Gastrointestinal Bleeding — Written Clinical Reasoning

SAQ 1 — Integrated Management (20 marks, 30 minutes)

Prompt: Outline your integrated management plan for this patient, including immediate resuscitation, risk stratification, anticoagulation and antiplatelet management, pharmacotherapy, and endoscopic strategy. Justify each decision with reference to evidence. ^[1]

Model Answer

Problem list (4 marks):

1. Acute upper GI bleed with haemodynamic compromise (shock: SBP 94, tachycardia, cool peripheries)
2. Likely non-variceal source — peptic ulcer probable (recent naproxen increase + aspirin); no stigmata of chronic liver disease, normal LFTs
3. Anticoagulation with apixaban (bleeding risk) plus aspirin (dual haemostatic impairment)
4. Significant cardiovascular comorbidity (recent NSTEMI with DES, AF) — high thrombotic risk if anticoagulation/antiplatelets are stopped
5. CKD stage 3a (eGFR 42) — contributes to anaemia, alters drug handling
6. Polypharmacy and multi-morbidity — coordinated care needed ^[1]

Immediate resuscitation and risk stratification (4 marks):

• ABCDE: secure IV access with two large-bore cannulae; crystalloid bolus (500 mL 0.9% sodium chloride, reassess); cross-match 2 to 4 units; monitor urine output (catheterise). Airway is currently protected — he is not actively vomiting now.
• Risk stratify with the Glasgow-Blatchford Score (GBS): his score is high (urea 14.2 = 4 points; Hb 72 in a man = 6 points; SBP 94 = 2 points; pulse >100 = 1 point) giving a GBS of at least 13 — confirmed high risk requiring admission and endoscopic therapy (Blatchford 2000).
• Restrictive transfusion: his Hb is 72 g/L and he has ischaemic heart disease (prior NSTEMI). Use a threshold around 80 g/L with a target of 80 to 90 g/L given the acute coronary context — Villanueva et al. (NEJM 2013) established that a restrictive strategy (threshold 70 g/L) improves survival, but the major exception is acute coronary syndrome or critical vascular disease where a higher threshold is reasonable. He should receive one to two units to reach 80 to 90 g/L. ^[1]