# Melaena (Black Tarry Stools) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class DS15 - condition scope only, no dose · Upper Gastrointestinal Bleeding - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK470300/ · Egyptian National Drug Formulary - GIT 2024 (esomeprazole monograph, p73) · Egyptian National Drug Formulary - GIT 2024 (esomeprazole monograph, p73), which for prevention of rebleeding after therapeutic endoscopy for acute bleeding gastric or duodenal ulcer gives an 80 mg intravenous bolus infusion over 30 minutes followed by a continuous infusion of 8 mg per hour over 3 days, then oral acid suppression. The same two figures appear in the card's own upper gastrointestinal bleeding article, which puts them before endoscopy as well. · Upper Gastrointestinal Bleeding - StatPearls - NCBI Bookshelf - disease-level clinical article (melaena-full.txt), which states that antibiotic prophylaxis for 2 to 5 days is advised in patients with cirrhosis presenting with acute gastrointestinal bleeding and that ceftriaxone 1 g intravenously per 24 hours is commonly used. - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - GIT 2024 (esomeprazole monograph, p73) - Egyptian National Drug Formulary - GIT 2024 (esomeprazole monograph, p73), which for prevention of rebleeding after therapeutic endoscopy for acute bleeding gastric or duodenal ulcer gives an 80 mg intravenous bolus infusion over 30 minutes followed by a continuous infusion of 8 mg per hour over 3 days, then oral acid suppression. The same two figures appear in the card's own upper gastrointestinal bleeding article, which puts them before endoscopy as well. - Upper Gastrointestinal Bleeding - StatPearls - NCBI Bookshelf - disease-level clinical article (melaena-full.txt), which states that antibiotic prophylaxis for 2 to 5 days is advised in patients with cirrhosis presenting with acute gastrointestinal bleeding and that ceftriaxone 1 g intravenously per 24 hours is commonly used. ## Treatment metadata - Esomeprazole — 40 mg — injection - Referral & safety-netting (no drug therapy) - Ceftriaxone — 1000 mg — injection ## Complete treatment card ```text MELAENA (BLACK TARRY STOOLS) Sources: ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class DS15 - condition scope only, no dose · Upper Gastrointestinal Bleeding - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK470300/ · Egyptian National Drug Formulary - GIT 2024 (esomeprazole monograph, p73) · Egyptian National Drug Formulary - GIT 2024 (esomeprazole monograph, p73), which for prevention of rebleeding after therapeutic endoscopy for acute bleeding gastric or duodenal ulcer gives an 80 mg intravenous bolus infusion over 30 minutes followed by a continuous infusion of 8 mg per hour over 3 days, then oral acid suppression. The same two figures appear in the card's own upper gastrointestinal bleeding article, which puts them before endoscopy as well. · Upper Gastrointestinal Bleeding - StatPearls - NCBI Bookshelf - disease-level clinical article (melaena-full.txt), which states that antibiotic prophylaxis for 2 to 5 days is advised in patients with cirrhosis presenting with acute gastrointestinal bleeding and that ceftriaxone 1 g intravenously per 24 hours is commonly used. Review status: REVIEWED against 2 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (7) - Melaena means black, sticky, tarry stool with a smell of its own [melaena] - Vomiting fresh blood or clots is haematemesis; coffee-ground vomit is dark specks of older blood [vomiting · vomiting blood] - Bright red blood or clots from the back passage usually means a lower gut source, but brisk upper bleeding can do the same [bleeding] - Red flag: fainting or a blood pressure that drops on standing means the bleed is heavy enough to destabilise [syncope] - Ask directly about NSAIDs, antiplatelet drugs, aspirin, anticoagulants and herbal remedies, which can interfere with anticoagulant metabolism and increase bleeding [bleeding] - Ask about other illnesses, previous endoscopy and previous abdominal operations - Alcohol and drug use flag up liver disease, and ask about gut cancers and bleeding disorders in the family [bleeding] SIGNS - what you find (3) - Have the patient describe exactly what came out, and confirm it with a rectal examination - Red flag: abdominal tenderness with rebound or guarding suggests the gut has perforated [abdominal tenderness · guarding · rebound tenderness] - Look for chronic liver disease: red palms, spider naevi, breast tissue in