58-Year-Old Woman With Melena

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Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN (T.G.C., B.A.-B.); Advisor to residents and Consultant in Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (C.G.L.). A 58-year-old woman presented to the emergency department with a 3-day history of passing dark, tarry stools. Her medical history was notable for symptomatic hemophilia A carrier state, gastroesophageal reflux disease, internal hemorrhoids, papillary thyroid cancer treated with thyroidectomy and radioactive iodine for nodal metastasis with secondary hypothyroidism, and obesity with a recent intentional 22.5-kg weight loss. She reported a 3-day history of passing black, tarry stools, averaging 3 stools per day. She did not have light-headedness on standing, any previous episodes, abdominal pain, vomiting, hematochezia, hematemesis, or history of liver or renal disease or alcohol abuse. She was not taking nonsteroidal anti-inflammatory drugs, iron, bismuth subsalicylate, or antiplatelet or anticoagulant medications. Her family history was notable for adenomatous colonic polyposis (at age 17 years, her son was diagnosed as having adenomatous colonic polyps that necessitated a subtotal colectomy). The patient’s last colonoscopy was 4 years before the current presentation and was negative for masses or polyps. On presentation, she had sinus tachycardia at 110 beats/min with a blood pressure of 111/ 51 mmHg. Examination findings were remarkable for conjunctival pallor and positive results on a fecal occult blood test with melenic stool noted on rectal examination. Examination revealed no abdominal tenderness or stigmata of chronic liver disease. Laboratory testing revealed the following notable results (reference ranges provided parenthetically): hemoglobin, 5.5 g/dL (12.015.5 g/dL); platelets, 179 10/L (150450 10/L); international normalized ratio, 1.0 (0.8-1.2); activated partial thromboplastin time, 27 seconds (28-38 seconds); factor VIII activity, 86% (55%-200%); sodium, 139 mmol/L (135-145 mmol/L); potassium, 4.2 mmol/L (3.6-5.2 mmol/L); serum urea nitrogen, 28 mg/dL (6-21 mg/dL); and creatinine, 0.7 mg/dL (0.6-1.1 mg/dL).