How to manage an elderly patient on anticoagulation therapy who presents with melena after recent antibiotic treatment for a urinary tract infection?

Management of Melena in an Elderly Patient on Rivaroxaban

Stop rivaroxaban immediately and perform urgent upper endoscopy within 24 hours after hemodynamic stabilization to identify and treat the bleeding source. 1, 2

Immediate Actions

Discontinue Anticoagulation

• Stop rivaroxaban now given active gastrointestinal bleeding manifested as melena. 3
• Rivaroxaban overdose or accumulation may lead to hemorrhage, and the drug should be discontinued when bleeding complications occur. 3
• In this 84-year-old patient, renal function should be assessed urgently, as rivaroxaban exposure increases significantly with declining renal function, and elderly patients are at higher risk for bleeding complications. 3

Hemodynamic Assessment and Resuscitation

• Immediately assess for shock: check pulse rate and blood pressure to determine if shock is present (pulse >100 beats/min and systolic BP <100 mmHg). 4, 1
• Begin intravenous fluid resuscitation if hemodynamically unstable, with the goal of normalizing blood pressure and heart rate prior to endoscopy. 1
• Transfuse packed red blood cells to maintain hemoglobin above 7 g/dL; consider a threshold of 9 g/dL given her age (84 years) and likely cardiovascular comorbidities. 1

Risk Stratification

This patient has multiple high-risk features for mortality and rebleeding: 4

• Age >80 years (mortality risk approximately 30% in patients >90 years, with progressive increase after age 60). 4
• Multiple comorbidities (polytrauma, pleural effusion requiring thoracentesis, recent UTI). 4
• Anticoagulation therapy increasing bleeding risk. 4
• Recent antibiotic use (amoxicillin-clavulanate can cause gastric irritation and bleeding). 4

Diagnostic Approach

Upper Endoscopy

• Perform early upper endoscopy within 24 hours (not urgent <12 hours, as outcomes are not improved compared to early endoscopy). 1, 2
• EGD is both diagnostic and therapeutic and should be the initial procedure of choice. 1
• Melena strongly predicts a bleeding source in the upper GI tract, typically proximal to the ligament of Treitz. 5, 6
• Given her stable condition after initial UTI treatment, she can likely undergo endoscopy on an early elective list (ideally the morning after admission) rather than emergency "out of hours" endoscopy. 4

Pre-Endoscopy Management

• Start high-dose intravenous proton pump inhibitor therapy immediately: 80 mg bolus followed by 8 mg/hour continuous infusion. 2
• This decreases the probability of high-risk stigmata seen during endoscopy. 5
• Consider prokinetic agents 30-60 minutes before endoscopy to aid visualization. 5

Endoscopic Management

Treatment Based on Findings

If peptic ulcer disease is identified (most common cause in elderly patients on NSAIDs or with recent antibiotic use): 1, 2

• For actively bleeding ulcers (Forrest Ia, Ib): Use combination therapy with epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). 2
• For non-bleeding visible vessel (Forrest IIa): Use contact or non-contact thermal therapy, mechanical therapy, or sclerosing agent injection, each as monotherapy or combined with epinephrine. 2
• For adherent clot (Forrest IIb): High-dose PPI therapy is recommended even if not treated endoscopically. 2

Post-Endoscopy PPI Therapy

• Continue high-dose PPI as intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post-endoscopy if endoscopic hemostasis was performed. 2
• Alternative regimens include twice-daily intravenous or oral high-dose PPI. 2

Anticoagulation Management

Timing of Rivaroxaban Resumption

• Do not resume rivaroxaban until bleeding is controlled and endoscopic therapy is successful. 2
• Once bleeding is controlled, anticoagulation should be resumed based on thromboembolic risk, preferably within or soon after 7 days of the bleeding event. 2
• The rapid onset of action of rivaroxaban (a direct oral anticoagulant) compared to warfarin must be considered—it reaches therapeutic effect within 2-4 hours. 2
• Given her indication (likely atrial fibrillation or VTE prophylaxis post-polytrauma), assess her thromboembolic risk: if she has no history of stroke and has atrial fibrillation, she is considered lower risk and can wait longer before resumption. 4

Monitoring Considerations

• Assess renal function urgently: In elderly patients with CrCl 15-30 mL/min, rivaroxaban concentrations are significantly elevated, and close observation for bleeding is required. 3
• Avoid rivaroxaban if CrCl <15 mL/min. 3
• Her concurrent furosemide use and recent infection may have affected renal function. 3

Management of Recurrent Bleeding

If rebleeding occurs after initial endoscopic therapy: 2

• Second endoscopic attempt should use cap-mounted clips. 2
• If second endoscopic hemostasis fails, transcatheter angiographic embolization (TAE) should be considered. 2
• Surgery is indicated when TAE is not available or after failed TAE. 2

Critical Pitfalls to Avoid

• Do not continue rivaroxaban in the setting of active GI bleeding—this is the most critical error and can lead to exsanguination. 3
• Do not delay endoscopy beyond 24 hours in this high-risk elderly patient with melena. 1, 2
• Do not use epinephrine injection alone for endoscopic hemostasis—it must be combined with another modality. 2
• Do not resume anticoagulation too early before confirming hemostasis, but also do not delay beyond 7 days if thromboembolic risk is high. 2
• Do not forget to assess for medication-induced causes: amoxicillin-clavulanate can cause gastric irritation, and the combination with rivaroxaban significantly increases bleeding risk. 4