Haematemesis and Melaena

Upper GI bleeds can result in haematemesis and melaena.

Haematemesis is the vomiting of blood, or partially digested blood (“coffee-ground”), from a bleeding site in the upper GI tract. Melaena is the passing of digested blood in the stool (dark/tarry/smelly/sticky) from a bleeding site in the upper GI tract, where acidic enzyme action is still present (i.e. small intestine and above).

Two main causal pathologies: ulceration (infection, acid erosion, drug erosion, malignant erosion — see GORD / PUD); portal hypertension from liver cirrhosis (see Liver Cirrhosis and Failure).

Acute management

If there’s no active haematemesis or melaena, take a detailed history of the timing, frequency, and volume of blood loss. Assess ABCDE and call an ambulance — do not let the patient drive, or have another member of the public transport them, given the risk of significant deterioration in a private vehicle. The patient needs hospital emergency transfer, as prompt fluid resuscitation and treatment to stop the bleeding may be required. Even if the patient is well with no acute findings, they should still be sent to ED for investigation of the cause.

Gold standard management is high-dose IV PPI plus endoscopic exploration, aiming to ablate the bleeding source.

If a patient is bleeding profusely, resuscitation with IV fluids, blood products, octreotide, and FFP is needed. Mechanical balloon catheter placement in the oesophagus or stomach can be performed in emergencies to tamponade bleeding from an oesophageal or gastric source.

Suitable IV PPI regimens (per eTG):

• Esomeprazole 80mg IV over 15–30 minutes, then 8mg/hour by IV infusion for up to 3 days — or esomeprazole 40mg IV 12-hourly for up to 3 days.
• Omeprazole 80mg IV over 15–30 minutes, then 8mg/hour by IV infusion for up to 3 days — or omeprazole 40mg IV 12-hourly for up to 3 days.
• Pantoprazole 80mg IV over 15–30 minutes, then 8mg/hour by IV infusion for up to 3 days — or pantoprazole 40mg IV 12-hourly for up to 3 days.