MELENA

Ask the Following Questions:

1. Is it true or false melena? False melena may be induced by iron ingestion, bismuth ingestion, charcoal ingestion, red wine ingestion, and many other substances.
2. Is there a history of alcohol or drug ingestion? It is surprising how often the ingestion of alcohol is overlooked. Aspirin, caffeine, anticoagulants, and reserpine are among the other drugs that may cause melena.
3. Is there associated hematemesis? The presence of hematemesis should prompt a search for esophageal varices, peptic ulcer, gastritis, and many other conditions. For a more thorough discussion of this topic, one is referred to the section on hematemesis ( page 206 ).
4. Is there abdominal pain? The presence of abdominal pain and heartburn should make one think of duodenal ulcer, esophagitis, gastritis, gastric ulcer, mesenteric embolism or thrombosis, and Meckel's diverticulum. On the other hand, the absence of abdominal pain would be more consistent with a blood dyscrasia or hereditary telangiectasia.

DIAGNOSTIC WORKUP

Routine laboratory tests include a CBC, sedimentation rate, urinalysis, chemistry panel, coagulation panel, VDRL test, and stool for occult blood. A stool for ovum and parasites may also need to be done. If these tests are inconclusive, an upper GI series and esophagogram would be the next step. Perhaps a small bowel series should be added to the above studies.

If all of these tests are negative or still inconclusive, referral to a gastroenterologist should be made. The gastroenterologist will probably perform panendoscopy and resolve the diagnostic dilemma. Occasionally, a fluorescein string test may be useful. A radioactive scan following intravenous chromium or technetium-99 may show the site of bleeding in obscure cases. When bleeding continues despite therapy, mesenteric angiography or splenic venography may assist in the diagnosis. Exploratory laparotomy may be necessary in some cases. Needless to say, a gastroenterologist should be consulted before undertaking this.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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