men, jaundice and ascites, which point to bleeding varices [ascites · bleeding · jaundice] TESTS (8) - Full blood count for haemoglobin, haematocrit and platelets; a small red cell volume points to slow chronic loss with iron deficiency - A urea to creatinine ratio above 30 points to an upper gut source of the bleeding - Clotting screen with INR, particularly with liver disease, on anticoagulants, or with a known bleeding tendency - Upper endoscopy is the reference test, both to find the cause and to treat it - Guidelines put endoscopy within 24 hours of admission, after the patient has been resuscitated - When variceal bleeding is suspected, endoscopy is brought forward to within 12 hours, because delay costs lives in cirrhosis - CT angiography localises the bleed when endoscopy finds nothing, is unavailable or unsuitable, or when surgery has changed the anatomy - CT angiography picks up bleeding at about 0.1 mL a minute but cannot treat, so a positive scan is followed by endoscopy or catheter angiography IF NOT THIS - what else fits (6) - Black stool that is not blood at all: iron tablets, bismuth, licorice and a range of foods all mimic it - Bismuth compounds taken for diarrhoea, and iron supplements, blacken the stool without any bleeding - Red flag: an aortoenteric fistula is rare and lethal, and melaena can be the warning bleed before a torrential one - Suspect that fistula in someone whose aorta has had an endovascular graft that has worn through into the bowel, or after aortic infection - Hemosuccus pancreaticus, an aneurysm bursting into the pancreatic duct, and haemobilia, bleeding from the bile ducts: both bleed out through the ampulla and are easily missed - Depending on the history, a hidden upper gut cancer or a deposit from elsewhere must be excluded Score Glasgow-Blatchford score - Does this upper-GI bleed need admission and treatment? Source StatPearls "Upper Gastrointestinal Bleeding" - disease-level clinical article Status traced to the source above Rx: Acid suppression, started before endoscopy | Main treatment | Antibiotic prophylaxis where cirrhosis makes a variceal bleed likely ACID SUPPRESSION, STARTED BEFORE ENDOSCOPY 1. ESOMEPRAZOLE [1st line] Adult 80 mg by intravenous bolus infusion over 30 minutes, then 8 mg per hour by continuous infusion. Where a pump is not available the article's alternative is intermittent dosing of 40 mg two to four times daily. x 72 hours of high-dose therapy, then twice-daily oral acid suppression for 14 days, then once daily to complete ulcer treatment Peds The 80 mg bolus and 8 mg per hour regimen is an adult one and neither document extends it to children. The formulary's separate paediatric intravenous entry is for gastric antisecretory treatment when the oral route is not possible - 0.5 mg/kg once daily from 1 month to under 1 year, 10 mg once daily from 1 to 17 years under 55 kg, 20 mg at 55 kg and over, each infused over 10 to 30 minutes for up to 10 days. Melaena in a child is an emergency paediatric referral. Source Egyptian National Drug Formulary - GIT 2024 (esomeprazole monograph, p73), which for prevention of rebleeding after therapeutic endoscopy for acute bleeding gastric or duodenal ulcer gives an 80 mg intravenous bolus infusion over 30 minutes followed by a continuous infusion of 8 mg per hour over 3 days, then oral acid suppression. The same two figures appear in the card's own upper gastrointestinal bleeding article, which puts them before endoscopy as well. Why The article states that patients with significant bleeding should have an 80 mg proton pump inhibitor bolus followed by 8 mg per hour, or intermittent 40 mg two to four times daily, and reports that giving a high-dose inhibitor before endoscopy reduced high-risk ulcer features and the need for endoscopic therapy in a randomised trial. It names the class rather than a drug; esomeprazole is the drug the Egyptian formulary carries at exactly these figures, and seven intravenous products are marketed here. Caution The transfer comes first. Acid suppression is started while the ambulance is arranged, never instead of it - black tarry stool means upper gastrointestinal bleeding until proven otherwise. Two documents place the same regimen at different moments and both are recorded: the formulary gives 80 mg then 8 mg per hour for preventing rebleeding after therapeutic endoscopy, while the article gives the identical figures before endoscopy. The evidence the article cites for the pre-endoscopy use showed fewer high-risk ulcer