Melena: Symptoms, Causes and Treatment

Melena is a clinical sign that often signals a potentially serious underlying medical condition. Recognizing its symptoms, understanding the range of possible causes, and knowing the treatment options are crucial for timely intervention and improved outcomes. This article provides a comprehensive, evidence-based overview of melena, using real-world clinical cases and up-to-date research to guide patients, caregivers, and healthcare professionals alike.

Symptoms of Melena

Melena refers to the passage of black, tarry stools, which typically result from the presence of digested blood in the gastrointestinal (GI) tract. This symptom is usually a sign of bleeding from a site above the ligament of Treitz, most commonly in the upper GI tract. Recognizing melena and its associated features is vital for early detection and management of underlying conditions.

Symptom	Description	Associated Findings	Source(s)
Black stools	Dark, tarry, foul-smelling feces	Often sticky; not red	2 3 4 5
Anemia	Low hemoglobin, pallor, fatigue	May be severe or progressive	2 5
Abdominal pain	Discomfort or pain in upper abdomen	May be epigastric or RUQ	2 4 5
Hemodynamic changes	Rapid heart rate, low blood pressure	Sweating, pallor, shock risk	2 4

Table 1: Key Symptoms of Melena

Recognizing Melena

The hallmark of melena is the appearance of black, tarry stools. Unlike red blood in stool (hematochezia), melena suggests that blood has been exposed to digestive enzymes and gastric acid, breaking down hemoglobin and resulting in a characteristic color and odor 2 3 4 5.

• Color and Consistency: Stools are jet black, shiny, sticky, and may have a distinct, often foul odor.
• Associated Symptoms: While black stool is the main feature, patients often experience additional symptoms due to blood loss.

Systemic Effects of Blood Loss

Blood loss through the GI tract can manifest as fatigue, pallor, and shortness of breath—classic signs of anemia. In more severe cases, blood pressure may drop (hypotension), and heart rate may increase (tachycardia), which are signs that the body is trying to compensate for lost blood volume 2 4.

• Fatigue and Weakness: Especially with ongoing bleeding.
• Dizziness or Fainting: In cases of significant blood loss.
• Pallor: Paleness noticeable in the skin, especially the conjunctiva (inner eyelids) 2.

Abdominal Symptoms

Melena is frequently accompanied by abdominal pain or discomfort, which can help point toward the underlying cause:

• Epigastric Pain: May suggest gastric or duodenal origin (ulcers, tumors).
• Right Upper Quadrant (RUQ) Pain: Can be seen with gallbladder or biliary tract involvement 4 5.

Additional Clinical Signs

• Diaphoresis (sweating): Seen in acute bleeding scenarios 2.
• Jaundice: Can occur if there is biliary obstruction or hemobilia (bleeding in the bile ducts), as in hemorrhagic cholecystitis 4.

Causes of Melena

Melena is a symptom, not a disease in itself. It results from upper GI bleeding, and its causes are diverse—ranging from common to extremely rare. Understanding these causes is fundamental for appropriate diagnosis and management.

Cause	Example Condition	Typical Presentation	Source(s)
Peptic ulcer disease	Gastric or duodenal ulcers	Pain, melena, anemia	2 3 5
GI malignancy	Lymphoma, leiomyosarcoma	Mass, ulcer, bleeding	3 5
Vascular abnormalities	Artery pseudoaneurysm, hemobilia	Acute bleeding, pain	2 4
Biliary disease	Hemorrhagic cholecystitis	Jaundice, RUQ pain	4

Table 2: Principal Causes of Melena

Peptic Ulcer Disease

Peptic ulcers are the most common cause of melena, occurring in the stomach or duodenum. The ulcers erode into blood vessels, leading to GI bleeding. Patients often present with epigastric pain, anemia, and black stools 2 3.

• Common risk factors: NSAID use, Helicobacter pylori infection, alcohol abuse, stress.

GI Malignancies

Rarely, tumors in the stomach or duodenum can cause melena by ulcerating into blood vessels:

• Lymphomas: Gastric and duodenal diffuse large B-cell lymphomas (DLBCL) can cause ulcerated lesions that bleed, leading to melena and anemia 3.
• Leiomyosarcoma: This rare tumor arises from smooth muscle cells in the stomach; it can ulcerate and bleed, presenting as melena 5. Leiomyosarcoma is distinct from more common gastrointestinal stromal tumors (GIST) and requires specialized pathologic diagnosis.
• Other Cancers: Adenocarcinomas and other rare malignancies may also present with melena.

Vascular Abnormalities

Vascular lesions can cause dramatic bleeding:

• Pseudoaneurysm: As in the case of left gastric artery pseudoaneurysm, rupture can lead to acute GI bleeding and melena 2.
• Arteriovenous malformations and Dieulafoy lesions (not detailed in the sources, but clinically relevant) are also possible, albeit less common.

