What is the most likely diagnosis in a patient presenting with two episodes of coffee‑ground emesis and two episodes of melena?

Upper Gastrointestinal Bleeding

The most likely diagnosis is acute upper gastrointestinal bleeding, with peptic ulcer disease being the leading cause (accounting for 35–50% of cases), followed by gastroduodenal erosions, esophagitis, Mallory-Weiss tears, and esophageal varices. 1, 2, 3

Clinical Significance of the Presentation

• Coffee-ground emesis results from gastric acid converting hemoglobin to hematin, creating the characteristic dark, granular appearance that indicates less active bleeding compared to bright red hematemesis, as the blood has had time to be partially digested. 2

• Melena is defined as the passage of black tarry stools, indicating digested blood in the gastrointestinal tract, and confirms an upper GI source in the vast majority of cases. 1

• The combination of coffee-ground emesis and melena strongly localizes the bleeding source to the upper GI tract (esophagus, stomach, or duodenum). 1, 2

Most Common Etiologies in Order of Frequency

• Peptic ulcer disease (gastric or duodenal ulcers) accounts for 35–50% of upper GI bleeding cases and is frequently associated with Helicobacter pylori infection or chronic NSAID use. 1, 3

• Gastroduodenal erosions cause 8–15% of cases, commonly associated with NSAID use, stress, or metabolic conditions like diabetes. 3

• Mallory-Weiss tears account for approximately 15% of cases, typically occurring after forceful vomiting or retching episodes. 3

• Esophagitis accounts for 5–15% of cases and is more frequently found in coffee-ground emesis compared to frank hematemesis. 3

• Esophageal varices cause 5–10% of upper GI bleeding overall, but when present typically cause massive hematemesis (66–70% of massive cases) rather than coffee grounds; however, variceal bleeding carries a 30% mortality versus 10% for nonvariceal sources. 2, 3

Critical Initial Assessment

• Check pulse, blood pressure, and hemoglobin immediately: patients with pulse >100 bpm, systolic BP <100 mmHg, and hemoglobin <100 g/L represent severe bleeding requiring intensive monitoring and aggressive resuscitation. 1, 2

• Establish two large-bore IV lines in the anticubital fossae and begin aggressive fluid resuscitation with normal saline (1–2 liters initially in hemodynamically compromised patients). 1, 2

• Transfuse red blood cells to maintain hemoglobin >7 g/dL (or >9 g/dL with massive bleeding or cardiovascular comorbidities). 1, 2

Important Diagnostic Considerations

• Specifically assess for cirrhosis, as variceal bleeding mortality approaches 30% versus 10% for nonvariceal sources and requires specialized management with prophylactic antibiotics and vasoactive medications. 2

• In hemodynamically stable patients with coffee-ground emesis, evaluate for non-GI conditions including acute myocardial infarction, sepsis, pulmonary emboli, small bowel obstruction, and acute renal failure, as these are frequently the primary diagnosis in stable patients with coffee-ground material. 2, 4

• Obtain a detailed medication history to identify NSAID use, anticoagulation (warfarin or direct oral anticoagulants), or aspirin, as these markedly raise the risk of GI bleeding from any pre-existing lesion. 1

Endoscopic Evaluation Timing

• Perform esophagogastroduodenoscopy (EGD) within 24 hours after achieving hemodynamic stability, as it has both diagnostic and therapeutic capabilities. 1, 2

• Critical pitfall: Do not perform endoscopy before adequate resuscitation in unstable patients, as this increases mortality; keep the patient fasted until hemodynamically stable. 1, 2

• In severely bleeding patients, consider endotracheal intubation before endoscopy to prevent pulmonary aspiration. 1

Special Population Considerations

• Elderly patients (>65 years) experience markedly higher mortality from melena, reaching up to 30% in those older than 90 years, and therefore require more aggressive inpatient management. 1, 2

• The presence of serious comorbid conditions (cardiovascular disease, renal insufficiency, liver disease, advanced malignancy) is the strongest predictor of death; virtually all fatalities occur in patients with such significant medical illnesses. 1

• Very low-risk young patients without hemodynamic compromise, significant comorbidities, or high-risk features may be managed as outpatients after appropriate evaluation, though this should be the exception rather than the rule. 1, 2