features and less endoscopic therapy, with no difference in transfusion, rebleeding or 30-day mortality. Ask about anticoagulants before anything else. The article's threshold for holding the drug and giving a reversal agent is a life-threatening bleed - shock, severe hypotension needing vasopressors, a haemoglobin fall of more than 5 g/dL, or 5 or more units transfused - and it prefers prothrombin complex concentrate to fresh frozen plasma on a vitamin K antagonist. Iron and bismuth blacken the stool without any bleeding. Confirm with a rectal examination rather than a history alone. Contraindicated in hypersensitivity to any substituted benzimidazole proton pump inhibitor. Egypt MERAZODEL 40 MG POWDER FOR I.V. INF. VIAL DELTA PHARMA 31.20 EGP ESOMEPEX 40 MG POWDER FOR I.V. INF. VIAL INTERNATIONAL DRUG AGENCY (IDI)... 41.50 EGP ZOMEGIPRAL 40MG POWDER FOR I.V. INF. VIAL GLOBAL PHARMACEUTICAL INDUSTRIES 48.00 EGP MEGAPRAZOLE 40 MG POWDER FOR I.V. INF. VIAL CHEMIPHARM 53.00 EGP ESMORAP 40 MG POWDER FOR I.V. INF. VIAL EL NILE. > AUG PHARMA 86.00 EGP NEXIUM 40 MG POWDER FOR I.V. INF. VIAL ASTRA ZENECA 100.00 EGP ESOMEPRAZOLE-EVA 40MG 3 POWDER FOR I.V. INF. VIAL EVA PHARMA 204.00 EGP MAIN TREATMENT 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Black tarry stools signal bleeding from the upper digestive tract, a medical emergency; a GP recognises it, may start empiric acid suppression, and arranges urgent hospital transfer rather than managing it alone. - Refer, with advice Peds The drug rows above are instilled, not dosed by weight. The referral threshold and the safety-netting are the same at any age. Source No dose - referral pathway, no medicine given in primary care Why Black tarry stools signal bleeding from the upper digestive tract, a medical emergency; a GP recognises it, may start empiric acid suppression, and arranges urgent hospital transfer rather than managing it alone. Caution The drug rows above are what the treating service gives. They are here so that the referral is an informed one and so the GP can recognise the regimen the patient comes back on - not as permission to start it without the referral. RED FLAG - Hemodynamic instability (low blood pressure, fast pulse), ongoing or large- volume bleeding, or known liver disease or varices with the risk of a variceal bleed requires emergency hospital referral. ANTIBIOTIC PROPHYLAXIS WHERE CIRRHOSIS MAKES A VARICEAL BLEED LIKELY - give alongside 3. CEFTRIAXONE [add-on - not a substitute] Adult 1 g intravenously every 24 hours x 2 to 5 days, stopping once the bleeding is controlled and no infection is evident Peds The article's prophylaxis figure is adult. Ceftriaxone is contraindicated in the neonate receiving calcium-containing intravenous fluids. AWaRe WATCH group - carries resistance cost. Egyptian EML 2025. Source Upper Gastrointestinal Bleeding - StatPearls - NCBI Bookshelf - disease-level clinical article (melaena-full.txt), which states that antibiotic prophylaxis for 2 to 5 days is advised in patients with cirrhosis presenting with acute gastrointestinal bleeding and that ceftriaxone 1 g intravenously per 24 hours is commonly used. Why In a patient with cirrhosis the article puts bacterial translocation, aspiration pneumonia and spontaneous bacterial peritonitis alongside the bleed itself, and gives prophylaxis its own recommendation with a stated dose. That matters in Egypt, where post-hepatitis and schistosomal cirrhosis put variceal bleeding high in the differential for melaena. Caution Only for the patient with known or suspected cirrhosis. It is not given for every melaena. The article's vasoactive drugs for suspected variceal bleeding - octreotide, somatostatin or terlipressin, run for 2 to 5 days - and its prokinetic erythromycin 250 mg intravenously 20 to 90 minutes before endoscopy are hospital treatments started by the receiving team, not in a clinic. Avoid in penicillin or cephalosporin hypersensitivity. Where renal and hepatic impairment coexist, the Egyptian formulary caps ceftriaxone at 2 g daily. Egypt ZOXIDEL 1 GM PD. FOR I.M. INJ. RAMEDA > DELT... 22.00 EGP CEFTRIAXONE SODIUM 1 GM I.M.VIAL (KAHIRA) KAHIRA 29.00 EGP ZOXIDEL 1 GM PD. FOR I.V. INJ. RAMEDA > DELT... 29.00 EGP WINTRIAXONE 1 GM PD. FOR I.V INJ. SANOFI 48.00 EGP VOTRIAXONE 1 GM I.M VIAL CHEMIPHARM 56.00 EGP OFRAMAX 1 GM I.M. VIAL RAMEDA > SUN ... 71.00 EGP TRIAXONE 1 GM I.M. VIAL TABUK PHARMAC... 106.00 EGP TRIAXONE 1 GM I.V VIAL TABUK PHARMAC... 106.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)