Upper GI Bleeding on Dual Antiplatelet Therapy After a Recent Stent

Resuscitation first, endoscopy second.

• Two large-bore IVs; type and crossmatch; balanced crystalloid for the orthostatic drop, but reassess frequently - she has active hemorrhage and over-resuscitation with crystalloid worsens coagulopathy and edema.
• Start an intravenous proton pump inhibitor (bolus then infusion) - it stabilizes clot at an acid-sensitive ulcer bed while you arrange endoscopy.
• Send CBC, INR, type and screen, and repeat hemoglobin serially.
• Consider a Glasgow-Blatchford score for triage and disposition.
• If she remains hypotensive after initial fluids or shows ongoing massive hematemesis, activate massive transfusion and call for urgent endoscopy.

Transfusion target:

• The general restrictive threshold is 7 g/dL, but patients with active cardiovascular disease are the standard exception - target 8 g/dL (and consider 9 g/dL with ongoing ischemia). Her hemoglobin is 7.4 with an active bleed, an NSTEMI four months ago, and tachycardia; transfuse to roughly 8 g/dL and reassess.
• Do not transfuse to normal (10+) - liberal transfusion increases rebleeding and mortality in GI bleeding.

Note the BUN of 44: an elevated BUN-to-creatinine ratio supports an upper source, and the BUN will fall with resuscitation without any renal-specific intervention.

Continue aspirin; hold or delay clopidogrel only if bleeding cannot be controlled, and restart as soon as hemostasis is achieved.

Competing risks:

• Stopping antiplatelet therapy risks stent thrombosis, which carries a mortality of 20–40%. Her stent is only four months old, and the highest-risk window for thrombosis with a drug-eluting stent is the first six months. Interrupting dual therapy in that window is the most dangerous thing you could do in this room.
• Continuing both agents increases the risk of failure to control the bleed endoscopically.

The balancing judgment:

• Aspirin is nearly always continued - it is the least likely to promote rebleeding and the most important to keep.
• Clopidogrel may be temporized for 24–48 hours around endoscopy if the bleed is severe, but should be resumed within about five days at the latest, and ideally immediately after successful endoscopic hemostasis.
• Involve cardiology as soon as possible; document a shared decision.
• Stop naproxen permanently and label her as NSAID-avoidant. If analgesia is needed, use acetaminophen (with attention to dose) or topical therapy.
• Test for H. pylori - eradication reduces recurrent ulcer bleeding - but do not delay discharge planning for it.

Timing:

• Urgent endoscopy within 24 hours after initial resuscitation for a high-risk presentation like hers. Immediate endoscopy (within hours, not the next morning) is reserved for ongoing exsanguination or hemodynamic instability despite resuscitation.
• Do not send her to endoscopy before she has IV access, blood products available, and a protected airway plan if she is vomiting large volumes.

If a bleeding ulcer with a visible vessel (or active spurting/oozing) is found:

• Endoscopic hemostasis with epinephrine injection plus a mechanical or thermal modality (clips or thermal coagulation).
• High-dose IV PPI infusion for 72 hours after successful endoscopic therapy, then convert to oral therapy.
• Continue aspirin; resume clopidogrel per the plan above.
• Repeat endoscopy for rebleeding rather than proceeding straight to surgery or embolization.

After stabilization:

• H. pylori testing and eradication if positive.
• PPI long term while on antiplatelet therapy.
• Permanent discontinuation of NSAIDs; consider topical or non-NSAID analgesia for her knee.
• Educate on melena and hematemesis as return precautions.