Case Presentation: Patients presenting with melena are often found to have an upper gastrointestinal source: melenic stool on exam has a likelihood ratio of 25 for upper gastrointestinal bleed (1). But what if repeated endoscopies are unimpressive? Mr. S is a 75 year old male with a history of atrial fibrillation on apixaban for three years, NASH cirrhosis, chronic anemia (baseline hemoglobin 12 mg/dl) who presented with two weeks of melena and weakness. His admission Hgb was 5.5 mg/dL and the rectal exam confirmed melena. He underwent multiple endoscopies, colonoscopies, and a capsule study which did not identify a source. CT chest, abdomen, and pelvis showed no evidence of a hematoma and laboratory studies showed no coagulopathy. His melena and anemia persisted, receiving in total nine units of blood across multiple days. Throughout admission, he noted periodic episodes of mild, self-limiting epistaxis and slight morning hemoptysis with associated metallic “gurgling” sensation in his throat. Otolaryngology performed a bedside direct laryngoscopy which revealed a minimal varicosity of the right vallecula which was probed without incident.Pulmonology performed a bronchoscopy to evaluate his hemoptysis, which was unremarkable, but the patient had an episode of brisk oral bleeding requiring intubation for airway protection. Repeat endoscopy after intubation showed fresh blood but no source. Otolaryngology subsequently visualized actively bleeding vallecular varices which were cauterized. He remained intubated overnight and was extubated without incident the following day. His hemoglobin remained stable and began recovering following cauterization.
Discussion: Vallecular varices are exceedingly rare causes of bleeding and more often present with hematemesis than melena. In the three other case reports published on vallecular varices, patients presented with hemoptysis, not melena (2-4).
Conclusions: This patient had an unusual presentation of a rare cause of bleeding that required considering sources above the gastrointestinal tract for a successful diagnosis. Three takeaway points:1. EGD does not examine the oropharynx2. Identifying a source of bleeding takes luck, persistence, and diagnostic flexibility3. Taking a good history is still important!