Case History

Personal Details:
Name: Mr. S
Age: 52 years
Sex: Male
Occupation: Shopkeeper
Address: [To be filled]

Presenting Complaints:

• Passage of black, tarry stools for 4 days

• Generalized weakness for 4 days

History of Presenting Illness:
Mr. S noticed the onset of black, tarry, foul-smelling stools 4 days ago. The stools are sticky and difficult to flush. He has experienced 2–3 such episodes daily since onset. He also complains of progressive fatigue and mild dizziness, especially on standing. There is no history of vomiting of blood (hematemesis) or fresh blood in stool. He reports mild upper abdominal discomfort and early satiety for about a week. There is no fever, significant abdominal pain, or recent change in bowel habits. He has noticed abdominal distension and swelling of both feet for the past month. There is a history of poor appetite and unintentional weight loss over the last 3 months. No history of trauma or recent NSAID use.

Past History:

• Diagnosed with chronic liver disease (CLD) secondary to hepatitis B infection 3 years ago

• Multiple episodes of ascites, managed with diuretics and paracentesis

• Previous upper GI endoscopy (1 year ago) showed esophageal varices

• No prior history of gastrointestinal bleeding or peptic ulcer disease

• No history of diabetes, hypertension, or cardiac disease

Personal History:

• Diet: Mixed

• Appetite: Reduced

• Bowel habits: Black, tarry stools; otherwise regular

• Bladder habits: Normal

• Sleep: Disturbed due to abdominal discomfort

• Addictions: Alcohol consumption for 18 years (stopped 1 year ago), non-smoker

Family History:

• No family history of liver disease, GI malignancy, or bleeding disorders

Socioeconomic History:

• Lower-middle socioeconomic status

• Lives with family in a semi-urban area

• Access to clean water and sanitation

• No known occupational exposure to toxins

Case Summary

Mr. S, a 52-year-old male with a known history of chronic liver disease (secondary to hepatitis B), presented with 4 days of black, tarry stools (melena) and generalized weakness. He denies hematemesis or fresh blood per rectum. He has a background of progressive abdominal distension, pedal edema, poor appetite, and weight loss. There is no history of NSAID use, trauma, or prior GI bleeding. He has a significant history of chronic alcohol intake, now abstinent. Past endoscopy revealed esophageal varices. Family and socioeconomic histories are non-contributory.

Differential Diagnosis

1. Bleeding Esophageal or Gastric Varices (due to portal hypertension in CLD)

   • Most likely, given history of CLD, previous varices, and absence of other risk factors.

2. Portal Hypertensive Gastropathy

   • Common in CLD and can cause chronic upper GI bleeding and melena.

3. Peptic Ulcer Disease

   • Possible, though less likely without NSAID use or prior history.

4. Gastric or Duodenal Erosions

   • Can occur in CLD, especially with coagulopathy.

5. Gastric Malignancy

   • Considered in older patients with weight loss, but less likely with known CLD and varices.

6. Dieulafoy Lesion

   • Rare, but possible cause of upper GI bleeding.

Common Viva Questions and Answers on Melena

1. What is melena?
Melena is the passage of black, tarry, foul-smelling stools due to the presence of altered blood, typically resulting from upper gastrointestinal bleeding (proximal to the ligament of Treitz)1234.

2. What are the common causes of melena?

• Esophageal or gastric varices (especially in chronic liver disease)

• Peptic ulcer disease (gastric or duodenal ulcer)

• Gastric or duodenal erosions

• Gastric malignancy

• Mallory-Weiss tear

• Dieulafoy lesion

• Portal hypertensive gastropathy124

3. How much blood loss is required to produce melena?
Usually, at least 50–100 mL of blood in the upper GI tract is required to cause melena14.

4. How do you differentiate melena from hematochezia?

• Melena: Black, tarry, sticky, foul-smelling stools due to upper GI bleeding13.

• Hematochezia: Passage of fresh, red or maroon blood per rectum, usually from lower GI sources, but can occur in massive upper GI bleeding3.

5. What are the important points to elicit in the history of a patient with melena?

• Onset, duration, and frequency of black stools

• Description of stool (color, consistency, odor)

• Associated symptoms (hematemesis, abdominal pain, weight loss, dizziness, fatigue)

• Drug history (NSAIDs, anticoagulants, steroids)

• History of liver disease, alcohol use, previous GI bleeding278

6. How do you confirm melena clinically?
By digital rectal examination, which reveals black, tarry, sticky stool that is difficult to wipe off2.

7. What drugs can cause black stools other than GI bleeding?
Iron supplements, bismuth-containing compounds (e.g., Pepto-Bismol), and some foods (like black licorice) can cause black stools without GI bleeding2.

8. What is the significance of melena in a patient with chronic liver disease?
In CLD, melena often indicates bleeding from esophageal or gastric varices or portal hypertensive gastropathy due to portal hypertension. Coagulopathy and thrombocytopenia in CLD can worsen bleeding risk.

9. What initial investigations would you order in a patient with melena?

• Complete blood count (for anemia and thrombocytopenia)

• Liver function tests

• Coagulation profile (PT/INR)

• Renal function tests

• Upper GI endoscopy (to identify the bleeding source)

• Stool occult blood test (if diagnosis is uncertain)78

10. How is melena managed in a patient with CLD?

• Hemodynamic stabilization (IV fluids, blood transfusion as needed)

• Correction of coagulopathy (vitamin K, FFP, platelets)

• Vasoactive drugs (e.g., octreotide, terlipressin)

• Prophylactic antibiotics

• Urgent upper GI endoscopy with variceal ligation or sclerotherapy if varices are found

• Long-term management: non-selective beta-blockers, endoscopic surveillance, management of portal hypertension

11. How do you differentiate melena due to upper GI bleeding from black stools due to iron therapy?

• Melena is associated with symptoms of GI bleeding (anemia, dizziness, fatigue) and has a characteristic tarry odor and stickiness.

• Iron-induced black stools are not associated with these symptoms and typically start after initiating iron therapy2.

12. What is the most common cause of upper GI bleeding in patients with chronic liver disease in India?
Bleeding from esophageal or gastric varices due to portal hypertension.