Upper Gastrointestinal Bleeding in Cirrhosis on Apixaban
A 64-year-old man with alcohol-related cirrhosis (Child-Pugh class B) and atrial fibrillation presents with melena and a syncopal episode. He takes apixaban 5 mg twice daily and his last dose was 8 hours ago. There is no previous variceal bleed. On arrival, he is pale and sweaty. BP is 96/60 mmHg, pulse 118/min, respiratory rate 22/min, and temperature 36.8°C. Abdomen is soft with mild ascites; rectal examination shows melena. Blood tests: haemoglobin 68 g/L, platelets 88 × 10^9/L, INR 1.8, creatinine 130 µmol/L, albumin 28 g/L, bilirubin 38 µmol/L. He is not encephalopathic. The endoscopy suite can take him in 6 hours, but a patient with a suspected perforated ulcer is already booked. There is no intensive care bed.
1. What are the immediate resuscitation priorities, and what transfusion strategy would you use?
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This is a life-threatening upper gastrointestinal bleed with hypovolaemia. Secure two large-bore cannulas, take blood for crossmatch, full blood count, coagulation, renal function, and lactate, and start balanced crystalloid cautiously while blood is arranged. Avoid over-transfusion; in cirrhosis with portal hypertension, a restrictive red-cell transfusion strategy is generally safer, often targeting haemoglobin around 70 g/L rather than aiming for a normal value. Over-transfusion can raise portal pressure and worsen variceal bleeding. Give platelets only if there is severe thrombocytopenia with active bleeding or before an intervention, not simply because the count is 88. Do not correct INR with fresh frozen plasma solely because it is 1.8; INR in cirrhosis does not reliably reflect bleeding risk and volume overload can worsen portal hypertension. Monitor for encephalopathy, renal injury, and electrolyte disturbance. Start a proton pump inhibitor, but do not delay resuscitation while waiting for endoscopy.
2. How would you manage his apixaban, and when would you request reversal?
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Apixaban was taken 8 hours ago, so some anticoagulant effect is likely present. In a patient with major gastrointestinal bleeding and haemodynamic compromise, stop apixaban and consider reversal. Andexanet alfa is specific where available, but access and cost often limit its use. Four-factor prothrombin complex concentrate is an alternative for life-threatening bleeding, although evidence for direct oral anticoagulant reversal is less strong than for vitamin K antagonists. Do not give vitamin K for apixaban. The decision to reverse should weigh the severity of bleeding, timing of the last dose, renal function, and availability. Because he is haemodynamically unstable, reversal is reasonable while arranging endoscopy. After bleeding is controlled, restarting anticoagulation requires a multidisciplinary decision balancing stroke risk against rebleeding risk; it should not be restarted automatically on the same day.
3. What pre-endoscopic and endoscopic management would you plan, and how would you decide on early endoscopy versus transfer?
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Resuscitate first, then arrange endoscopy as soon as feasible after stabilisation. In cirrhosis with upper gastrointestinal bleeding, start a vasoactive drug such as terlipressin or octreotide before endoscopy if variceal bleeding is suspected, and give prophylactic antibiotics. These measures reduce bleeding and complications even before the source is confirmed. Endoscopy should identify whether the source is variceal or non-variceal and allow appropriate therapy. Six hours is reasonable if he is stabilised, but if he remains hypotensive despite resuscitation, he needs urgent endoscopy or transfer to a centre with critical care and gastroenterology expertise. The competing perforated-ulcer patient should not automatically displace him; triage should be based on physiological instability and likely benefit. Document the ceiling of care and discuss risks of aspiration, encephalopathy, and renal deterioration.