Abstract
Background and Aims
Melena is a symptom of upper gastrointestinal bleeding and usually indicates bleeding proximal to the ligament of Treitz. However, whether melena predicts bleeding in the proximal small intestine in patients with obscure gastrointestinal bleeding (OGIB) is unknown and the objective of this study.
Methods
A retrospective cohort study of consecutive patients undergoing capsule endoscopy for OGIB between July 2009 and May 2016 was conducted. Subjects were categorized based on the presence of melena, and the primary outcome was identification of a bleeding source within the proximal 2/3 of the small intestine. Multi-variable regression was performed to control for confounders.
Results
During the study, 288 patients met the eligibility criteria. Subjects with melena accounted for 37.1% of the cohort and were more likely to be older (mean age 66.9 vs. 63.9, p = 0.0457), take warfarin (15.1 vs. 9.4%, p = 0.0122), and have a lower 12-month hemoglobin nadir (7.3 vs. 8.3 g/dL, p = 0.0002). On crude analysis, 56.1% of patients with melena had a bleeding source within the proximal small intestine compared to 34.8% for those without (RR 1.61, 95% CI 1.24–2.09, p = 0.0004). On multi-variable analysis, the presence of melena doubled the odds of finding a bleeding site within the proximal small intestine (OR 1.97, 95% CI 1.17–3.33, p = 0.010).
Conclusions
The presence of melena doubles the odds of finding a bleeding site within the proximal small intestine among patients with OGIB, and deep enteroscopy, if performed before a capsule study, should begin with an antegrade approach in these patients.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Hilsman JH. The color of blood-containing feces following the instillation of citrated blood at various levels of the small intestine. Gastroenterology. 1950;15:131–134.
Schiff L, Stevens RJ, Shapiro N, Goodman S. Observations on the oral administration of citrated blood in man. AM J Med Sci. 1942;203:409–412.
Luke RG, Lees W, Rudick J. Appearances of the stools after the introduction of blood into the caecum. Gut. 1964;5:77–79.
Etzel JP, Williams JL, Jiang Z, Lieberman DA, Knigge K, Faigel DO. Diagnostic yield of colonoscopy to evaluate melena after a nondiagnostic EGD. Gastrointest Endosc. 2012;75:819–826.
Elena RM, Riccardo U, Rossella C, Bizzotto A, Domenico G, Guido C. Current status of device-assisted enteroscopy: technical matters, indication, limits and complications. World J Gastrointest Endosc. 2012;4:453–461.
Ell C, May A, Nachbar L, et al. Push-and-pull enteroscopy in the small bowel using the double-balloon technique: results of a prospective European multicenter study. Endoscopy. 2005;37:613–616.
Messer I, May A, Manner H, Ell C. Prospective, randomized, single-center trial comparing double-balloon enteroscopy and spiral enteroscopy in patients with suspected small-bowel disorders. Gastrointest Endosc. 2013;77:241–249.
Efthymiou M, Desmond PV, Brown G, et al. SINGLE-01: a randomized, controlled trial comparing the efficacy and depth of insertion of single- and double-balloon enteroscopy by using a novel method to determine insertion depth. Gastrointest Endosc. 2012;76:972–980.
Domagk D, Mensink P, Aktas H, et al. Single- vs. double-balloon enteroscopy in small-bowel diagnostics: a randomized multicenter trial. Endoscopy. 2011;43:472–476.
Khashab MA, Pasha SF, Muthusamy VR, et al. The role of deep enteroscopy in the management of small-bowel disorders. Gastrointest Endosc. 2015;82:600–607.
Vandenbroucke JP, von Elm E, Altman DG, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Epidemiology. 2007;18:805–835.
Gerson L, Kamal A. Cost-effectiveness analysis of management strategies for obscure GI bleeding. Gastrointest Endosc. 2008;68:920–936.
Somsouk M, Gralnek IM, Inadomi JM. Management of obscure occult gastrointestinal bleeding: a cost-minimization analysis. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2008;6:661–670.
Pennazio M, Spada C, Eliakim R, et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2015;47:352–376.
Teshima CW, Kuipers EJ, van Zanten SV, Mensink PB. Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: an updated meta-analysis. J Gastroenterol Hepatol. 2011;26:796–801.
Enns RA, Hookey L, Armstrong D, et al. Clinical practice guidelines for the use of video capsule endoscopy. Gastroenterology. 2017;152:497–514.
Acknowledgments
Cindy Zhu and Joshua Friedland received grant support through the Schulich Research Opportunities Program at Western University.
Author information
Authors and Affiliations
Contributions
CNZ contributed to study question, study design, data collection, and data analysis; JF helped with data collection, data analysis, and drafting and reviewing manuscript; BY, AW, JG, and VJ were involved in study question, study design, and drafting and reviewing manuscript MS helped with study question, study design, data collection, data analysis, and drafting and reviewing manuscript.
Corresponding author
Ethics declarations
Conflict of interest
None.
Rights and permissions
About this article
Cite this article
Zhu, C.N., Friedland, J., Yan, B. et al. Presence of Melena in Obscure Gastrointestinal Bleeding Predicts Bleeding in the Proximal Small Intestine. Dig Dis Sci 63, 1280–1285 (2018). https://doi.org/10.1007/s10620-018-5003-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10620-018-5003-x