Ask: What are the observations? Is he pale, sweaty, dizzy? How much? Any vomiting, and what colour? Is he on anticoagulation?
Tell the nurse: two large-bore cannulae · full vitals, with a lying and standing BP only if he is genuinely stable and it is safe to do — not in someone actively vomiting blood, syncopal or tachycardic · crossmatch and full bloods including coagulation · keep the bedpan contents, do not flush them away · nil by mouth.
Melena means an upper GI bleed until proven otherwise — and once in a while it is a slow right colon or small bowel, so “until proven” is doing real work in that sentence. The patient who looks fine now is the one who arrests at handover.
- Variceal bleed in known or suspected liver disease — different pathway, different drugs, high mortality
- Peptic ulcer, often with NSAIDs, steroids or Helicobacter
- Anticoagulant- or antiplatelet-associated — and the reversal question is the one you must answer explicitly
- Aorto-enteric fistula in anyone with a previous aortic graft — rare, unforgiving, and asked about almost never
FIRST MOVES Resuscitate before you diagnose. Two cannulae, crossmatch, full blood count, urea (a disproportionately raised urea supports an upper source), coagulation, liver function, lactate. Restrictive transfusion is the evidence-based default in stable, non-exsanguinating bleeding — commonly a threshold of 7 g/dL — so do not reflexively chase a normal haemoglobin, while individualising for massive haemorrhage, shock, active cardiac ischaemia or significant cardiovascular disease. Withhold the anticoagulant and make an explicit, documented reversal decision. The antiplatelet is a separate conversation: aspirin for secondary prevention is not automatically stopped, and dual antiplatelet therapy after a recent stent is a phone call to cardiology and gastroenterology tonight, not a line you cross out on the chart. Proton pump inhibitor per local practice. If varices are plausible, add a vasoactive agent and antibiotic prophylaxis per protocol, and call gastroenterology now rather than in the morning.
Ward call: [AGE]-year-old [SEX], day [X] for [REASON]. Melena [ESTIMATED VOLUME], onset [TIME]. Haematemesis: [Y/N, colour]. HR [X], BP [X] lying / [X] standing, sats [X]%, RR [X], pale/clammy [Y/N]. Hb [X] (previous [X]), urea [X], creatinine [X], platelets [X], INR [X], albumin/bilirubin [X]. Anticoagulant or antiplatelet: [WHICH, last dose WHEN]. Liver disease or known varices: [Y/N]. Previous aortic graft: [Y/N]. NSAIDs/steroids: [Y/N]. Available tonight: [ENDOSCOPY ON CALL / NOT]. Give me the resuscitation sequence first. Then: variceal or non-variceal, and what in my description points which way. Give me an explicit reversal recommendation for this specific anticoagulant with agent and dose, and a transfusion threshold with the reasoning. Then tell me exactly what makes this an overnight endoscopy rather than a morning one.