Approach to melena and hematemesis: Clinical sciences

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Introduction0:00–1:12

Melena, or stool containing partly broken down blood, and hematemesis, or vomit containing blood, are most commonly seen in patients who present with acute upper gastrointestinal bleeding, which is typically defined as the gastrointestinal portion that’s proximal to the ligament of Treitz.
It’s important to keep in mind that melena may sometimes be caused by slow bleeds from the lower gastrointestinal tract.
Melena presents as black or tarry stools and can be seen in variable amounts of blood loss. On the other hand, hematemesis can present as frank, bright red bloody emesis suggesting a recent or ongoing bleed that might be moderate to severe; or coffee-ground emesis, which suggests that the bleeding is limited or the blood is older.
The presentation of emesis can help you start localizing the bleed, since coffee-ground emesis usually develops when blood comes in contact with gastric acid, such as a peptic ulcer; while bright red blood can indicate either a brisk bleed or that the blood didn’t come in contact with gastric acid, such as an epistaxis draining posteriorly, oropharyngeal or esophageal bleeds.When assessing a patient with melena or hematemesis, you should first perform an ABCDE assessment to determine whether your patient is unstable or stable.

Unstable patient1:12–2:26

If the patient is unstable, first stabilize the airway, breathing, and circulation. You might need to intubate the patient to protect the airway.
Next, obtain IV access and start IV fluids. Additionally, patients who are acutely hemorrhaging might require blood product transfusions.
Finally, put your patient on continuous vital sign monitoring, including pulse oximetry, blood pressure, and heart rate.Once these important steps are done, you can move on to obtaining a focused history and physical exam, as well as labs like CBC and CMP.
History might reveal massive hemorrhage, or lesser but brisk bleeding. On the flip side, the physical exam might show signs of hemodynamic instability, like hypotension and tachycardia.
As a result of severe blood loss and contraction, initial labs may show decreased hemoglobin along with elevated BUN to creatinine ratio.
Now, since these patients are acutely bleeding, the next step is an emergent upper endoscopy to locate and identify the source of bleeding.
Alright, let’s talk about some important causes of acute bleeding. First up, there are aortoenteric fistulas, which are rare, but very dangerous.

Aortoenteric fistula2:26–3:16

An aortoenteric fistula is a connection between the GI tract and the aorta. A patient might present with an initial, smaller, "herald bleed" manifested by hematemesis.
The smaller bleed is then followed by massive bleeding and exsanguination, which might occur soon after it, or might even occur up to several weeks later.
On a physical exam, you might feel a pulsatile abdominal mass or hear an abdominal bruit. Finally, endoscopy usually reveals an ulcer or erosion at the site of bleeding or an extrinsic pulsatile mass.
So, if you see these findings, you can diagnose an aortoenteric fistula.Next cause of bleeding is called Mallory-Weiss tear, which is a tear in the distal esophagus or upper part of the stomach.

Mallory-Weiss tear3:16–3:40

These patients typically report severe epigastric or back pain and have a history of vomiting or retching. The endoscopy is very important here.
So, if it shows a gastroesophageal mucosal laceration, you can diagnose a Mallory-Weiss Tear.Let’s switch gears and talk about other types of vascular lesions, including angiodysplasia, vascular ectasia, and Dieulafoy's lesion.

Vascular lesions3:40–4:26

Now, in this case, your patient might tell you that they have noticed new cutaneous lesions. Additionally, a physical exam might reveal signs of these lesions such as venous malformations, cutaneous hemangiomas, or occasionally telangiectasias.
Once again, endoscopy will help you make the final diagnosis. On endoscopy, you might find small ectatic vessels in the vascular ectasia, cherry-red spots in the angiodysplasia, or an ulcer with raised vessels in Dieulafoy's lesion.
So, if you see any of these, you can diagnose vascular lesions as a cause of GI bleeding.The final cause of severe upper gastrointestinal bleeding are gastroesophageal varices.
These patients might have a history of hepatic conditions like cirrhosis. Additionally, the physical exam usually shows signs of chronic liver disease such as jaundice, splenomegaly, or ascites.

