Gastrointestinal Bleeding — Written Clinical Reasoning

SAQ 1 — Integrated Management (20 marks, 30 minutes)

Prompt: Outline your integrated management plan for this patient, including immediate resuscitation, risk stratification, anticoagulation and antiplatelet management, pharmacotherapy, and endoscopic strategy. Justify each decision with reference to evidence. [1]

Model Answer

Problem list (4 marks):

1. Acute upper GI bleed with haemodynamic compromise (shock: SBP 94, tachycardia, cool peripheries)
2. Likely non-variceal source — peptic ulcer probable (recent naproxen increase + aspirin); no stigmata of chronic liver disease, normal LFTs
3. Anticoagulation with apixaban (bleeding risk) plus aspirin (dual haemostatic impairment)
4. Significant cardiovascular comorbidity (recent NSTEMI with DES, AF) — high thrombotic risk if anticoagulation/antiplatelets are stopped
5. CKD stage 3a (eGFR 42) — contributes to anaemia, alters drug handling
6. Polypharmacy and multi-morbidity — coordinated care needed [1]

Immediate resuscitation and risk stratification (4 marks):

• ABCDE: secure IV access with two large-bore cannulae; crystalloid bolus (500 mL 0.9% sodium chloride, reassess); cross-match 2 to 4 units; monitor urine output (catheterise). Airway is currently protected — he is not actively vomiting now.
• Risk stratify with the Glasgow-Blatchford Score (GBS): his score is high (urea 14.2 = 4 points; Hb 72 in a man = 6 points; SBP 94 = 2 points; pulse >100 = 1 point) giving a GBS of at least 13 — confirmed high risk requiring admission and endoscopic therapy (Blatchford 2000).
• Restrictive transfusion: his Hb is 72 g/L and he has ischaemic heart disease (prior NSTEMI). Use a threshold around 80 g/L with a target of 80 to 90 g/L given the acute coronary context — Villanueva et al. (NEJM 2013) established that a restrictive strategy (threshold 70 g/L) improves survival, but the major exception is acute coronary syndrome or critical vascular disease where a higher threshold is reasonable. He should receive one to two units to reach 80 to 90 g/L. [1]

Anticoagulation and antiplatelet management (4 marks):

• Apixaban: withhold immediately. For a life-threatening bleed, discuss specific reversal with haematology (andexanet alfa, or prothrombin complex concentrate if andexanet unavailable or delayed). Weigh reversal against his high thrombotic risk — but in active major haemorrhage, haemostasis takes priority. Plan to resume apixaban once haemostasis is secured, typically 7 to 14 days post-bleed, balancing his CHA2DS2-VASc thrombotic risk against rebleeding.
• Aspirin: continue for secondary cardiovascular prevention where possible — stopping aspirin in a patient with a prior stent carries a real risk of stent thrombosis. If bleeding is uncontrolled, withhold temporarily and resume as soon as haemostasis is achieved (usually within 24 to 48 hours). Do not stop without cardiology input given his recent NSTEMI with DES.
• Naproxen (NSAID): cease permanently — this is the likely precipitant of the peptic ulcer. Switch analgesia to paracetamol-based regimens. [1]

Pharmacotherapy (4 marks):

• Start an IV PPI infusion immediately — esomeprazole or omeprazole 80 mg IV bolus, then 8 mg/hour infusion for 72 hours after endoscopic haemostasis (Lau et al., NEJM 2000). Give the bolus before endoscopy.
• He is low probability for variceal bleeding (no cirrhosis signs, normal LFTs), so vasoactive agents and prophylactic antibiotics are not indicated. If endoscopy reveals varices, add terlipressin and ceftriaxone. [1]

Endoscopic strategy (4 marks):

• Arrange upper GI endoscopy within 24 hours (within 12 hours if variceal bleeding is suspected or he destabilises) once resuscitation is underway. Do not scope an under-resuscitated, shocked patient.
• At endoscopy, if a bleeding peptic ulcer with high-risk stigmata (active spurting, visible vessel) is found, apply dual endoscopic therapy — adrenaline submucosal injection plus a mechanical or thermal method (haemoclip, heater probe). Adrenaline alone has an unacceptably high rebleeding rate.
• Post-endoscopy, calculate the full Rockall score to quantify mortality and rebleeding risk and guide level of care (his pre-endoscopic Rockall is already high: age >60 = 1, tachycardia/shock = 2, comorbidity (cardiac/renal) = 2, total at least 5 pre-endoscopy).
• If endoscopic therapy fails, repeat endoscopy once, then proceed to mesenteric angiography with embolisation or surgical oversew. [1]

Communication and follow-up: discuss the plan with the patient and family, explaining the need to temporarily hold apixaban and the plan for safe resumption. Arrange multidisciplinary coordination (gastroenterology, cardiology, haematology, nephrology). After recovery, test and treat H. pylori, continue a maintenance PPI, and review his complete medication regimen. [1]