Biliary and Pancreatic Causes

• Hemorrhagic Cholecystitis: This rare condition involves bleeding into the gallbladder, often presenting as melena and jaundice. It may be associated with gallstones, infection, or medications like antiplatelet agents 4.
• Hemobilia: Bleeding into the biliary tract can result from trauma, tumors, or medical procedures.

Other Causes

• Chronic Alcoholic Pancreatitis: Chronic inflammation and vascular changes can predispose to bleeding, as seen in some case reports 2.
• Medications: NSAIDs, anticoagulants, and antiplatelet drugs increase bleeding risk.

Treatment of Melena

Managing melena requires both urgent stabilization and targeted therapy for the underlying cause. The approach is multidisciplinary, often involving gastroenterologists, surgeons, interventional radiologists, and critical care specialists.

Treatment Approach	Example Intervention	Indication	Source(s)
Supportive care	IV fluids, blood transfusion	Acute blood loss, anemia	2 4 5
Endoscopic therapy	Hemostasis, biopsy	Ulcers, tumors, bleeding sites	3 5
Surgery	Resection, cholecystectomy	Tumors, unresponsive bleeding	4 5
Medical management	Antibiotics, drug adjustment	Infection, anticoagulation	4

Table 3: Main Treatment Strategies for Melena

Initial Stabilization

Immediate priorities are to assess and stabilize the patient:

• IV fluids: To maintain blood pressure and organ perfusion.
• Blood transfusion: For significant anemia or hemodynamic instability.
• Monitoring: Vital signs, urine output, and laboratory tests (hemoglobin, hematocrit) 2 4 5.

Diagnostic Evaluation

• Endoscopy (EGD): The gold standard for identifying the source of upper GI bleeding. It allows for direct visualization, biopsy, and sometimes therapeutic interventions (e.g., cautery, clipping) 3 5.
• Imaging: CT scans or angiography may be required for vascular causes or when endoscopy is inconclusive 2 4 5.

Targeted Therapy

Endoscopic Management

• Ulcer Bleeding: Endoscopic hemostasis (e.g., injection therapy, cautery, clipping) is first-line.
• Tumors: Biopsy for diagnosis; some bleeding tumors may be treated endoscopically or require surgery 3 5.

Surgical Intervention

• Persistent Bleeding: Surgery is indicated if bleeding cannot be controlled endoscopically or by interventional radiology.
• Tumors: Surgical resection is standard for localized neoplasms like leiomyosarcoma, sometimes followed by adjuvant therapy 5.
• Hemorrhagic Cholecystitis: Cholecystectomy (removal of the gallbladder) is definitive, but initial conservative management may be used in unstable patients 4.

Medical Management

• Antibiotics: For infectious causes (e.g., cholecystitis) 4.
• Adjustment of Medications: Temporary discontinuation of anticoagulants or antiplatelet agents if possible 4.
• Proton Pump Inhibitors: Reduce gastric acid, promote ulcer healing.

Follow-Up and Surveillance

• Repeat Endoscopy: May be required to confirm hemostasis or monitor for recurrence.
• Imaging: Regular surveillance for tumor recurrence, especially in rare malignancies like leiomyosarcoma 5.

Special Considerations

• Multidisciplinary Care: Complex cases may need input from multiple specialties.
• Recurrence Risk: Some tumors have a high risk of recurrence; ongoing monitoring is vital 5.
• Patient Education: Importance of medication adherence, recognizing warning signs, and attending follow-up appointments.

Conclusion

Melena is a critical clinical sign that warrants prompt attention. Key takeaways include:

• Melena indicates upper GI bleeding: Most commonly presents as black, tarry stools, often with anemia and abdominal pain 2 3 4 5.
• Causes are diverse: Ranging from peptic ulcers and malignancies (lymphoma, leiomyosarcoma) to vascular and biliary disorders 2 3 4 5.
• Treatment is multidisciplinary: Involves stabilization, endoscopic therapy, surgery, and tailored medical management 2 3 4 5.
• Early recognition and intervention: Are essential for improved outcomes and can be lifesaving in severe cases.

Summary of Main Points:

• Melena is a symptom of upper gastrointestinal bleeding, characterized by black, tarry stools.
• Common symptoms include fatigue, anemia, abdominal pain, and signs of blood loss.
• Causes range from peptic ulcers to rare tumors and vascular abnormalities.
• Management includes supportive care, endoscopic and surgical interventions, and ongoing surveillance.
• Timely diagnosis and individualized therapy are key for effective management.

If you or someone you know experiences symptoms of melena, seek medical attention immediately, as it may be a sign of a potentially life-threatening condition.