Gastroesophageal varices4:26–4:56

However, endoscopy is crucial in making a diagnosis. If you see swollen, enlarged veins within the esophageal or gastric lumen, you can diagnose gastroesophageal varices.Now that unstable patients are diagnosed, let's switch gears and talk about stable patients.
The first step when approaching a stable patient with melena or hematemesis is to obtain a focused history and physical examination.

Stable patient4:56–5:25

This will help you assess other causes of active bleeding or limited bleeding. In addition, keep in mind that these patients will likely require upper endoscopy, but this can be done non-emergently as long as they remain stable.First, let's talk about gastric or duodenal ulcers, which are one of the most common sources of upper gastrointestinal bleeding.
Your patient might report upper abdominal pain, pain with eating, or dyspepsia. They might also have a history of NSAID use or anemia, or have a positive fecal occult blood test requiring further workup.

Gastric or duodenal ulcer5:25–6:07

If this is the case, you should consider a gastric or duodenal ulcer and proceed with upper endoscopy as your next step.
On endoscopy, you will typically see ulcers with smooth, regular, or rounded edges, which may be filled with exudate. With these endoscopy findings, the diagnosis of gastric or duodenal ulcer can be made.The next most common source of bleeding is esophagitis.
Patients with esophagitis usually report dysphagia, retrosternal pain, or sometimes food impaction. They may also have a history of gastroesophageal reflux disease or even anemia.

Esophagitis6:07–6:56

Just like before, these patients may come with a positive fecal occult blood test requiring further workup. If you see these findings, consider esophagitis as the most likely source of bleeding and order upper endoscopy to confirm the diagnosis.
Now, endoscopy usually shows signs of erythema of the esophageal mucosa, mucosal breaks and erosions, and exudative lesions.
You might also see new superficial or deep ulcers, or find stenosis and scarring from old or chronic lesions. These findings are enough to diagnose esophagitis.Next, let's talk about gastritis and gastropathy or duodenitis and duodenopathy.
These patients usually have a history of dyspepsia and anemia. They might also present with a positive fecal occult blood test.

Gastritis/gastropathy or duodenitis/duodenopathy6:56–8:12

This combination in the absence of other symptoms might suggest gastritis and gastropathy or duodenitis and duodenopathy.
Your next step would be to perform an upper endoscopy. Endoscopy typically shows erythematous mucosa, superficial erosions, or mucosal nodularity with possible diffuse oozing.
If this is the case, you can make a diagnosis of gastritis and gastropathy or duodenitis and duodenopathy.Alright, let’s move on to a final cause of limited upper gastrointestinal bleeding, which are GI tumors.
Patients with GI tumors usually present with anorexia, weight loss, anemia, or a positive fecal occult blood test. If you see these signs, consider a possible GI tumor and order an upper endoscopy with a biopsy.
Now, if there is a tumor, you’ll be able to see it on endoscopy as an ulcerated mass in the esophagus, stomach, or duodenum.
These findings aren’t actually enough to diagnose the condition, so you’ll need a positive biopsy to confirm the diagnosis of an upper GI tumor.Alright, as a quick recap… Patients with melena or hematemesis might be unstable or stable.
Unstable patients often have massive bleeding and may be exsanguinating. You should first stabilize the patient and then identify the source of the bleeding by performing an emergency upper endoscopy.

Review8:12–8:51

For massive bleeding, your patient may have an aortoenteric fistula, a Mallory-Weiss tear, a vascular lesion, or gastroesophageal varices.On the other hand, stable patients with signs and symptoms of GI bleeding should be evaluated for active bleeding or limited bleeding with an upper GI endoscopy.
In this case, the patient might have a gastric or duodenal ulcer, esophagitis, gastritis or gastropathy; duodenitis or duodenopathy; or an upper