Should a patient with a 5 mm Forrest III duodenal ulcer and a gastrointestinal bleed 10 days ago continue daily aspirin 75 mg?

Aspirin Should Be Continued in This Patient

In a patient with a Forrest III duodenal ulcer (clean-based or flat pigmented spot) who had GI bleeding 10 days ago, aspirin 75 mg daily should be continued immediately, as the ulcer is at low risk for rebleeding and discontinuing aspirin significantly increases mortality risk. 1, 2

Risk Stratification of the Ulcer

Forrest class III ulcers represent the lowest risk category for rebleeding:

• Forrest III ulcers do not require endoscopic hemostasis due to their low rebleeding risk 2
• These lesions (clean base or flat pigmented spot) can be managed with standard PPI therapy alone
• The 5mm size is small and further reduces concern

Critical Evidence on Aspirin Continuation

The most recent and highest-quality guideline evidence strongly supports continuing aspirin:

ESGE 2021 Guideline (most recent): For patients taking low-dose aspirin for secondary cardiovascular prophylaxis with acute UGIH, aspirin should not be interrupted. If interrupted, it should be restarted as soon as possible, preferably within 3-5 days 1

ESGE 2015 Guideline: In patients with low-risk ulcers (Forrest IIc or III), aspirin should be resumed immediately following index endoscopy 2

Mortality Data Trumps Rebleeding Risk

The evidence hierarchy prioritizes mortality over rebleeding:

• Discontinuing aspirin after GI bleeding doubles one-year all-cause mortality (HR 2.16,95% CI 1.39-3.35) 3
• Continuing aspirin shows lower 30-day cardiovascular mortality without significantly increasing rebleeding rates 4
• The absolute increase in rebleeding risk with continued aspirin is small and acceptable given the mortality benefit 4, 5

Management Algorithm

1. Continue aspirin 75 mg daily immediately - do not interrupt
2. Add high-dose PPI therapy: Standard oral PPI twice daily (or IV if still hospitalized)
3. Test for H. pylori and eradicate if positive 2
4. Ensure PPI co-prescription continues long-term for gastroprotection 6

Common Pitfalls to Avoid

• Do not reflexively stop aspirin after GI bleeding - this is outdated practice that increases mortality
• Do not wait weeks to restart - the 10-day interval since bleeding is already adequate; further delay increases thrombotic risk
• Do not substitute clopidogrel - it carries similar or higher GI bleeding risk without proven benefit 7
• Do not use aspirin without PPI - gastroprotection is mandatory, not optional 6

Context Matters: Secondary vs Primary Prevention

This recommendation assumes aspirin is for secondary cardiovascular prevention (prior MI, stroke, stent, or established cardiovascular disease). If aspirin were only for primary prevention, discontinuation would be reasonable 4. However, the clinical context of asking whether to "continue" aspirin suggests established cardiovascular indication.

The combination of a low-risk Forrest III ulcer, adequate time since bleeding (10 days), and the overwhelming mortality benefit of aspirin continuation makes this decision straightforward. 1, 2, 3