Haematemesis in a patient anticoagulated with apixaban
A 68-year-old man presents with two episodes of haematemesis and black tarry stools since yesterday. He has atrial fibrillation, hypertension and osteoarthritis. His medicines are apixaban 5 mg twice daily, bisoprolol 5 mg daily, atorvastatin 20 mg daily and ibuprofen as required; he stopped lansoprazole two months ago because he felt better. His last apixaban dose was 10 hours before arrival. He is pale and clammy. Blood pressure 96/58 mmHg, pulse 112 beats/min, respiratory rate 22, oxygen saturation 97% on air, temperature 36.8 °C. There is epigastric tenderness but no guarding or rebound. Digital rectal examination shows melaena. Haemoglobin 74 g/L, platelets 210 × 10⁹/L, INR 1.1, urea 18.0 mmol/L, creatinine 110 µmol/L. Two large-bore cannulae have been inserted and 1 litre of crystalloid has been given, with a rise in blood pressure to 104/62 mmHg.
1. Outline your immediate management in the first two hours, including whether you would reverse his anticoagulation.
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Resuscitation first
- Airway, breathing, circulation with continuous monitoring; protect the airway if he vomits or becomes drowsy.
- Two large-bore cannulae are already in place. Send full blood count, urea and electrolytes, liver tests, coagulation screen, group and save, and crossmatch 4 units.
- Restrictive transfusion: transfuse if haemoglobin falls below 70 g/L, or below 80 g/L if there is cardiac ischaemia; target 70–90 g/L rather than normalising.
- Correct coagulopathy and thrombocytopenia if present; avoid over-transfusion, which can raise portal pressure.
Anticoagulant and acid suppression
- Withhold apixaban. Stop ibuprofen permanently.
- Start intravenous proton-pump inhibitor therapy (for example omeprazole 80 mg bolus then infusion) after resuscitation.
- Tranexamic acid is not routine in non-variceal upper GI bleeding.
Reversal
Apixaban was taken 10 hours ago and he is not exsanguinating. Activated charcoal is not useful at this interval. If bleeding is life-threatening or emergency endoscopy/surgery is required, use andexanet alfa where available, or four-factor prothrombin complex concentrate (around 50 units/kg) if not - accepting an off-label thrombotic risk. Do not reverse simply because the INR is normal; INR does not reflect factor Xa inhibitor effect. Arrange endoscopy within 24 hours after resuscitation, sooner if he destabilises.
2. Calculate the Glasgow-Blatchford score from the data given and explain how it influences disposition.
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Components (adult, non-variceal):
- Urea 18.0 mmol/L (10.0–25.0) = 4
- Haemoglobin 74 g/L (<100) = 6
- Systolic BP 96 mmHg (90–99) = 2
- Pulse 112 beats/min (≥100) = 1
- Melaena = 1
- No syncope, no hepatic disease, no cardiac failure = 0
Total = 14
Interpretation
A score of 14 is very high risk. Scores of 0–1 identify patients suitable for outpatient management; a score ≥1 generally requires admission, and scores ≥7 predict a high likelihood of endoscopic therapy, transfusion or death. His score supports admission to a monitored bed, early consultant review, cross-matched blood and urgent endoscopy rather than a ward-based routine list.
The score is a triage tool, not a substitute for clinical judgement: his ongoing tachycardia after fluid suggests he is still under-resuscitated, and he needs reassessment for ongoing bleeding. Post-endoscopy, the Rockall score adds prognostic information about rebleeding and mortality.
3. Endoscopy shows a duodenal ulcer with a visible vessel, which is clipped successfully. When and how would you restart anticoagulation?
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Frame the competing risks explicitly. His CHA₂DS₂-VASc score is at least 2 (age 65–74, hypertension), so long-term anticoagulation is indicated; his HAS-BLED-type bleeding risk is high, particularly with concurrent NSAID use.
Timing
- Do not restart immediately. After secure endoscopic haemostasis, most guidance supports restarting oral anticoagulation at around 7–14 days, individualised by rebleeding risk, comorbidity and stroke risk. Involve cardiology and gastroenterology.
- If he rebleeds, delay further and reconsider the agent.
Agent and dose
- A direct oral anticoagulant is reasonable; apixaban has a favourable gastrointestinal bleeding profile compared with warfarin. He does not meet dose-reduction criteria (age <80, weight >60 kg, creatinine <133 µmol/L), so full-dose apixaban 5 mg twice daily is appropriate - do not reduce the dose “because of the bleed” without a pharmacokinetic reason.
- Restart a proton-pump inhibitor long term and permanently avoid NSAIDs; use paracetamol for osteoarthritis.
Practical points
Document the discussion with the patient, including the reason for continuing anticoagulation, and provide written safety advice about recurrent melaena or haematemesis.