Melena refers to black tarry stools, which usually occurs as a result of upper gastrointestinal bleeding.
It has a characteristic tarry colour and offensive smell, and is often difficult to flush away, which is due to the alteration and degradation of blood by intestinal enzymes.
In this article, we shall look at the differential diagnosis, clinical features and investigations for melena.
Melena usually occurs as a result of an upper gastrointestinal bleed (rarely it can be due to bleeding in the small intestine or right colon).
Upper GI haemorrhage has a number of causes, the most common of which are peptic ulcer disease, liver disease, and gastric cancer.
Peptic Ulcer Disease
Peptic ulcer disease is the most common cause of melena, and should be suspected in those with:
- Known active peptic ulcer disease
- History of NSAID or steroid use
- Previous epigastric symptoms suggestive of ulceration
- H. Pylori positive
Classically, the most significant bleeding will occur if an ulcer erodes through the posterior gastric wall into the gastroduodenal artery. However, in reality, extensive bleeding can occur with the erosion of any blood vessel.
Oesophageal varices refer to dilations of the porto-systemic anastomoses in the oesophagus. They most commonly occur due to portal hypertension secondary to liver cirrhosis and are very prone to rupture.
The most common underlying cause for oesophageal varices is alcoholic liver disease. Any significant melena in a patient with a known history of alcohol abuse should be investigated as urgently as possible for potential variceal bleeding.
Upper GI Malignancy
Ulcerating oesophageal or gastric malignancies (Fig. 2) can first present with melena, causing a gradual flow of blood that may present prior to any other cancer-associated symptoms.
In the assessment of any patient with melena, it is important to enquire about other upper GI symptoms, weight loss, or relevant family history, potentially suggestive a diagnosis of malignancy.
Other less common causes of melena include gastritis or oesophagitis, Mallory–Weiss tear, Meckel’s diverticulum, or vascular malformations (e.g. Dieulafoy lesion).
The key facts to ascertain from a history of melena are:
- Colour and texture of the stool– jet black, tar-like, and sticky.
- Associated symptoms – including haematemesis, abdominal pain, or a history of dyspepsia, dysphasia or odynophagia.
- Past medical history – including smoking and alcohol status, and inflammatory bowel disease.
- Drug history– use of steroids, NSAIDs, anticoagulants, or iron tablets.
A PR exam is essential to confirm the melena, as well as a full abdominal examination to assess for epigastric tenderness or peritonism, hepatomegaly, and for any stigmata of liver disease.
Investigations should be tailored to the specific presentation, but a generic outline would involve a structured approach as below:
Routine bloods (FBC, U&Es, LFTs, and clotting):
- Check for any drop in Hb, however remember that an acute bleed may not initially show with an anaemia
- Liver function tests may reveal underlying liver damage as a potential cause.
- Any drop in haemoglobin and rise in the urea:creatinine ratio* is very indicative of an upper GI bleed.
- All patients with melena should have a Group and Save requested; those with significant melena (especially suspected variceal bleed) should have at least 4 units of blood cross-matched.
Arterial blood gas:
- Useful in bleeding or septic patients, especially for the pH, pO2, and lactate, for signs of tissue hypoperfusion.
- The definitive investigation in most cases of melena. It also forms part of the management in cases of ongoing unstable bleeding; occasionally colonoscopy or capsular endoscopy may be required to determine the site of bleeding.
*Digested haemoglobin produces urea as a by-product and is readily absorbed by the intestine; an elevated serum urea to creatinine ratio (>30:1) suggests an upper GI source of bleeding
CT abdomen with IV contrast (triple phase) can be useful in assessing any active bleeding, especially if endoscopy is unremarkable or the patient is too unwell to undergo invasive investigation.
RBC Scintigraphy is a sensitive test that can be used to identify active bleeding, however is currently only used routinely in select centres
In any critically unwell patient, an A to E approach should be used to stabilise the patient before considering definitive management steps.
Once the patient is stable (or initial resuscitation attempts have proved ineffective and more invasive management for resuscitation is required), an endoscopy should be arranged.
During the OGD, a range of therapeutic options are available, depending on the underlying cause:
- Peptic ulcer disease – requires injections of adrenaline and cauterisation of the bleeding. High dose intravenous PPI therapy should be administered (e.g. IV 40mg omeprazole) to control the acidic environment
Oesophageal varices – management should be swift and performed at the same time as active resuscitation, including the use of blood products.
- Endoscopic banding is the most definitive method of management but can be technically difficult (Fig. 3)
- Prophylactic antibiotic therapy should be initiated, alongside somatostatin analogues (e.g. terlipressin or octreotide), acting to reduce splanchnic blood flow and hence reduce bleeding
- A Sengstaken-Blakemore tube can be used in severe or uncontrollable cases, inserted to the level of the varices and inflated to compress the bleeding to act as a temporary control
- Upper GI malignancies– will require biopsies to be taken and a definitive long-term surgical and oncological management to be put in place
Blood transfusions should be given to those with low Hb or ongoing significant blood loss. Correct any deranged coagulation as appropriate, such as use of appropriate reversal agents if the patient is on any anti-coagulants or use of FFP for impaired liver function.
- Peptic ulcer disease, oesophageal varices, and malignancy are the most common causes of melena
- Urgent resuscitation is the mainstay of initial treatment for any cases of melena
- Any drop in haemoglobin and rise in the urea:creatinine ratio is very indicative of an upper GI bleed
- Definitive investigation in most cases of melena is via OGD