The Hypotensive Patient with Dark Stool on the Ward
A 68-year-old man is day 3 after an uncomplicated laparoscopic cholecystectomy. He has known atrial fibrillation on apixaban 5 mg twice daily, withheld since the night before surgery. At 07:00 he reports feeling lightheaded and passes a large black tarry stool. Observations: HR 118 irregular, BP 92/58, RR 22, SpO2 97% on air, temperature 36.8 C. Abdomen is soft and non-tender, with no bruising at port sites. Hb is 74 g/L (pre-operative 131 g/L), platelets 190, INR 1.3, creatinine 118 micromol/L (baseline 88). Two 18G cannulae are in situ and 500 mL of crystalloid has been given. The surgical registrar is scrubbed in theatre for another 90 minutes and asks you to 'sort him out and call me later'.
1. Outline your immediate assessment and resuscitation priorities over the next 30 minutes, justifying each step.
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This is a post-operative upper GI bleed with haemodynamic compromise, not a simple anaemia. Priorities:
- Recognise shock and call for help. HR 118 with BP 92/58 and a 57 g/L fall in Hb means class II-III haemorrhage. Activate the rapid response team and request senior surgical and anaesthetic review now; do not wait for the scrubbed registrar.
- Airway/breathing are currently intact but reassess frequently; a further large haematemesis could compromise the airway.
- Circulation: two large-bore cannulae are in. Give a 500 mL crystalloid bolus and reassess, but adopt a restrictive/balanced strategy targeting a systolic BP around 90 mmHg and a palpable radial pulse rather than normalising pressure, to avoid clot disruption. Cross-match 4 units of red cells urgently and activate the major haemorrhage protocol if he deteriorates.
- Reverse anticoagulation. Apixaban was last taken over 72 hours ago, but renal impairment prolongs effect. Check a specific anti-Xa level if available and discuss with haematology; consider prothrombin complex concentrate or andexanet if available and bleeding is ongoing. Avoid vitamin K, which does not reverse apixaban.
- Investigations: repeat FBC, coagulation, fibrinogen, U&E, LFTs, group and save, and request an urgent OGD once resuscitated.
- Monitoring: catheterise for urine output, continuous cardiac monitoring, arterial line if unstable.
- Medications: hold apixaban, stop any NSAIDs, start a proton pump inhibitor infusion.
The key judgement is not to be falsely reassured by a soft abdomen or a normal INR; apixaban does not prolong INR.
2. The patient stabilises after 2 units of red cells. Endoscopy shows a 1.5 cm posterior duodenal ulcer with a visible vessel and oozing. Describe your endoscopic and subsequent management plan, including the anticoagulation dilemma.
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Endoscopic therapy: The lesion is Forrest Ib (oozing with a visible vessel), so endoscopic haemostasis is indicated. Inject dilute adrenaline around the base to reduce bleeding, then apply a mechanical or thermal modality: either a heater probe with coaptive coagulation or, preferably for a large vessel, through-the-scope clips. A combination of adrenaline plus a second modality is superior to adrenaline alone. Do not over-inject adrenaline, as this risks necrosis.
Immediate post-endoscopy: Continue high-dose proton pump inhibitor infusion for 72 hours, keep nil by mouth initially, and monitor Hb, lactate and urine output. Re-bleed risk for Forrest Ib is around 20-30%, so keep IV access and cross-matched blood available and have a low threshold for repeat endoscopy.
Anticoagulation: This is the central dilemma. Apixaban was for atrial fibrillation, so stroke risk is real but the immediate threat is exsanguination. Hold apixaban until haemostasis is secure and the patient is tolerating diet, typically 3-7 days, after multidisciplinary discussion weighing CHA2DS2-VASc score against re-bleed risk. Bridge only if stroke risk is very high and after bleeding has clearly stopped; routine bridging is not recommended. When restarting, consider a reduced dose if renal function is impaired and the bleeding risk remains high.
Failure: If re-bleeding occurs, repeat endoscopy; if that fails, interventional radiology embolisation is preferred to surgery in this comorbid patient. Surgery (undersewing plus vagotomy or partial gastrectomy) is a last resort.
Also: test for H. pylori and eradicate if positive, stop any ulcerogenic drugs, and document the discussion with the patient and family.