notes by dr Claudio Italiano
Not always a patient who emits black stools has melena. In fact it is possible
to evacuate dark stools if we have taken bismuth salts (an antacid per os), if
we take medicinal specialties based on iron, if we ate pasta seasoned with
cuttlefish ink, culinary specialty of Messina, Sicily!
We talk about
melena when the patient emits feces stipples , due to the presence of digested blood in the faeces,
characterized by the degradation that the hydrochloric acid of the stomach exerts on
hemoglobin, during a hemorrhage of the digestive tract, usually of the high tract up to the ligament of Treiz, ie a hemorrhage of the esophagus of the
stomach and duodenum, although it may also originate from the jejunum and even
from the ascending colon, even if it is rare, in the sense that the blood will
not be dark; because a melena appears, however, 60 ml of blood are needed. If
the loss is impressive, the blood rather than being digested and, therefore,
of a pinkish color, will be redder, tending to bright red-dark and the stools
emitted foul-smelling.
In this case, particular care must be taken as a hypovolaemic shock may occur and the patient will be pale and sweaty. Quickly research other signs of shock such as tachycardia and tachypnea, always check the pressure, cannulate a vein and administer emagel, fluids, electrolytes and blood, depending on the drop in hemoglobin; the patient should be placed in a supine position with the head turned on one side and the feet raised. In addition, oxygen will also need to be administered. Hematemesis, hematemesis, usually indicates a gastrointestinal bleeding above the Treitz ligament, which suspends the duodenum at its junction with the jejunum. A bright red vomit or blood-streaked indicates a recent bleeding. A dark red, brown or coffee vomit (coffee color and consistency) indicates stagnation in the stomach of partially digested blood. Although haematemesis is usually caused by gastrointestinal diseases, it may be due to coagulation disorders and treatments that irritate the gastrointestinal tract. Even during epistaxis, swallowed blood may also cause blood vomiting.
Hematemesis is always an important sign, but its severity depends on the
quantity, the origin and the rapidity of hemorrhage. Massive haematemesis (vomit
of 500- 1000 ml of blood) can be potentially lethal. The color of hemathemesis
is similar to that ofa coke, or the color of coffee.
Emergency endoscopy may be necessary to determine the cause of bleeding.
Prepare to introduce a nasogastric tube (NG) for aspiration or ice washing or
to compress a special balloon-inflated tube (see Sengstaken-Blackemore).
Does our patient regularly take aspirin or other non-steroidal
anti-inflammatory drugs (NSAIDs), such as phenylbutazone or indomethacin?
These substances can cause erosive gastritis or ulcer.
A rectorrhagia, instead, is the emission of red blood from the anus, a sign of a
hemorrhage of the lower digestive tract, usually due to congestion and loss of
blood from the hemorrhoidal plexus or acute diverticulitis, or RCU, cancer and
colitis, of the color of currant jam. Rectorrhages are distinguished in
major, when they determine hypovolaemia, and minors. The
rectorrhagias vary according to the
place of origin of the bleeding, to its quantity and frequency and to the
possible concomitance with the defecation. If the bleeding is concomitant, the
blood may be mixed up in the faeces or on their surface, or appear only at the
end of defecation, for example with dripping, or if it is found during
cleaning. Based on the characteristics of bleeding, it is possible to
formulate a first diagnostic hypothesis:
a) If the blood is mixed in the
feces, a loss up to the sigma will be thought, usually in colon cancer or
inflammatory bowel disease, Crohn's disease and ulcerative Rettocolitis
b) If the blood covers the faeces from the outside, then the pathology is of
the last tract of the digestive, that is of the channel and, therefore, will
depend on anal fissures or hemorrhoid
c) When the blood is massive, then the bleeding can also be located in the
upper tract of the digestive tract.
If the patient's condition allows it, the doctor must investigate to
understand when the patient has discovered that he has feces and black feces.
Inquire about the frequency and extent of peristalsis and whether the melena
or rectorrhagiasis was already manifested before. It is necessary to
investigate other signs such as the presence of coffee or hematemesis or
hematocritia, ie emission of faeces with blood. Also, does the patient use
anti-inflammatory drugs, alcohol, or other irritants for the gastrointestinal
tract? In addition, investigate whether the patient has a history of
gastrointestinal lesions (cancer, gastritis, esophagitis, ulcer, stomach
surgery, etc.)
Next, inspect the patient's mouth and nasopharynx to detect the presence of
bleeding, for example from tongue varices. Perform an examination of the
abdominal region with auscultation, palpation and percussion.
gastroenterology index