What is the appropriate initial assessment and management for a patient presenting with melena?

History of Present Illness for a Patient Presenting with Melena

Chief Complaint and Onset

Document the precise timing and character of the melena, specifically asking about the color (dark black, tarry stools), consistency, frequency, and duration of symptoms. 1, 2 The presence of melena typically indicates bleeding proximal to the ligament of Treitz, though it can occasionally originate from the proximal small intestine or even the colon in cases of slow transit. 3, 4

• Quantify the number of melenic stools in the past 24-48 hours, as this helps estimate the severity and acuity of bleeding 5
• Ask specifically about associated hematemesis (present in approximately 65% of upper GI bleeding cases), as this combination indicates more proximal and potentially more severe bleeding 5
• Determine if symptoms began suddenly or gradually, as acute onset suggests active hemorrhage requiring more urgent intervention 1, 2

Associated Symptoms and Hemodynamic Status

Systematically assess for signs of hemodynamic compromise, which directly impacts management urgency and mortality risk. 1, 6

• Document presence of lightheadedness, dizziness, syncope, or presyncope, as these suggest significant blood loss with orthostatic changes 2
• Ask about chest pain, palpitations, or shortness of breath, particularly in elderly patients where cardiovascular ischemia may complicate bleeding 6, 2
• Inquire about abdominal pain, nausea, or vomiting, as epigastric pain suggests peptic ulcer disease while painless bleeding may indicate vascular malformations or malignancy 7, 5
• Note any recent changes in mental status or confusion, which may indicate shock or severe anemia 2

Medication History

Obtain a detailed medication history with specific attention to agents that increase bleeding risk or suggest underlying pathology. 6

• Document all anticoagulants (warfarin, rivaroxaban, apixaban, dabigatran) with dosing and timing of last dose, as these dramatically increase bleeding severity and alter management 6
• Record all antiplatelet agents (aspirin, clopidogrel, prasugrel, ticagrelor), including over-the-counter aspirin use 6
• Ask about NSAIDs (ibuprofen, naproxen, ketorolac), including frequency and duration of use, as these are major risk factors for peptic ulcer bleeding 5
• Note recent antibiotic use, particularly amoxicillin-clavulanate, which can cause gastric irritation and bleeding 6
• Document proton pump inhibitor or H2-blocker use, as absence suggests unprotected gastric mucosa in high-risk patients 7

Past Medical History

Identify comorbidities that significantly impact mortality risk and guide management intensity. 1, 6

• Cardiovascular disease (coronary artery disease, heart failure, arrhythmias) increases mortality risk and may require higher hemoglobin transfusion thresholds 1, 2
• Liver disease or cirrhosis with portal hypertension, as variceal bleeding accounts for approximately 50% of upper GI bleeding in these patients and requires different management 5
• Chronic kidney disease, particularly in elderly patients on anticoagulation where drug clearance is impaired 6
• Previous peptic ulcer disease or H. pylori infection, as recurrent ulcers are common 5
• Known malignancy, particularly gastric or esophageal cancer, which may present with chronic or acute bleeding 7
• History of inflammatory bowel disease, as ulcerative colitis can rarely present with melena from colonic bleeding 4

Prior GI History

Document any previous episodes of GI bleeding and their management, as this predicts recurrence risk. 7, 5

• Previous endoscopy findings, including ulcers, varices, vascular malformations, or malignancy 5
• History of H. pylori testing and eradication therapy, as untreated infection leads to recurrent ulcer bleeding 5
• Prior endoscopic or surgical interventions for bleeding (band ligation, sclerotherapy, embolization, surgery) 7

Social History

Identify lifestyle factors that contribute to bleeding risk and guide counseling. 7

• Alcohol use (quantity, frequency, duration), as heavy use causes gastritis, varices, and coagulopathy 5
• Tobacco use, which impairs ulcer healing and increases gastric cancer risk 7

Risk Stratification Elements

Categorize the patient into high or low mortality risk based on specific clinical parameters. 1, 6

• Age >65 years (particularly >80 years) dramatically increases mortality risk to approximately 30% in patients >90 years 6
• Presence of shock (pulse >100 bpm, systolic BP <100 mmHg) defines massive bleeding requiring immediate intervention 1, 8
• Multiple comorbidities (polytrauma, pleural effusion, recent infections) compound bleeding risk in elderly patients 6

Quantifying Blood Loss

Estimate the severity of bleeding through specific historical details. 8

• Ask about estimated blood volume in vomitus or stool, though patient estimates are often inaccurate 8
• Document transfusion requirements if already initiated, as >1000 mL in one hour or >2000 mL in 24 hours defines massive bleeding 8
• Note baseline hemoglobin if known, as a drop to ≤8.0 g/dL combined with shock indicates massive hemorrhage 8