Melena + Hematemesis

[Apoplexy__]

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I thought that the combo of melena + hematemesis was indicative of a GI bleed proximal to the Ligament of Treitz. Then I heard Goljan say that this presentation is seen in Meckel's Diverticulum (...2 ft proximal to the ileocecal valve =/= proximal to Treitz). My question: is there anything else that produces this clinical presentation combo?

 

[thinkbig]

Mechel's with hematemesis .....


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[Missorleans]

Bleeding ulcer?

 

[Transposony]

I thought that the combo of melena + hematemesis was indicative of a GI bleed proximal to the Ligament of Treitz. Then I heard Goljan say that this presentation is seen in Meckel's Diverticulum (...2 ft proximal to the ileocecal valve =/= proximal to Treitz). My question: is there anything else that produces this clinical presentation combo?

That is true in general but is not very reliable.
However, if there is massive bleed it can go in either/both directions.
For it to be called malena the Hb has to be oxidized by the enzymes in the small intestine which takes about 12 hours. So if transit time is less than 12 hrs it will present as hematochezia irrespective of the site of bleeding. For example, if there is massive bleed from duodenal ulcer it will present as hematemesis +/-hematochezia and if there is less bleed than it will present as melena +/- hematemesis.

 

[Myxedema]

For the purposes of the exam:
- Melena: Upper GI bleed
- Hematochezia: Lower GI bleed
- Hematemesis: Fresh GI bleed
- Coffee ground emesis: Old GI bleed

 

[Apoplexy__]

That is true in general but is not very reliable.
However, if there is massive bleed it can go in either/both directions.
For it to be called malena the Hb has to be oxidized by the enzymes in the small intestine which takes about 12 hours. So if transit time is less than 12 hrs it will present as hematochezia irrespective of the site of bleeding. For example, if there is massive bleed from duodenal ulcer it will present as hematemesis +/-hematochezia and if there is less bleed than it will present as melena +/- hematemesis.

For the purposes of the exam:
- Melena: Upper GI bleed
- Hematochezia: Lower GI bleed
- Hematemesis: Fresh GI bleed
- Coffee ground emesis: Old GI bleed

Very nice, thanks guys. Just to be clear, you can't vomit contents distal to the ileocecal valve right?

And are there any pathologies that you instantly think of when you see coffee ground emesis?

 

[Myxedema]

I've never heard of vomiting as being separated into those distal and proximal to the ileocecal valve. I don't think that would be an important issue. What would be relevant is the difference between bilious and non-bilious vomiting. If you see bilious vomiting, you can tell that: (1) the obstruction is distal to the ampulla of Vater and (2) bile can flow into the gut.
Coffee ground emesis indicates time, rather than a specific pathology. For example, a peptic ulcer can present as an active bleeding (patient's vomit will have bright red blood), or it can present as an ulcer that did bleed and some time has passed (meaning patient's blood will be exposed to stomach acid --> vomit will have "coffee ground" appearance). It is more likely that coffee ground emesis is the result of an upper GI bleed.

 

[Transposony]

Very nice, thanks guys. Just to be clear, you can't vomit contents distal to the ileocecal valve right?

And are there any pathologies that you instantly think of when you see coffee ground emesis?

It is very much possible to vomit contents distal to ileocecal valve. For example, if there is complete obstruction @ transverse colon. The contents proximal to the obstruction will be emptied in a step wise manner i.e. first the stomach contents will be vomited followed by duodenum, jejunum, ileum and then the right colon if the ileocecal valve is incompetent (feculent vomiting). This happens in very late stages and if the obstruction is not relieved usually seen in third world countries and /or where medical care is not readily available. If the ileocecal valve is competent then it will eventually lead to perforation. I am just trying to explain the simple concept but it is really for the surgical boards.😉

To answer your second question: I'll think of bleeding DU or esophageal/gastric varices since these are the most common causes but it depends on the presentation.

 

[Apoplexy__]

If the ileocecal valve is competent then it will eventually lead to perforation. I am
just trying to explain the simple concept but it is really for the surgical boards.😉

This was actually very helpful, thanks for going into that extra detail.

I've never heard of vomiting as being separated into those distal and proximal to the ileocecal valve. I don't think that would be an important issue. What would be relevant is the difference between bilious and non-bilious vomiting. If you see bilious vomiting, you can tell that: (1) the obstruction is distal to the ampulla of Vater and (2) bile can flow into the gut.
Coffee ground emesis indicates time, rather than a specific pathology. For example, a peptic ulcer can present as an active bleeding (patient's vomit will have bright red blood), or it can present as an ulcer that did bleed and some time has passed (meaning patient's blood will be exposed to stomach acid --> vomit will have "coffee ground" appearance). It is more likely that coffee ground emesis is the result of an upper GI bleed.

Ok, thanks. I was just wondering if it was associated with any specific pathologies so that seeing "coffee ground emesis" in a Q stem wouldn't just help me say "Oh, it's an old bleed". I appreciate the insight.

 

[Instatewaiter]

For the purposes of the exam:
- Melena: Upper GI bleed
- Hematochezia: Lower GI bleed
- Hematemesis: Fresh GI bleed
- Coffee ground emesis: Old GI bleed

One does not vomit bright blood from a lower GI Bleed. You can however have hematochezia from an upper GI bleed.

If you ever see hematemesis with hematochezia it is a brisk (life threatening) upper GI bleed until proven otherwise.

First step should be place a cordis in the neck and rapid transfusion no matter the hemoglobin. Trust me on this one. One or two of you will see this in your time as a doctor. If you see this, don't hesitate. Drop a cordis, call the blood bank and have them ready to send you 10 units of blood + plt + FFP. If you don't act quickly, the patient may die.

 

[Instatewaiter]

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