Presentations - Melena & Rectal Bleeding

Question 1

What causes melena?

Answer 1

UGI bleeding

Due to degradation of blood by enzymes in GI tract

Question 2

What are the most common causes of melena?

Answer 2

Peptic ulcer disease
Variceal bleeds
UGI malignancy

Question 3

What is the most common artery affected in peptic ulcer disease?

Answer 3

Gastroduodenal artery

Question 4

What clinical features should you ask the patient about?

Answer 4

Colour and texture of the stool
- Dark black
- Tar
- Sticky

Associated symptoms
- Haematemesis
- Abdo pain
- Weight loss
- Dyspepsia

Clarify any iron tablets

Question 5

What examinations should be performed on a patient with melena?

Answer 5

DRE
Full abdominal examination

Question 6

What investigations are done in melena?

Answer 6

Initial
- Routine bloods - help identify underlying cause
- Drop in Hb and rise in urea:creatinine ratio - digested Hb produces urea which gets absorbed
- G&S

Further
- OGD, can identify cause or necessary interventions
- CT angiogram if OGD inconclusive
- Colonoscopy

Question 7

How is melena managed?

Answer 7

A-E
Blood products if unstable

Treat the underlying cause

Question 8

What is rectal bleeding also called?

Answer 8

Haematochezia

Question 9

What causes haematochezia?

Answer 9

Generally caused by LGI tract bleeding, can be caused by small bowel lesions

Question 10

What are the most common causes of haematochezia?

Answer 10

Diverticulosis
Haemorrhoids
Malignancy

Question 11

What key aspects of the history should be asked with PR bleeding?

Answer 11

Nature of bleeding
- Duration
- Frequency
- Colour
- Related to stool

Associated symptoms
- Pain
- Haematemesis
- Melena
- PR mucus
- Weight loss

Question 12

What examinations should be done in rectal bleeding?

Answer 12

Abdomen - localised tenderness or palpable masses
PR

Question 13

What is used to see if patients with LGI bleeds can be managed as an outpatient?

Answer 13

Oakland Score

Question 14

What investigations are done for rectal bleeding?

Answer 14

Routine bloods
G&S
Stool cultures - exclude infective causes

Haemodynamically unstable - resuscitate with blood, urgent CT angiogram

Question 15

What further investigations can be done for haematochezia?

Answer 15

Colonoscopy - exclude left colonic pathology

UGI endoscopy (OGD) if normal colonoscopy

Question 16

How is haematochezia managed?

Answer 16

95% of cases settle spontaneously

Unstable - urgent resuscitation

Reverse any anti-coagulation in unstable patients

Arterial embolisation - identified bleeding point

Question 17

What is the first-line investigation in a haemodynamically unstable patient with haematochezia?

Answer 17

CT angiogram