Proper evaluation of patients with melena and nondiagnostic esophagogastroduodenoscopy is comparatively undefined. We sought to determine the percentage of patients with melena and nondiagnostic upper endoscopy and assess the yield of further evaluation. Of 209 patients presenting with melena, 180 underwent esophagogastroduodenoscopy as the initial study, which was nondiagnostic in 43 cases (24%). Further evaluation was pursued in 30. A presumed source of melena was found in 11 patients (37%), identified by colonoscopy in seven, bleeding scan in three, and barium enema plus flexible sigmoidoscopy in one. Nearly all such defined cases originated from the right colon. Small bowel contrast studies, flexible sigmoidoscopy of barium enema alone, and angiography failed to reveal a source. Our findings suggest that many (24%) patients presenting with melena will have nondiagnostic upper endoscopy; further evaluation reveals a potential source in 37% of this group, with the right colon being the most likely location of pathology; and colonoscopy is the test of choice in this cohort.
Retrospective chart review of 330 patients undergoing ERCP over a two-year period yielded five patients with choledocholithiasis whose serum liver enzyme and total bilirubin levels were repeatedly normal. All were female, three were elderly, and the gallbladder was in situ in three of the five, one of whom had a large gallbladder remnant. In four patients, the common bile duct was dilated (> 10 mm), whereas none had intrahepatic duct dilatation. Four patients had a prominent ampulla, and stone size varied widely. Each patient was managed with endoscopic sphincterotomy and stone extraction followed by cholecystectomy for the four patients with the gallbladder or its remnant in situ. This small series proves that common duct stones may exist in patients with repeatedly normal serum liver enzyme and total bilirubin levels. We hypothesize that marked dilatation of the common bile duct or gallbladder may serve as a pressure sump and blunt liver enzyme elevation. Normal liver enzymes should not dissuade one from performing cholangiography in patients with suspected choledocholithiasis.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.