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ElisaMäkäräinen

Haematemesis and Melaena

Essentials

  • Patients continuing to bleed and requiring emergency investigations, and patients who can safely be discharged should be recognized.
  • If the patient continues to bleed, treatment should already be started in the referring unit.

Aetiology

  • The most common causes of haematemesis and melaena are gastric and duodenal ulcers and, in patients with cirrhosis, variceal bleeding. See table T1.
  • Nevertheless, melaena may be due to bleeding in any part of the gastrointestinal tract.

Causes and treatment of haematemesis and melaena

Aetiology of bleedingTreatmentFollow-up examinationsNotes
TumoursProton pump inhibitorArrange further treatment
OesophagitisProton pump inhibitor for 6-8 weeksFollow-up endoscopy after 2-3 months
Oesophageal varicesLigation of blood vessel trunks Band Ligation for Primary Prevention of Upper Gastrointestinal Bleeding in Adults with Cirrhosis and Oesophageal Varices
Medication to lower portal pressure
In case of emergency, Sengstake-Blakemoore tube or stent to control bleeding		Follow-up endoscopy and religation as necessary after 6-8 weeksConsider transjugular intrahepatic portosystemic shunt (TIPS).
For use at home, medication to lower portal pressure such as carvedilol
Mallory-Weiss tearUsually self-limiting
Proton pump inhibitor for 2-6 weeks		No need for follow-up endoscopy
Gastric ulcerGastroscopic treatment of bleeding and prevention of recurrent bleeding as necessary
Proton pump inhibitor for 6-8 weeks		Follow-up endoscopy after 6-8 weeksNote the treatment of Helicobacter and either withdraw NSAIDs or combine them with permanent acid blocker treatment
Duodenal ulcerGastroscopic treatment of bleeding and prevention of recurrent bleeding as necessary
Proton pump inhibitor		No need for follow-up endoscopyNote the treatment of Helicobacter and either withdraw NSAIDs or combine them with permanent acid blocker treatment

History and examination

  • Melaena means thick, dark faeces suggesting bleeding primarily in the upper gastrointestinal tract. However, faeces resembling melaena may also be due to bleeding elsewhere in the gastrointestinal tract.
  • Bright red bleeding primarily suggests bleeding in the lower gastrointestinal tract.
  • Issues to examine
    • Use of analgesics and glucocorticoids (gastric ulcers and erosion)
    • Drug treatment affecting coagulation, and any haemorrhagic diseases
    • History of bleeding in the gastrointestinal tract or abdominal surgery
    • Alcohol consumption, and the possibility of liver cirrhosis
    • Smoking
    • Any underlying diseases, particularly cardiovascular diseases
    • Assessment of the bleeding volume
      • Blood clots in vomit, vomit resembling dark coffee grounds, or blood streaks towards the end of vomiting
      • Amount of melaena, any blood clots
  • Clinical examination should aim at determining the severity of bleeding. High-risk bleeding is suggested by
    • sudden onset
    • low blood pressure, tachycardia
    • low blood haemoglobin concentration
    • age over 65 years
    • associated diseases, such as heart failure or liver cirrhosis
    • profuse vomiting of fresh blood or detection of red blood in digital rectal examination.
  • Various scales or scores such as the Glasgow-Blatchford Bleeding Score (GBS) http://www.mdcalc.com/calc/518/glasgow-blatchford-bleeding-score-gbs can be used to assess the severity of bleeding.
    • Patients with low-risk scores can probably be discharged to wait for further investigations.
  • Patient in a haemorrhagic shock is pale with cold sweats, the pulse is rapid and the blood pressure is low.
  • Rectal examination is mandatory in every patient with haematemesis. Melaena (dark, tarry faeces) indicates that the patient has had the bleeding already for at least some hours. Normal colour of the faeces does not rule out bleeding. In extremely severe upper gastrointestinal bleeding, the faeces can be clearly bloody (haematochezia).
  • In case of slower bleeding or if the diagnosis is uncertain, it is useful to determine the blood haemoglobin concentration. Haemoglobin < 100 g/l usually means an increased risk, but the patient may have a low haemoglobin concentration without shock, if the bleeding has been slow (lasting for several days). However, even quite heavy bleeding causes only a slight decrease in the haemoglobin concentration at first.

Initial treatment

  • In severe, continuous bleeding, the treatment must be started immediately and the patient must be transported to a surgical unit for any emergency procedures that are required.
  • Intravenous access should be established.
  • In a stable patient with no heart disease, the haemoglobin threshold for blood transfusion is 70 g/l. If the patient is unstable, which suggests continuous bleeding, or if they have a chronic heart disease, the haemoglobin threshold for blood transfusion is 80 g/l.
  • Tranexamic acid is not recommended for gastrointestinal tract bleeding.
  • High-dose proton pump inhibitor therapy can be started for mere suspicion of bleeding.
    • For example, 80 mg pantoprazole i.v., continued with an infusion of 8 mg/h
  • If bleeding from oesophageal varices is suspected, medication lowering portal pressure can be started, such as

Follow-up treatment

  • In hospital, gastroscopy should be arranged within 24 hours for patients who have had melaena. If bleeding from oesophageal varices is suspected, gastroscopy should be performed within 12 hours.
  • If samples taken during gastroscopy are negative for Helicobacter, further testing for it using a faecal sample, for example, is advisable.
  • If the patient is on any medication affecting coagulation, permanent treatment with a proton pump inhibitor should be considered.
  • Transjugular intrahepatic portosystemic shunt (TIPS) should be considered for patients with liver cirrhosis and a high risk of recurrent bleeding, regardless of whether the treatment of variceal bleeding was successful or unsuccessful.
  • For patients with liver cirrhosis and bleeding after variceal bleeding, carvedilol or propranolol should be started to lower portal pressure; repeat ligation of varices should be performed as necessary.
  • If the cause of melaena cannot be reliably confirmed by gastroscopy, colonoscopy should be arranged either during in-hospital treatment or otherwise urgently.
  • Resuming the patient's own anticoagulant treatment depends on the aetiology and severity of bleeding, indications for anticoagulant treatment and patient-specific factors.

    References

    • Gralnek IM, Camus Duboc M, Garcia-Pagan JC, et al. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022;54(11):1094-1120 [PubMed]
    • Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021;53(3):300-332 [PubMed]
    • Laine L, Barkun AN, Saltzman JR, et al. Correction to: ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol 2021;116(11):2309 [PubMed]
    • Barkun AN, Almadi M, Kuipers EJ, et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med 2019;171(11):805-822 [PubMed]