A duodenal ulcer with a visible vessel in a man taking aspirin and naproxen
Mr Lee, 66, presents with two episodes of coffee-ground vomiting and melaena. He is pale and sweaty: BP 104/62 mmHg, HR 112/min, capillary refill 3 seconds. Hb 78 g/L, urea 14.2 mmol/L, creatinine 88 µmol/L, platelets 240 ×10⁹/L, INR 1.0. He takes aspirin 80 mg daily following a drug-eluting stent to the left anterior descending artery two years ago, and for three weeks has been taking naproxen bought over the counter for knee pain. Endoscopy shows a 1.5 cm duodenal ulcer with a non-bleeding visible vessel; haemostasis is achieved with adrenaline injection and a heater probe. He is admitted to a medical ward at 02:00 and is haemodynamically stable after 1 L of crystalloid.
1. Would you transfuse this man, and to what target? Justify your answer in a patient with ischaemic heart disease.
Read the worked answer
He is actively bleeding with a Hb of 78 g/L and haemodynamic compromise, so fluid resuscitation and packed cells are appropriate, but the target should be restrictive. Trials in acute upper GI bleeding show that a threshold of about 70 g/L (with a target range of 70–90 g/L) reduces further bleeding and death compared with liberal transfusion; over-transfusion raises portal and mucosal pressure and can precipitate rebleeding.
His stable ischaemic heart disease shifts the practical threshold to about 80 g/L, but he does not need to be transfused to a normal haemoglobin. Give one unit, reassess symptoms, BP, heart rate and Hb, then decide; avoid routine FFP and platelets, as his coagulation is normal. Note also that the initial Hb may be falsely reassuring before haemodilution. Use crystalloid cautiously rather than large volumes, and involve the cardiologist only if he develops chest pain or ischaemic ECG changes.
2. When should aspirin be restarted, and what would you do about his naproxen and analgesia?
Read the worked answer
Aspirin should not be stopped indefinitely. Continuing or restarting it within 3–5 days of endoscopic haemostasis reduces mortality and stent thrombosis without a clinically important increase in rebleeding. His stent is two years old, so he is not in the highest-risk early post-stent window, but secondary prevention after a coronary event still matters, and the risk of stopping antiplatelet therapy in a bleeding patient is often underappreciated on a surgical ward.
He does not need dual antiplatelet therapy. The naproxen must stop: a non-selective NSAID plus aspirin is the main driver of this ulcer, and NSAIDs increase both rebleeding and cardiovascular risk. For his knee, use paracetamol with or without topical NSAID; if an oral NSAID is unavoidable after discussion, use the lowest dose of celecoxib for the shortest period with continuous PPI cover. Document the advice and warn him explicitly about over-the-counter NSAIDs.
3. What acid-suppression, infection-related and follow-up measures would you institute, and why?
Read the worked answer
For a duodenal ulcer with a non-bleeding visible vessel, give a high-dose proton pump inhibitor: an IV bolus followed by infusion for 72 hours (for example omeprazole 80 mg bolus then 8 mg/hour), then oral therapy. This stabilises the clot and reduces rebleeding in high-risk stigmata.
Test for Helicobacter pylori with a rapid urease test on antral and body biopsies taken at endoscopy; the result may be falsely negative while on PPI, so if negative, repeat with a urea breath test or stool antigen after stopping PPI for two weeks. Eradicate if positive, with a documented regimen, and confirm eradication, since this reduces ulcer recurrence and rebleeding. Record the Glasgow-Blatchford score, admit for observation, and give clear advice to return if there is fresh haematemesis, melaena or syncope. Arrange early outpatient review and consider whether repeat endoscopy is needed if bleeding recurs.