In most cases, patients will report hematemesis, coffeeground emesis, hematochezia, or melena. The duration and frequency of these symptoms should be elicited. For hematemesis, it is important to determine whether blood was present initially or appeared after several episodes of vomiting. The latter history suggests a Mallory-Weiss tear. A history compatible with cirrhosis (chronic alcohol use, hepatitis, IV drug use) suggests varices. These patients may also have a coagulopathy, making control of hemorrhage more difficult. When bleeding has been slow but chronic, the patient may present with lightheadedness, fatigue, chest pain, or shortness of breath owing to anemia without any knowledge of GI bleeding. Patients with peptic ulcer disease may report epigastric abdominal pain related to eating. Agents that increase the risk of peptic ulcer disease include nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and cigarettes. Elderly patients with acute hemorrhage may initially present with syncope or near-syncope.
Vital signs should be obtained immediately. When abnormalities are present, treatment is frequently necessary before obtaining a thorough history. Tachycardia and hypotension indicate hypovolemic shock and require immediate resuscitation. Cool, pale, and clammy skin is evidence of anemia or shock. The abdomen should be thoroughly examined, noting areas of tenderness or peritonitis. Rectal examination should be performed with Hemoccult testing. The presence of hemorrhoids should be documented. They may or may not be the source of lower GI bleeding. Examination should also elicit any evidence of the stigmata of cirrhosis including ascites, spider angioma, jaundice, or palmar erythema.