaluation and diagnosis of melena require consideration of other sources of blood in the gastrointestinal tract (ie, oropharyngeal sources) and common melena mimics

Category	Examples
Mimics for hematemesis	Nosebleeds, tonsillar bleeding, red drinks and food
Mimics for melena	Iron supplements, bismuth medications (eg, Pepto-Bismol)
Mimics for bright red blood	Red food, vaginal bleeding, gross hematuria
False-positive fecal occult blood test	Red meat, turnips, horseradish, vitamin C

Citation: Data from Meltzer AC et al: Upper gastrointestinal bleeding: patient presentation, risk stratification, and early management. Gastroenterol Clin North Am. 43(4):665-75, 2014, Table 1.

How is Melena treated?

Treatment Goals

• Stabilize hemodynamic status and oxygenation
• Control bleeding

Management can occur in outpatient setting, general inpatient wards, or ICU, depending on severity of bleeding and risk assessment

Admission criteria

Glasgow Blatchford score should be used for risk assessment for patients with upper gastrointestinal tract bleeding 

• Online calculator is available 
• Scores of 1 or lower have very low risk for rebleeding and may not require hospitalization
  • Patient preferences/access to care should be considered in admission decision 
• Score greater than 1 shows high risk for requiring endoscopic intervention, transfusion, or surgery, and patient should be hospitalized

Admission risk marker	Score component value
Blood urea (mmol/L)
6.5 or more but less than 8	2
8 or more but less than 10	3
10 or more but less than 25	4
25 or more	6
Hemoglobin (g/dL) for men
12 or more but less than 13	1
10 or more but less than 12	3
Less than 10	6
Hemoglobin (g/dL) for women
10 or more but less than 12	1
Less than 10	6
Systolic blood pressure (mm Hg)
100-109	1
90-99	2
Less than 90	3
Other markers
Pulse 100 or more (beats per minute)	1
Presentation with melena	1
Presentation with syncope	2
Hepatic disease	2
Cardiac failure	2

Citation: From Blatchford O et al: A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 356(9238):1318-21, 2000, Table 1.

Criteria for ICU admission 

• Signs of active, persistent bleeding (eg, recurrent melena, bloody gastric lavage, persistent bloody emesis)
• Tachycardia or hypotension (hemodynamic status is at risk of deterioration)
• Unstable, serious comorbid conditions
• Glasgow Blatchford score of 8 or more

Recommendations for specialist referral

• Refer all patients with melena to gastroenterologist for consideration of endoscopic evaluation

Treatment Options

Treatment of melena is based on (1) severity of bleed and (2) underlying cause, with respect to presence or absence of esophageal varices

Urgent action should be taken to stabilize hemodynamic status and oxygenation and to control bleeding

• Establish IV access with 2 large-bore catheters to provide hemodynamic support with crystalloid IV fluids while patient undergoes assessment of need for transfusion of blood products 
• ICU transfer should be initiated for patients with significant upper gastrointestinal tract bleeding, altered mental status, and hemodynamic instability

Medical therapy to control bleeding should be chosen according to suspected underlying cause, with respect to presence or absence of esophageal varices

Suspected variceal bleeding 

• Pre-endoscopic medical therapy 
  • Initiate IV vasoactive medications, such as a somatostatin analogue (octreotide) or vasopressin, as soon as variceal bleeding is suspected 
    • Induces splanchnic artery vasoconstriction
    • Use of vasopressin or octreotide reduces 7-day mortality and transfusion requirements, according to data from a meta-analysis of 30 randomized controlled trials 
  • Initiate short-term empiric IV antibiotics for patients with cirrhosis as prophylaxis against spontaneous bacterial peritonitis 
    • Ceftriaxone reduces risks of infection, rebleeding, and mortality 

Suspected nonvariceal bleeding

• Pre-endoscopic medical therapy 
  • Consider proton pump inhibitor (grade 1B recommendation per international clinical practice guidelines) 
    • May reduce severity of lesions with high-risk stigmata (ie, lesions with active bleeding or visible vessel in ulcer bed) 
    • Not associated with decreased risk of rebleeding, surgical intervention, or mortality
    • Use of proton pump inhibitor should not delay endoscopy
  • H₂ receptor antagonists are not recommended, because they are not associated with improved outcomes in acute upper gastrointestinal tract bleeding 
  • Avoid routine use of promotility agents (eg, erythromycin) 
    • May be useful for select patients in whom there is suspicion of large quantities of blood in stomach 

