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Melena: Causes, Symptoms & Treatment

Melena refers to black, tarry stools caused by bleeding in the upper gastrointestinal tract. It is a medical emergency requiring immediate evaluation.

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Things worth knowing about "Melena"

Melena refers to black, tarry stools caused by bleeding in the upper gastrointestinal tract. It is a medical emergency requiring immediate evaluation.

What is Melena?

Melena (also spelled melaena) describes black, shiny, tarry stools with a distinctive sweet-foul odor. This characteristic appearance results from the digestion of blood originating in the upper gastrointestinal (GI) tract – including the esophagus, stomach, or duodenum. Stomach acid converts the hemoglobin in the blood into hematin, a dark pigment responsible for the black coloration and sticky consistency of the stool. Melena is a medical emergency and always requires prompt medical assessment.

Causes

Melena typically arises from a bleeding source located above the ligament of Treitz, an anatomical landmark in the small intestine. Common causes include:

Peptic ulcers (gastric or duodenal ulcers): The most frequent cause of melena.
Erosive gastritis: Inflammation and damage to the stomach lining, often caused by NSAIDs or alcohol.
Esophageal varices: Enlarged veins in the esophagus, typically associated with liver cirrhosis and portal hypertension.
Mallory-Weiss syndrome: Mucosal tears at the gastroesophageal junction, often following forceful vomiting.
Gastric or esophageal cancer and other upper GI tumors.
Medications such as aspirin, anticoagulants (blood thinners), or NSAIDs that can damage the gastric mucosa or impair clotting.

Symptoms

Melena itself is a symptom of an underlying condition. It may be accompanied by additional signs that indicate the severity of the bleeding:

Black, sticky, tar-like stools with a characteristic odor
Dizziness and weakness in cases of significant blood loss
Anemia: Fatigue, pallor, and rapid heartbeat
Low blood pressure and rapid pulse (signs of shock in severe bleeding)
Hematemesis: Vomiting of bright red blood or coffee-ground-like material
Upper abdominal pain or discomfort

Diagnosis

When melena is suspected, rapid diagnosis and immediate treatment are essential. The following diagnostic steps are typically performed:

Medical history and physical examination: Assessment of symptoms, current medications, alcohol use, and circulatory status.
Blood tests: Complete blood count, coagulation studies, liver and kidney function tests to estimate blood loss and identify possible causes.
Upper endoscopy (esophagogastroduodenoscopy, EGD): The most important procedure for locating and treating the bleeding source in the upper GI tract.
Rectal examination: To confirm the tarry nature of the stool and rule out lower GI bleeding sources.
In unclear cases: Imaging such as CT angiography for further evaluation.

Note: Black stools can also result from taking iron supplements, activated charcoal, or consuming certain foods (e.g., beetroot, licorice). These must be distinguished from true melena.

Treatment

Treatment of melena depends on the underlying cause and the severity of bleeding:

Hemodynamic stabilization: Intravenous fluids and, if necessary, blood transfusions.
Endoscopic hemostasis: During upper endoscopy, bleeding vessels can be cauterized, clipped, or treated with injection therapy.
Pharmacological therapy: Proton pump inhibitors (PPIs) such as omeprazole or pantoprazole reduce gastric acid secretion and support ulcer healing.
Treatment of the underlying condition: For example, eradication of Helicobacter pylori in peptic ulcer disease, or management of liver cirrhosis in variceal bleeding.
Surgical intervention: In severe cases where endoscopic measures are insufficient.
Medication review: Discontinuing or replacing blood thinners or gastric mucosal-damaging drugs.

When to Seek Medical Attention?

Melena is always a warning sign and must never be ignored. Seek immediate medical attention or go to an emergency room if you notice black, tarry stools – especially when accompanied by dizziness, weakness, rapid heartbeat, or nausea. The earlier the cause is identified and treated, the better the prognosis.

References

Laine L, Jensen DM. Management of patients with ulcer bleeding. American Journal of Gastroenterology. 2012;107(3):345-360. PubMed.
Wilkins T, Khan N, Nabh A, Schade RR. Diagnosis and management of upper gastrointestinal bleeding. American Family Physician. 2012;85(5):469-476.
Holster IL, Kuipers EJ. Management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives. World Journal of Gastroenterology. 2012;18(11):1202-1207.

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