Melena Flashcards

1
Q

What is melena?

A
  • Black, tarry stools often due to upper GI bleeding
  • Characteristic tarry colour and offensive smell, difficult to flush away
  • Stool consistency changes due to alteration and degredation of blood via intestinal enzymes
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2
Q

Causes of upper GI bleed

A
  • Peptic ulcer disease
  • Variceal bleeding
  • Malignancy
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3
Q

RF for peptic ulcer disease causing bleeding

A
  • Recent NSAID use
  • Steroid use
  • H-pylori infection
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4
Q

How does PUD cause melena?

A
  • Ulcer erodes through posterior gastric wall
  • Erodes gastroduodenal artery
  • = bleed
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5
Q

Variceal bleeding - how?

A
  • Portal HTN secondary to liver cirrhosis
  • = dilation of porto-systemic anastomosis within oesophagus
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6
Q

Most common cause of oesophageal varices bleeding

A
  • Alcoholic related liver disease
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7
Q

Other less common causes of melena

A
  • Gastritis
  • Oesophagitis
  • Meckels diverticulum
  • Small bowel tumout
  • Vascular malformations - angiodysplasia
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8
Q

History to ask for melena

A
  • Colour and texture of stool - jet black, tar like, sticky
  • Associated symptoms - haematemesis, abdominal pain, weight loss, dysphagia, dyspepsia
  • PMH - smoking and alcohol
  • DH - steroids, NSAIDs, anticoags, iron tablets
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9
Q

Examination for melena

A
  • DRE needed
  • Full abdominal exam - assess for peritonism, hepatomegaly, stigmata of chronic liver disease
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10
Q

Why to ask about iron tablets?

A
  • They can cause black stool
  • Clarify timing started and timing melena started
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11
Q

Bedside and bloods for melena presentation

A
  • FBC
  • U&E
  • LFT
  • Group and save
  • Crossmatch if drop in Hb/haemodynamically unstable
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12
Q

Characteristic blood results for upper GI bleed

A
  • Drop in Hb
  • Rise in urea:creatinine ratio
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13
Q

Imaging for melena

A
  • Gastroscopy - OGD - identify cause and allow for intervention
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14
Q

How is urgency of OGD for melena determined?

A
  • Glasglow blatchford bleeding score
  • Risk stratify patients based purely on clinical and biochemical parameters
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15
Q

Further investigations if OGD inconclusive

A
  • CT angiogram - assess for active bleeding, esp if ongoing +/- haemodynamic compromise
  • Colonoscopy - esp if haemodynamically unstable ensure cause is not proximal eg caecum tumour
  • IF STILL normal - capsule endoscopy or RBC scintigraphy (tag RBC with radioactive material)
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16
Q

Management melena - ALL causes

A
  • A-E assessment and manage accordingly
  • Blood products - if low Hb or haemodynamically unstable (urgent)
  • Correct deranged coagulation - FFP, platelets esp if impaired liver
  • Underlying cause
17
Q

Management of PUD causing melena

A
  • Injection of adreanline and cauterisation of bleeding during endoscopy
  • Then high dose PPI
18
Q

Management of varices causing melena

A
  • Urgent endoscopy - then endoscopic banding
  • Resuscitation using blood products
  • Prophylactic abx
  • Somatostatin analogues - eg terlipressin, ocreotide to reduce splanchnic blood flow
19
Q

What is endoscopic banding doesn’t work for variceal bleeding?

A
  • Sengstaken Blakemore tube can be used if severe or uncontrolled
  • = temporarily compress bleeding
20
Q

Management of upper GI malignancy cause of melena

A
  • Biopsies
  • Definitive surgical and oncological plan needed