Clinical problem-solving. A not-so-obscure cause of gastrointestinal bleeding.

A 66-year-old man was admitted to the hospital with a 2-day history of fatigue, dizziness on standing, and bright red blood from the rectum that transitioned to black, tarry stools. He reported no abdominal pain, nausea, vomiting, or weight loss. He had a history of several myocardial infarctions and subsequent ischemic cardiomyopathy (ejection fraction, approximately 20%); a HeartMate II left ventricular assist device (LVAD) had been placed 2.5 months earlier as destination therapy (i.e., permanent therapy for a patient who is not a candidate for heart transplantation). He also had chronic atrial fibrillation. Medications included warfarin (target international normalized ratio [INR], 2.0 to 3.0), low-dose aspirin, amiodarone, and metoprolol. On physical examination, the patient’s skin and conjunctiva were pale. The heart rate and blood pressure (measured by automated sphygmomanometry) were 74 beats per minute and 117/99 mm Hg, respectively. A continuous hum from the LVAD was heard in the precordial region. The abdomen was soft, with normoactive bowel sounds. Melena was noted in the patient’s bed. There were no stigmata of chronic liver disease.