22-Year-Old Female with Black Tarry Stools and Complex GI History

Case at a Glance

A 22-year-old female with a history of recurrent Mallory-Weiss tears, chronic acid reflux, and frequent emergency department visits presents with new-onset melena. Patient reports feeling well despite concerning stool appearance and seeks guidance on urgency of evaluation.

Patient's Story

The patient is a 22-year-old female with a complex gastrointestinal history including recurrent hematemesis secondary to Mallory-Weiss tears that reopen due to stress-induced nausea and chronic acid reflux. She experiences frequent vomiting episodes and has a pattern of monthly emergency department visits for various complications including kidney stones, electrolyte imbalances (previous hypokalemia with K+ 2.3), and gastrointestinal bleeding. Two weeks prior to current presentation, she noticed red material in her stool, prompting an ED visit where hematocrit was normal and she was discharged. Her primary care physician attributed the red material to dietary causes. The patient now presents with black, tarry stools but reports feeling otherwise well. She expresses reluctance to seek emergency care due to frequent prior visits and frustration with healthcare utilization.

Initial Assessment

Patient appears clinically stable with new-onset melena in the setting of known upper GI pathology. Vital signs stable, patient ambulatory and conversational. No acute distress noted despite concerning stool appearance. Recent hematocrit within normal limits two weeks prior.

The Diagnostic Journey

Given the patient's history of Mallory-Weiss tears and current presentation of melena, upper gastrointestinal bleeding was the primary concern. The timing relationship between her known esophageal injury and new lower GI symptoms suggested possible ongoing or recurrent upper GI bleeding with transit time allowing for melena formation. Differential diagnosis included reactivation of previous Mallory-Weiss tear, medication-induced gastritis, or new peptic ulcer disease.

Final Diagnosis

Suspected upper gastrointestinal bleeding with melena secondary to chronic Mallory-Weiss tear in a hemodynamically stable patient.

Treatment Plan

Given hemodynamic stability and recent normal hematocrit, outpatient management was considered appropriate with close follow-up. Plan included: 1) Urgent gastroenterology consultation within 24-48 hours, 2) Complete blood count to assess for anemia, 3) Proton pump inhibitor therapy optimization, 4) Dietary modifications to reduce acid production, 5) Stress management techniques to minimize vomiting episodes, 6) Patient education on warning signs requiring immediate medical attention.

Outcome and Follow-up

Patient was advised to seek non-emergent medical evaluation with her gastroenterologist within 1-2 days rather than immediate emergency department presentation, given her hemodynamic stability and recent normal laboratory values. This approach balanced appropriate medical caution with the patient's expressed concerns about healthcare overutilization and her established pattern of frequent emergency visits.