This document discusses haematemesis and melaena, which refer to vomiting and passing black tarry stool containing blood from the upper GI tract. Haematemesis with bright red or dark coffee ground blood requires emergency care. Melaena results from oxidation of iron in haemoglobin as it passes through the lower GI tract. Upper GI bleeding has an annual incidence over 100 per 100,000 people and increases with age. Risk factors include NSAID use and hospitalization for other conditions. Patients may experience vomiting blood, black tarry stool, hypovolemic shock, lethargy or abdominal pain. Initial treatment involves stabilization, blood transfusion, risk assessment and endoscopy after stabilization.

1. Mahdi pourfathi group 5
Hematemesis and Melaena

2. Haematemesis is the vomiting of blood from the upper GI tract
Bright red blood or clots imply active bleeding and are a
medical emergency. Altered blood with a dark, granular
appearance ('coffee-grounds') suggests that bleeding has
ceased or has been relatively modest .This must be
differentiated from haemoptysis when the blood is coughed
up.

3. Melaena refers to the black, tarry stool produced in the
presence of upper gastrointestinal haemorrhage.
The black appearance of the stool is caused by
oxidation of iron in the haemoglobin as it passes
through the ileum and colon.

4. Incidence:
Upper gastrointestinal hemorrhage remains a major medical problem
with an incidence of over 100/100 000 per year in Western practice that
increases with increasing age.
Haemorrhage is strongly associated with NSAID use.
Despite improvements in diagnosis and the proliferation in treatment
modalities over the last few decades, an in-hospital mortality of 10 -5per
cent can be expected. This rises to 33 per cent when bleeding is
fi
rst
observed in patients who are hospitalised for other reasons.

5. Presentation:
Haematemesis with or without melaena.
There may be associated symptoms of lethargy, dizziness, shortness of
breath, abdominal or retrosternal pain.
There may be signs of hypovolaemic shock.

7. There are occasions when life saving manoeuvres have to be undertaken without
the bene
fi
t of an absolute diagnosis
For instance, in patients with known esophageal varices and uncontrollable
bleeding, a Sengstaken -Blakemore tube may be inserted before an endoscopy
has been carried out. This practice is not to be encouraged, except in extremis.
In some patients, bleeding is secondary to a coagulopathy. The most important
current causes of this are liver disease and inadequately controlled warfarin
therapy. In these circumstances the coagulopathy should be corrected, if possible,
with fresh-frozen plasma or concentrated clotting factors.

9. Initial assessment and risk strati
fi
cation:
Hemodynamic status should be assessed immediately upon presentation and
resuscitative measures begun as needed.
Blood transfusions should target hemoglobin >= 7 g/dl, with higher hemoglobins
targeted in patients with clinical evidence of intravascular volume depletion or
comorbidities, such as coronary artery disease.
Risk assessment should be performed to stratify patients into higher and lower risk
categories and may assist in initial decisions such as timing of endoscopy, time of
discharge, and level of care

10. After Stabilization
Upper gastrointestinal endoscopy should be carried out by an experienced
operator as soon as practicable after the patient has been stabilised.
In patients in whom the bleeding is relatively mild, endoscopy may be carried out
on the morning after admission.
In all cases of severe bleeding it should be carried out immediately.
A number of scoring systems have been advocated for the assessment of
rebleeding and death after upper gastrointestinal .haemorrhage