Melena
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Melena or melaena refers to the black, "tarry" feces that are associated with gastrointestinal hemorrhage. The black color is caused by oxidation of the iron in hemoglobin during its passage through the ileum and colon.
Melena vs. hematochezia
Bleeding originating from the lower GI tract (such as the sigmoid colon and rectum) is generally associated with the passage of bright red blood, or hematochezia, particularly when brisk. Blood acts as a cathartic agent in the intestine, promoting its prompt passage. Only blood that originates from a high source (such as the small intestine), or bleeding from a lower source that occurs slowly enough to allow for oxidation, is associated with melena. For this reason, melena is often associated with hemorrhage in the stomach or duodenum (upper gastrointestinal tract), for example by a peptic ulcer. A rough estimate is that it takes about 14 hours for blood to be broken down within the intestinal lumen; therefore if transit time is less than 14 hours the patient will have hematochezia and if greater than 14 hours the patient will exhibit melena. One often-stated rule of thumb is that melena only occurs if the source of bleeding is above the ligament of Treitz.
Diagnosis
Patients present with signs of anemia. The presence of blood must be confirmed with either a positive hemoccult slide on rectal exam, frank blood on the examining finger, or a positive stool guaiac from the lab. If a source in the upper GI tract is suspected, an upper endoscopy can be performed to diagnose the cause. Lower GI bleeding sources usually present with hematochezia or frank blood. A test with poor sensitivity/specificity that may detect the source of bleeding is the tagged red blood cell scan, whereas mesenteric angiogram is the gold standard. Hence, the commonly referenced quote goes as follows: "when you go the bathroom it spells melana in the toilet."
Differential diagnosis of causes of melena
The most common cause of melena is peptic ulcer disease. Any other cause of bleeding from the upper gastro-intestinal tract, or even the ascending colon, can also cause melena. Melena may also be a sign of drug overdose if a patient is taking anti-coagulants, such as warfarin. A less serious, self-limiting case of melena can occur in newborns two to three days after delivery, due to swallowed maternal blood.
Treatment
Urgent care however is required.