Digestive Diseases and Sciences

, Volume 63, Issue 5, pp 1280–1285 | Cite as

Presence of Melena in Obscure Gastrointestinal Bleeding Predicts Bleeding in the Proximal Small Intestine

  • Cindy Ningfu Zhu
  • Joshua Friedland
  • Brian Yan
  • Aze Wilson
  • Jamie Gregor
  • Vipul Jairath
  • Michael Sey
Original Article


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.


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.


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).


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.


Obscure gastrointestinal bleeding Melena Small intestine Capsule endoscopy 



Cindy Zhu and Joshua Friedland received grant support through the Schulich Research Opportunities Program at Western University.

Author’s contribution

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.

Compliance with ethical standards

Conflict of interest



  1. 1.
    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.PubMedGoogle Scholar
  2. 2.
    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.CrossRefGoogle Scholar
  3. 3.
    Luke RG, Lees W, Rudick J. Appearances of the stools after the introduction of blood into the caecum. Gut. 1964;5:77–79.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    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.CrossRefPubMedGoogle Scholar
  5. 5.
    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.CrossRefPubMedGoogle Scholar
  6. 6.
    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.CrossRefPubMedGoogle Scholar
  7. 7.
    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.CrossRefPubMedGoogle Scholar
  8. 8.
    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.CrossRefPubMedGoogle Scholar
  9. 9.
    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.CrossRefPubMedGoogle Scholar
  10. 10.
    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.CrossRefPubMedGoogle Scholar
  11. 11.
    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.CrossRefPubMedGoogle Scholar
  12. 12.
    Gerson L, Kamal A. Cost-effectiveness analysis of management strategies for obscure GI bleeding. Gastrointest Endosc. 2008;68:920–936.CrossRefPubMedGoogle Scholar
  13. 13.
    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.Google Scholar
  14. 14.
    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.CrossRefPubMedGoogle Scholar
  15. 15.
    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.CrossRefPubMedGoogle Scholar
  16. 16.
    Enns RA, Hookey L, Armstrong D, et al. Clinical practice guidelines for the use of video capsule endoscopy. Gastroenterology. 2017;152:497–514.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Cindy Ningfu Zhu
    • 1
  • Joshua Friedland
    • 1
  • Brian Yan
    • 2
  • Aze Wilson
    • 2
  • Jamie Gregor
    • 2
  • Vipul Jairath
    • 2
    • 3
  • Michael Sey
    • 2
    • 4
  1. 1.Schulich School of Medicine and DentistryWestern UniversityLondonCanada
  2. 2.Division of Gastroenterology, Department of Medicine, Schulich School of Medicine & DentistryWestern UniversityLondonCanada
  3. 3.Robarts Clinical TrialsLondonCanada
  4. 4.London Health Sciences Centre-Victoria HospitalLondonCanada

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