Drug therapy

• Suspected variceal bleeding
  • Initiate IV somatostatin analogue (octreotide) or vasopressin as soon as variceal bleed is suspected 
    • Somatostatin analogue
      • Octreotide Acetate Solution for injection; Adults: 50 mcg IV followed by 50 mcg/hour continuous IV infusion for 2 to 5 days. May repeat bolus dose in first hour if ongoing bleeding.
    • Antidiuretic hormone analogue
      • Vasopressin Solution for injection; Adults: 0.2 to 0.4 units/minute continuous IV infusion for 24 hours. May increase up to 0.8 units/minute.
  • Ceftriaxone reduces risks of infection, rebleeding, and mortality
    • Ceftriaxone Sodium Solution for injection; Adults: 1 g IV every 12 to 24 hours for 2 to 7 days beginning immediately after endoscopy has been studied and may be more effective than norfloxacin.
• Suspected nonvariceal bleeding
  • Proton pump inhibitor may reduce severity of lesions with high-risk stigmata (ie, lesions with active bleeding or visible vessel in ulcer bed)
    • Pantoprazole Sodium Solution for injection; Adults: 80 mg IV bolus infusion over 30 minutes, followed by 8 mg/hour IV continuous infusion for 72 hours is recommended after successful endoscopic hemostasis in patients with active bleeding, a non-bleeding visible vessel, or an adherent clot. Patients with flat pigmented spots or clean bases upon endoscopy can receive a standard oral PPI once daily. Consider pre-endoscopic IV PPI therapy to downstage the lesion. If endoscopic therapy is to be delayed or cannot be performed, use IV PPI. Patients with an underlying etiology (e.g., peptic ulcers, erosions) should be discharged on standard PPI therapy PO once daily; otherwise, discontinue the PPI before discharge.

Nondrug and supportive care

Obtain ICU evaluation for patients with significant upper gastrointestinal tract bleeding, altered mental status, and hemodynamic instability 

Secure airway with endotracheal intubation for patients with significant hematemesis and altered mental status

Provide aggressive hemodynamic support with IV fluids while patient undergoes assessment of need for transfusion of blood products 

• Insert 2 large-bore IV catheters or central venous access if needed
• Crystalloid fluids are recommended over colloid owing to similar outcomes and lower cost of crystalloid, according to international clinical practice guidelines 
• Blood pressure, pulse, and oxygen saturation should be monitored regularly

Hold antiplatelet and anticoagulant medications during initial evaluation and work-up

Order NPO status during work-up

Transfusion of blood products

• Packed RBC transfusion
  • Use restrictive transfusion threshold (hemoglobin level of 7-8 g/dL) for patients without underlying cardiovascular disease 
    • Associated with mortality benefit compared with liberal transfusion threshold (9 g/dL) and recommended broadly across clinical practice guidelines 
  • Higher transfusion threshold is recommended for patients with cardiovascular disease 
  • Transfusion thresholds do not apply to patients who are actively exsanguinating

Platelet transfusion

• Consider platelet transfusion for platelet count less than 50,000 cells/mm³ (based on expert consensus) 
• No indication for platelet transfusion for patients who take antiplatelet medications 

Reversal of anticoagulation and coagulopathy

• Coagulopathy should be corrected for patients with severe or life-threatening bleeding who are receiving anticoagulants, but endoscopy should not be delayed 
  • Reversal strategy depends on category of anticoagulant and severity of bleeding; it may include fresh frozen plasma, prothrombin complex concentrate, vitamin K, protamine, or reversal agents for a specific direct oral anticoagulant (Related: Long-term anticoagulation)
  • International consensus guidelines do not specify threshold for INR correction 
  • Endoscopy can be safely performed among those with partial correction of INR without increased rate of rebleeding 
• INR correction is not recommended for patients with cirrhosis who present with elevated INR 
  • INR is not a reliable indicator of coagulation status in cirrhosis

Procedures

Upper endoscopy

General explanation

• Goals is to identify and definitively treat source of bleeding
  • Perform in first 24 hours for nonvariceal upper gastrointestinal tract bleeding and within 12 hours for suspected variceal bleeding 

Indication

• Active upper gastrointestinal tract bleeding due to:
  • Gastroesophageal varices
    • Endoscopic band ligation is recommended for esophageal varices 
    • If banding is not possible, may consider injection sclerotherapy with ethanolamine 
  • Nonvariceal cause
    • Injection of epinephrine to control bleeding plus definitive treatment with clips, argon plasma coagulation, or bipolar cautery 

Contraindications

• Relative contraindications include hemodynamic instability and unstable comorbid conditions 
• Risk-benefit profile of procedure should guide medical decision making for each patient and clinical scenario

Complications

• Perforation
• Bleeding
• Adverse reaction to anesthesia

Monitoring

• Depending on severity of bleeding and risk assessment, management can occur in outpatient setting, general inpatient wards, or ICU
• Blood pressure, pulse, and oxygen saturation should be monitored regularly
• Serial CBC should be monitored periodically
• Patients should be risk stratified using the Glasgow Blatchford score to determine acuity based on recommendations from multiple international clinical practice guidelines 
  • Scores of 1 or lower have very low risk for rebleeding and may not require hospitalization
  • Score greater than 1 should prompt hospitalization
  • Score greater than 8 should prompt ICU evaluation/admission, as should serious unstable comorbid conditions, signs of active and persistent bleeding (eg, recurrent melena, bloody gastric lavage, persistent bloody emesis), and hemodynamic instability

Prognosis of Melena

• Prognosis of melena varies by cause (ie, by underlying condition)
• 30-day mortality for melena alone is estimated at 5.5% based on observational data 
• 30-day mortality for melena with gross hematemesis is estimated at 9.9% 
• Nonvariceal upper gastrointestinal tract bleeds carry 10% to 14% annual mortality 
• Variceal bleeds carry higher mortality rates 
  • 20% 5-year mortality when associated with cirrhosis
  • 80% 5-year mortality when associated with other causes of portal hypertension

Sources

Gaiani F et al: Clinical approach to the patient with acute gastrointestinal bleeding. Acta Biomed. 89(8-S):12-9, 2018 Reference