SHM Converge Scientific Abstract ePoster Gallery-A Mysterious Source of Melena

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A 75-year-old man with atrial fibrillation on apixaban, NASH cirrhosis, and chronic anemia presented with two weeks of melena and severe weakness. His hemoglobin was 5.5 g/dL, and despite repeated evaluation with endoscopies, colonoscopies, capsule endoscopy, and CT imaging, no gastrointestinal bleeding source was identified. He required nine units of blood during hospitalization.<br /><br />He also reported intermittent mild nosebleeds, morning hemoptysis, and a metallic “gurgling” sensation in his throat. Initial bedside laryngoscopy showed only a subtle vallecular varicosity. Bronchoscopy was unremarkable, but during preparation he developed brisk oral bleeding requiring intubation for airway protection. Repeat endoscopy again showed fresh blood without a GI source. Otolaryngology then identified actively bleeding vallecular varices, which were cauterized. After this intervention, his hemoglobin stabilized and began to recover.<br /><br />This case highlights an unusual cause of apparent upper GI bleeding: vallecular varices, which are rare vascular lesions at the base of the tongue near the epiglottis. They more commonly present with hematemesis or hemoptysis than melena, and prior published cases have not described melena as the main presentation. The report emphasizes that standard EGD does not evaluate the oropharynx, and bleeding sources above the GI tract should be considered when melena persists despite negative GI workup.<br /><br />Key takeaways are that diagnosing obscure bleeding may require persistence, broad differential thinking, and careful history-taking.

Asset Subtitle

Jennifer A. Woodard

Meta Tag

Author List Jacob Jewulski, Jennifer A. Woodard

Category Clinical Vignettes

Concept Melena

Concept Vallecular Varices

Concept Upper Gastrointestinal Bleeding

Concept Obscure Bleeding

Concept Bleeding History

Distinguished Non-Finalist

Presenter Organization Medical College of Wisconsin

Presenting Author Jennifer A. Woodard

Track Adult

Keywords

vallecular varices

melena

upper gastrointestinal bleeding

atrial fibrillation

apixaban

cirrhosis

hemoptysis

oropharyngeal bleeding

endoscopy

anemia

Melena

Vallecular Varices

Upper Gastrointestinal Bleeding

Obscure Bleeding

Bleeding History