From the Guidelines
The risk of rebleeding in this 30-year-old patient with upper GI bleeding from NSAID abuse, an adherent clot on endoscopy, stable vital signs, and no comorbidities is moderate, approximately 20-30%. This patient should immediately discontinue all NSAIDs and receive high-dose proton pump inhibitor (PPI) therapy, such as esomeprazole 40mg or pantoprazole 40mg twice daily for 72 hours intravenously, followed by once-daily oral PPI for 4-8 weeks, as recommended by the most recent guidelines 1.
Key Considerations
- The presence of an adherent clot on endoscopy represents a Forrest class IIb lesion, which carries a significant rebleeding risk, as highlighted in studies 1.
- The patient's young age and absence of comorbidities are favorable prognostic factors, but NSAID-induced ulcers can be aggressive.
- Endoscopic therapy with clot removal followed by treatment of the underlying lesion is recommended to further reduce rebleeding risk, as suggested by the guidelines 1.
- The patient should be monitored for at least 24-48 hours with serial hemoglobin measurements and vital sign checks.
Management Plan
- Discontinue all NSAIDs immediately.
- Initiate high-dose PPI therapy as soon as possible, as recommended by the guidelines 1.
- Perform endoscopic therapy with clot removal and treatment of the underlying lesion.
- Monitor the patient closely for signs of rebleeding.
- Test for H. pylori after the acute phase and prescribe eradication therapy if positive, as recommended by the guidelines 1.
- Long-term, the patient should avoid NSAIDs completely or use COX-2 selective inhibitors with gastroprotection if absolutely necessary for pain management.
From the Research
Patient's Condition and Risk Assessment
- The patient is 30 years old with upper GI bleeding from NSAID abuse, and endoscopy showed an adherent clot.
- The patient has stable vital signs and no comorbidities.
- The Rockall score is used to assess the risk of rebleeding and mortality in patients with upper GI bleeding.
Rockall Score and Its Applicability
- The Rockall score is predictive of rebleeding and mortality in patients with variceal hemorrhage and peptic ulcers 2.
- The score can be used in patients undergoing therapeutic endoscopy for upper GI bleeding to identify those with high risk for mortality 3.
- The post-endoscopy Rockall score is associated with rebleeding and mortality in patients with non-varicose UGIB 4.
Patient's Rockall Score and Risk of Rebleeding
- The patient's Rockall score is 2, which indicates a moderate risk of rebleeding.
- The Forest score is also relevant in this case, with a score of 2 for an adherent clot.
- The patient has an increased risk of rebleeding due to the presence of an adherent clot and NSAID abuse 5, 6.
Treatment and Management
- The use of proton pump inhibitors (PPIs) may reduce the risk of rebleeding in patients with upper GI bleeding 6.
- The patient may require PPIs to reduce the risk of rebleeding, but the optimal dose and duration of treatment need to be established 6.
- The role of prostaglandins in preventing NSAID-induced gastrointestinal injury is well established, but their use in this patient is not clearly indicated 5.