Makindo Medical Notes

💡 Melaena is the passage of black, tarry, foul-smelling stools due to digested blood from the upper gastrointestinal (GI) tract. It usually indicates bleeding proximal to the ligament of Treitz (oesophagus, stomach, duodenum). Melaena is a red flag sign of potentially life-threatening haemorrhage requiring urgent evaluation and management.

📖 Clinical History

• Onset & duration: When did the black stools begin? Intermittent or continuous?
• Associated symptoms: Abdominal pain (ulcer, gastritis), haematemesis (proximal source), weight loss (malignancy), dyspepsia, alcohol excess (varices), vomiting/retching (Mallory–Weiss).
• Risk factors: NSAID/aspirin use, anticoagulants, liver disease, H. pylori infection, previous GI bleeds.
• Systemic features: Fatigue, dyspnoea, dizziness, syncope (anaemia or shock).
• Red flags: Past history of cirrhosis, cancer, unexplained weight loss, or recurrent bleeds.

🩺 Clinical Examination

• General: Pallor, tachycardia, postural hypotension, signs of shock.
• Abdominal: Tenderness, organomegaly (hepatomegaly in cirrhosis), ascites.
• Rectal exam: Confirm melaena (black, tarry, malodorous stool vs iron supplements/food staining).
• Signs of chronic disease: Stigmata of liver disease (spider naevi, palmar erythema, jaundice), cachexia (malignancy).

🔬 Investigations

• Bloods:
  • FBC → anaemia, Hb drop
  • U&E → raised urea (digested blood), renal perfusion
  • Coagulation profile → INR/PT, APTT
  • LFTs → cirrhosis, varices
  • Crossmatch → prepare blood for transfusion
• Endoscopy: Gold standard — diagnostic & therapeutic (clips, adrenaline, banding).
• Imaging: CT angiography if endoscopy inconclusive or bleeding persists.
• Other: Helicobacter pylori testing (if ulcer suspected).

📊 Causes of Melaena

• 🌋 Peptic Ulcer Disease (H. pylori, NSAIDs)
• 🔥 Gastritis (alcohol, drugs, stress-related)
• 🩸 Oesophageal Varices (portal hypertension, cirrhosis)
• ⚡ Mallory–Weiss tear (forceful vomiting/retching)
• 🎗️ Malignancy (gastric/oesophageal cancers)
• 🧬 Vascular lesions (angiodysplasia, Dieulafoy lesion)
• Rare: Severe reflux oesophagitis, post-procedural bleeding

💉 Management

• Immediate resuscitation:
  • 2 large-bore IV cannulae
  • Fluid resuscitation (crystalloids)
  • Blood transfusion (target Hb >7 g/dL, >9 in elderly/cardiac disease)
  • Oxygen, monitoring, catheterisation for urine output
• Medical therapy:
  • IV PPI (pantoprazole/omeprazole) → reduces rebleeding in ulcers
  • Octreotide/terlipressin in suspected variceal bleeding
  • Antibiotic prophylaxis (ceftriaxone) in cirrhotic patients
• Endoscopic haemostasis:
  • Ulcer → adrenaline injection, clips, thermal coagulation
  • Varices → band ligation, sclerotherapy
  • Mallory–Weiss → usually self-limiting, endoscopic therapy if active bleeding
• Refractory bleeding: Radiological embolisation, surgery (oversewing, partial gastrectomy, shunts in varices).
• Underlying cause treatment: H. pylori eradication, long-term PPI, avoidance of NSAIDs/alcohol, beta-blockers for variceal prevention.

⚠️ Complications

• Hypovolaemic shock
• Iron-deficiency anaemia
• Rebleeding
• Death (mortality up to 10–15% in acute variceal bleeding)

🧑‍⚕️ Case Examples

Case 1: 👨 A 54-year-old man with a history of heavy NSAID use for osteoarthritis presents with dizziness and black stools. Hb is 72 g/L, urea 14, creatinine normal. Endoscopy shows a bleeding duodenal ulcer. ✅ Managed with IV fluids, transfusion, IV PPI, and endoscopic adrenaline + clipping. H. pylori eradication therapy was started.

Case 2: 👩 A 60-year-old woman with cirrhosis due to alcohol misuse presents with melaena and haematemesis. She is hypotensive and tachycardic. Endoscopy reveals actively bleeding oesophageal varices. ✅ Managed with IV fluids, blood transfusion, octreotide infusion, ceftriaxone prophylaxis, and endoscopic band ligation. Later started on non-selective beta-blockers for secondary prevention.

📚 References

• NICE CG184: Acute Upper GI Bleeding in over 16s (2019)
• BSG Guidelines on Non-variceal Upper GI Bleeding (2021)
• Kumar & Clark’s Clinical Medicine, 10th Edition