Medical History

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Although the medical history may suggest the source of bleeding, it is often misleading. Thus, clinicians should strive to maintain a broad differential and clinical approach. Although most patients will volunteer complaints of hematemesis, hematochezia, or melena, GI bleeding may have more subtle presentations. Patients who present with hypotension, tachycardia, angina, syncope, weakness, confusion, or even cardiac arrest may harbor occult, underlying GI hemorrhage.

Historical features such as hematemesis, coffee-ground emesis, melena, or hematochezia should be sought. Classically, hematemesis or coffee-round emesis suggests a source proximal to the right colon, and hematochezia indicates a more distal colorectal lesion. However, exceptions to these rules occur. Weight loss and changes in bowel habits are classic symptoms of malignancy. Vomiting and retching, followed by hematemesis, is suggestive of a Mallory-Weiss tear. A history of an aortic graft should suggest the possibility of an aortoenteric fistula. A history of medication use should be determined, particularly salicylates, glucocorticoids, nonsteroidal anti-inflammatory agents, and anticoagulants. Alcohol abuse is strongly associated with a number of causes of GI bleeding, including peptic ulcer disease, erosive gastritis, and esophageal varices. Ingestion of iron or bismuth can simulate melena, and certain foods, such as beets, can simulate hematochezia. In such instances, stool guaiac testing will be negative. Finally, a prior history of GI bleeding should be sought, although recurrent bleeding episodes often originate from different sources.

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