What is the appropriate assessment for a 40-year-old man with a history of falls and syncope (fainting) over the last 2 days, presenting with melena (black, tarry stools), normal Blood Pressure (BP), and tachycardia (elevated heart rate of 110 beats per minute), with no comorbidities?

From the Guidelines

The patient's presentation with melena, tachycardia, and a history of falls and syncope suggests a high clinical concern for upper gastrointestinal bleeding.

Initial Assessment

Given the presence of melena, which is a sign of upper GI bleed, and the absence of comorbidities, the Rockall score 1, used to predict the risk of rebleeding and mortality in patients with upper GI bleeding, would likely be low, suggesting a pre-endoscopy Rockall score of 1 is plausible if no other high-risk features are present.

• The Blatchford score 1 can also be used to identify patients at low risk for clinical intervention, and it includes factors such as hemoglobin level, blood urea level, pulse, systolic blood pressure, and the presence of syncope or melena.
• An urgent ECG is not necessarily required unless there are symptoms suggestive of cardiac ischemia or arrhythmia, but given the tachycardia, monitoring may be prudent 1.

Laboratory Testing

• Targeted blood tests are reasonable in the evaluation of selected patients with syncope identified on the basis of clinical assessment from history, physical examination, and ECG 1.
• Complete blood count and electrolyte panel are frequently obtained during syncope evaluation, but the diagnostic yield is low when these are used routinely; however, when these blood tests are conducted in patients with a suspected related diagnosis (e.g., history of peptic ulcer disease, or tarry stools associated with orthostatic hypotension on physical examination), test results can be diagnostic and useful for guiding therapy 1.

Management

• Blood transfusions should be administered to a patient with a hemoglobin level of 70 g/L or less 1.
• The threshold for transfusion for each patient should be based on his or her underlying condition, hemodynamic status, and markers of tissue hypoxia in acute situations 1.