Melaena

Question 1

What is malaena?

Answer 1

The passage of tarry, shiny black stools with a characteristic odour.

Question 2

What causes malaena?

Answer 2

Upper gastrointestinal bleeding (UGIB)

Question 3

Give examples of other causes of matt black stools

Answer 3

• Oral iron
• Bismuth therapy

Question 4

Give examples of causes of upper gastrointestinal bleeding (UGIB)

Answer 4

• Peptic ulceration
• Erosive gastritis
• Mallory-Weiss tear
• Oesophagogastric varices

Question 5

What scoring systems are used to assess the risk of GI bleeding?

Answer 5

• Rockall score
• Blatchford score

Question 6

Briefly describe the Rockall score used to assess risk of GI bleeding

Answer 6

http://www.gastrotraining.com/calculators/rockall-score

Question 7

Briefly describe Blatchford score used to assess risk of GI bleeding

Answer 7

http://www.gastrotraining.com/calculators/glasgow-blatchford-score

Question 8

What investigations should be ordered for malena?

Answer 8

• Routine bloods:
  
  • FBC
  • U&Es
  • LFTs
  • Clotting profile
• ABG
• Oesophagogastroduodenoscopy (OGD)
• CT abdomen with IV contrast

Question 9

Briefly describe the treatment of malaena

Answer 9

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.

Question 10

Briefly describe the treatment of peptic ulcer disease

Answer 10

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.

Question 11

Briefly describe the treatment of oesophageal varices

Answer 11

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
• 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

Question 12

Briefly describe the treatment of upper GI malignancies

Answer 12

Will require biopsies to be taken and a definitive long-term surgical and oncological management to be put in place.