Upper GI bleed in a patient on a direct oral anticoagulant with a duodenal ulcer
A 71-year-old man presents with 18 hours of melena and one episode of hematemesis. He takes apixaban 5 mg twice daily for atrial fibrillation, last dose 10 hours ago, plus aspirin 81 mg daily for prior TIA. BP 104/64 mmHg, HR 112/min, RR 22, afebrile. Hb 78 g/L, platelets 210 ×10^9/L, INR 1.1, creatinine 118 µmol/L (eGFR ~55), ALT normal. He is alert but pale and clammy; capillary refill 3 seconds. Two large-bore IVs are placed and 1 L crystalloid has been started. There is no evidence of cirrhosis; he has never had prior endoscopy. The on-call gastroenterology fellow is 45 minutes away, and the ICU has one open bed.
1. Outline your immediate resuscitation and pharmacologic plan over the next 2 hours, including how you would handle his anticoagulant and antiplatelet therapy. Justify each decision.
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Resuscitation priorities
- Airway/breathing first: he is clammy and tachycardic; give oxygen if saturations <94%, position supine, and place a urinary catheter to monitor output.
- Restrictive transfusion: target Hb 70–80 g/L (transfuse 1–2 units packed cells to reach ~75 g/L). Over-transfusion raises portal pressure and re-bleeding risk even in non-cirrhotics; a restrictive strategy is supported by evidence in acute upper GI bleeding.
- Do not over-resuscitate with crystalloid; aim for permissive hypotension (MAP ~65 mmHg) until bleeding is controlled. Start a proton-pump inhibitor infusion (e.g., 80 mg bolus then 8 mg/h) - this stabilises clot at the ulcer base and reduces re-bleeding/stigmata progression.
- Correct coagulopathy only if bleeding is uncontrolled or invasive procedures planned. INR 1.1 and platelets 210 do not require product replacement.
Anticoagulant/antiplatelet management
- Apixaban: last dose 10 h ago, eGFR ~55, so residual effect is likely. For life-threatening GI bleeding, give andexanet alfa if available; otherwise 4-factor PCC (e.g., 25–50 U/kg) is a reasonable off-label reversal. Activated charcoal is not indicated (late, and airway risk).
- Avoid tranexamic acid routinely in GI bleeding (HALT-IT showed no benefit and possible harm).
- Aspirin: continue it in most patients with recent TIA/cardiovascular disease once haemostasis is achieved; stopping aspirin increases thrombotic risk. If bleeding is torrential and uncontrolled, hold temporarily and restart after endoscopic haemostasis (usually within 24–72 h).
- Restart apixaban only after endoscopic haemostasis and usually after 3–7 days, in discussion with cardiology, balancing stroke risk (CHA2DS2-VASc likely high).
Disposition
- Admit to a monitored bed (ICU/HDU) given ongoing tachycardia and comorbidity. Arrange urgent endoscopy within 12–24 h (after resuscitation); if he deteriorates, the fellow should be called in emergently.
2. Endoscopy shows a 1.5 cm posterior duodenal bulb ulcer with a non-bleeding visible vessel. What is your endoscopic and post-endoscopic management, and what would you do if he re-bleeds 6 hours later with hematemesis and BP 88/50?
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Endoscopic therapy
- A non-bleeding visible vessel (Forrest IIa) carries a high re-bleeding risk (~40–50% without therapy). Treat with combination endoscopic therapy: epinephrine injection (1:10,000) to slow bleeding, followed by a mechanical or thermal method - either through-the-scope clips or thermal coagulation (bipolar/heater probe).
- Do not use epinephrine alone (inferior to combination).
- After haemostasis, mark the site if re-look is planned (e.g., India ink tattoo is not standard in the duodenum; document position carefully).
Post-endoscopic care
- Continue high-dose PPI infusion for 72 h, then oral PPI.
- Keep NPO until stable, then clear fluids and advance.
- Eradicate H. pylori if positive (biopsy or rapid urease test at index endoscopy; if negative but high suspicion, repeat testing). Eradication markedly reduces re-bleeding.
- Stop NSAIDs; review aspirin timing with cardiology.
- Second-look endoscopy is not routine but is reasonable in high-risk lesions (large ulcer, visible vessel, comorbid) or if there is doubt about haemostasis.
Re-bleeding at 6 h with shock
- This is a failure of initial endoscopic therapy. Resuscitate (airway, large-bore access, blood products, PPI infusion) and call the GI fellow for repeat endoscopy - repeat endoscopic therapy is first-line for re-bleeding and is successful in most.
- If repeat endoscopy fails or is not feasible, proceed to interventional radiology angiography with embolisation (gastroduodenal artery branches) - preferred over surgery in a comorbid patient.
- Surgery (oversewing/duodenotomy with ligation of the gastroduodenal artery, or partial gastrectomy) is reserved for failure of endoscopic and radiological measures or massive uncontrolled haemorrhage. Involve anaesthesia and ICU early.