What history of symptoms and signs should be extracted in a patient with hematemesis of fresh blood and melena (black tarry stool), considering their past medical history, medication use, including Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), aspirin, anticoagulants, or steroids, and demographic factors such as age and sex?

History Taking in Hematemesis with Melena

In a patient presenting with fresh hematemesis and melena, immediately obtain a focused history targeting hemodynamic severity indicators, medication use (particularly NSAIDs, aspirin, anticoagulants, and steroids), prior GI bleeding or ulcer disease, liver disease, and cardiovascular comorbidities, as these directly determine mortality risk and guide urgent management. 1, 2, 3

Immediate Severity Assessment

Document the following to stratify bleeding severity:

• Hemodynamic symptoms: Syncope, presyncope, dizziness, or ongoing lightheadedness indicating significant blood loss 1, 3
• Volume of hematemesis: Fresh red blood versus coffee grounds, frequency of episodes, and estimated volume (massive hematemesis suggests variceal bleeding in 66-70% of cases) 2
• Stool characteristics: Confirm true melena (black, tarry, sticky consistency with characteristic odor) versus simple black stools from dietary causes; patients with both hematemesis and melena have more severe bleeding than melena alone 1, 4
• Timing: Duration of symptoms and whether bleeding is ongoing or resolved 1

Critical Medication History

NSAIDs and Aspirin: These are the most common iatrogenic causes of upper GI bleeding 2, 5

• Any NSAID use (prescription or over-the-counter) within the past 7 days, including dose and duration 6, 7
• Aspirin use at any dose (even low-dose carries 2.6-3.1 times increased risk of major bleeding regardless of formulation—enteric-coated and buffered forms are NOT safer) 6
• Duration of NSAID use (0.5-3 months carries specific risk patterns) 7

Anticoagulants and Antiplatelet Agents:

• Warfarin, direct oral anticoagulants, clopidogrel, or dual antiplatelet therapy (antiplatelet drugs increase bleeding risk 3.1-fold) 7, 8
• Compliance and most recent INR if on warfarin 3

Corticosteroids: Concurrent use with NSAIDs dramatically increases bleeding risk 5

Past Medical History—High-Risk Conditions

Prior GI Disease:

• Previous peptic ulcer disease (increases risk 4.1-fold) 7
• Prior episodes of GI bleeding or family history of GI bleeding (increases risk 3.3-fold) 7
• Known esophageal varices or gastroesophageal reflux disease 1, 2
• Helicobacter pylori infection history (increases risk 1.3-fold) 7

Liver Disease:

• Any history of cirrhosis, chronic hepatitis, or portal hypertension (variceal bleeding mortality approaches 30% versus 10% for nonvariceal sources; requires specialized management) 2, 3
• Alcohol use (3 or more drinks daily increases bleeding risk with NSAIDs) 5, 7

Cardiovascular Disease:

• History of cardiovascular or cerebrovascular disease (increases risk 1.5-fold and affects transfusion thresholds) 3, 7
• Aortic stenosis (consider Heyde syndrome with angiodysplasia as cause) 9

Other Comorbidities:

• Chronic kidney disease or end-stage renal disease (associated with angiodysplasia and uremic platelet dysfunction) 3, 9
• Diabetes mellitus (increases bleeding risk 1.4-fold) 7

Associated Symptoms

GI-Specific Symptoms:

• Upper abdominal discomfort or pain (increases risk 3.5-fold and may predict NSAID-related bleeding) 7
• Anorexia (increases risk 2.0-fold) 7
• Nausea or vomiting preceding hematemesis (suggests Mallory-Weiss tear if forceful retching occurred) 1, 2
• Weight loss (raises concern for malignancy) 2

Systemic Symptoms:

• Fever (consider infection, sepsis, or inflammatory causes) 2
• Jaundice or confusion (suggests hepatic decompensation in cirrhotic patients) 3

Demographic and Social History

• Age: Patients over 60-65 years have significantly higher mortality and require more aggressive management; elderly patients are more prone to vascular lesions (40% of causes over age 40) 2, 3, 4
• Sex: Document for risk stratification 1
• Socioeconomic status: Lower status correlates with higher incidence 1
• Alcohol consumption: Quantify daily intake (≥3 drinks daily with NSAIDs dramatically increases risk) 5, 7
• Smoking history: Independent risk factor 3

Common Pitfalls to Avoid

• Do not assume enteric-coated or buffered aspirin is safer—all formulations carry similar 2.6-3.1 times increased bleeding risk at low doses 6
• Do not overlook dietary causes of black stools—obtain detailed dietary history to distinguish from true melena 3, 4
• Do not miss concurrent antiplatelet therapy—many patients on aspirin also take clopidogrel or NSAIDs, compounding risk 7, 8
• Do not delay history for endoscopy—but recognize that hemodynamic stabilization takes absolute priority over detailed history-taking in unstable patients 3