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DD of Melena
(Chat GPT) - Coggle Diagram
DD of Melena
(Chat GPT)
Melena refers to the passage of black, tarry stools, typically caused by upper gastrointestinal (GI) bleeding. The dark color results from the digestion of blood by gastric acids and enzymes. The most common sources of bleeding are proximal to the ligament of Treitz, but some cases may originate from the small bowel or even the right colon. Below is a detailed differential diagnosis:
- Peptic Ulcer Disease (PUD)
Cause: Erosions or ulcers in the stomach or duodenum due to Helicobacter pylori infection, NSAIDs, or stress-related mucosal damage.
Features: Associated with epigastric pain, often worse after eating in gastric ulcers and relieved by food in duodenal ulcers. May have a history of NSAID use.
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- Gastritis and Gastropathy
Cause: Inflammation or irritation of the gastric mucosa due to alcohol, NSAIDs, stress, or bile reflux.
Features: May present with dyspepsia, nausea, and hematemesis in severe cases.
Tests: Endoscopy shows erythema, erosions, or friable mucosa.
- Esophageal or Gastric Varices
Cause: Dilated submucosal veins due to portal hypertension, often secondary to liver cirrhosis.
Features: Painless bleeding, often massive, with signs of liver disease (jaundice, ascites, spider angiomas).
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Cause: Mucosal tear at the gastroesophageal junction due to severe vomiting, retching, or coughing.
Features: Associated with a history of alcohol use or intense vomiting. Presents with hematemesis and melena.
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- Esophagitis (Severe Cases)
Cause: Inflammation of the esophagus due to GERD, infections (Candida, HSV, CMV), or pills (pill esophagitis).
Features: Heartburn, dysphagia, and retrosternal pain; bleeding is rare but possible.
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Cause: Gastric, esophageal, or duodenal cancers leading to mucosal erosion or tumor bleeding.
Features: Weight loss, anemia, early satiety, or dysphagia; may present with occult bleeding before overt melena.
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Cause:
Angiodysplasia: Aberrant blood vessels, often in older adults or those with chronic kidney disease.
Dieulafoy's Lesion: Large-caliber arterial erosion, often in the stomach.
Features: Recurrent, painless bleeding.
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Cause: Rare but life-threatening connection between the aorta and the GI tract, often due to prior aortic surgery or aneurysms.
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Cause:
Meckel's Diverticulum: Common in younger patients, may bleed due to ectopic gastric mucosa.
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Features: Anemia, abdominal pain, and obscure bleeding.
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Cause: Bleeding disorders (e.g., thrombocytopenia, anticoagulation therapy, liver disease).
Features: Diffuse bleeding tendency, petechiae, or bruising.
Tests: Coagulation profile (PT/INR, aPTT, platelets).
Diagnosis
History:
Onset, associated symptoms (pain, vomiting, dysphagia).
Medication history (NSAIDs, anticoagulants).
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Physical Exam:
Signs of anemia (pallor, tachycardia).
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Investigations:
Labs: CBC (hemoglobin, MCV), liver function tests, BUN/creatinine ratio (elevated in upper GI bleeding).
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Management:
Stabilize with IV fluids, blood transfusions if needed.
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Treat the underlying cause (e.g., band ligation for varices, H. pylori eradication).