Very rapid upper gastrointestinal hemorrhage, often from an arterial site in a peptic ulcer, may cause hematochezia. If slow intestinal transit occurs, melenic stools may be due to bleeding from sites as distal as the cecum. A melenic stool usually means upper gastrointestinal hemorrhage, whereas hematochezia usually has a colonic source. ![]() Other substances, such as iron or bismuth, can turn the stool black. Melenic stools also have a stickiness that the patient often remembers. Make the patient understand that you mean jet black by comparing the stool color to a black object. The direct question, "Are your stools black or bloody?" should be used when active bleeding may be occurring. The patient with profuse epistaxis is almost invariably aware that a nosebleed has occurred. Hemoptysis is associated with coughing and is bright, foamy red in color. A careful history usually resolves this confusion. ![]() Occasionally hemoptysis or vomiting of swallowed blood from epistaxis can be confused with hematemesis. Hematemesis indicates that the bleeding is from the upper gastrointestinal tract, usually from the esophagus, stomach, or proximal duodenum. A bloody appearance is readily identified as hematemesis, but the coffee-ground appearance will not be recognized without direct questioning. The examiner should ask the patient if vomiting occurred, if blood or clots were present in the emesis, and if the vomitus looked brown, like coffee grounds, indicating the probable presence of blood. In the patient who may be bleeding profusely and need immediate treatment, directed rather than open-ended questions are appropriate. The patient having an acute gastrointestinal hemorrhage seeks a physician's help because of hematemesis, melena, or hematochezia, or because of symptoms of hypovolemia such as fainting or lightheadedness.
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