total colectomy - another question - significance of melena

I submitted a question on November 25 "Life after a total colectomy" to which you kindly replied with very helpful comments.  Thank you very much.  However, based on further medical information which I have subsequently learned, I would like to ask for some clarification.  By the way I forgot to let you know that I am male aged 59.

As you may recall, I suffered torrential rectal bleeding (losing up to one litre of blood/mucus on each occasion - perhaps 3-4 times per day) over a period of four days.  I received 16 pints of blood plus a large volume of IV fluids.  In case of the need for urgent surgery I was "nil by mouth".

An endoscopic examination was performed on the second day - result normal.  An angiogram failed to detect the source of the blood flow into the large intestine.  After about six days I was allowed to start eating again and then discharged from hospital on day 8 with a follow-up colonoscopy recommended.  When I left hospital, my motions were formed of what I think you describe as "melena".

A couple of months later I suffered a further minor episode of rectal bleeding - so back to hospital for 3 days but no blood transfusions although I did receive IV fluids (glucose and saline??).  Once again I left hospital with "melena".  Then came the colonoscopy (diagnosis severe diverticulitis) followed by the total colectomy.

My question relates to the implications and significance of the "melena".  I have recently read that melena is/are formed as a result of intestinal blood releases interacting with the digestive juices/processes.  I have become concerned that perhaps my original torrential bleeding may have originated in the "small bowel" thus causing eventual melena when digested food passed into the bowel and the bowel became active again.  In other words could it be that the decision to carry out a total colectomy might not have eliminated the original cause of the torrential bleeding which, based on the brief existence of melena, could have originated somewhere between the stomach and the beginning of the colon rather than totally in the colon?  Or is it the case that melena can be expected to be formed when the bowels start working again after torrential bleeding from somewhere in the colon as opposed to the small bowel?

The "dark cloud" of torrential rectal bleeding requiring emergency admission to hospital was a severe strain and, after the total colectomy, I was sure that this burden had been lifted but the interpretation I have (perhaps wrongly) made on the presence of melena has filled me with fear again.

Thank you very much in anticipation of your clarification.

[Kevin Pho, MD]

Surgeon has quite kindly illustrated a case where the melana may have stemmed from the diverticular disease, via the blood refluxing back into the upper digestive system.  

If there is continued concern about the melena, you can consider an upper GI workup - involving either an upper endoscopy (the more comprehensive test) or an upper GI series with small bowel follow-through - to completely rule out upper GI causes (i.e. ulcers or inflammation of the upper digestive tract).

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[surgeon]

The odds are with you: such bleeding as you describe is highly associated with diverticular disease, and since that's what they found it's likely that one plus one makes two. Melana indeed usually comes from bleeding above the colon. But in cases of large amounts of blood, it can also be seen in colonic bleeding. One way is that blood may actually reflux backward into the small intestine if the colon is full enough of blood. Another is that some digestive juices from the small intestine are still active in the colon. So melana is not a rare phenomenon in lower gi bleeding.