What is the management approach for an elderly patient presenting with hematemesis, melena, hypotension, and confusion after heavy Non-Steroidal Anti-Inflammatory Drug (NSAID) use?

Management of Elderly Patient with NSAID-Induced Upper GI Bleeding

This elderly patient with hematemesis, melena, hypotension, and confusion after heavy NSAID use requires immediate aggressive resuscitation with IV fluids and blood products, urgent upper endoscopy within 24 hours (or emergently if hemodynamically unstable despite resuscitation), high-dependency unit admission, and immediate discontinuation of NSAIDs with initiation of high-dose IV proton pump inhibitor therapy. 1, 2

Immediate Resuscitation (First Priority)

• Establish two large-bore IV cannulae (18-gauge or larger) in the antecubital fossae immediately 2
• Infuse normal saline rapidly to achieve hemodynamic stability, typically 1-2 liters initially, targeting mean arterial pressure >65 mmHg (preferably >80 mmHg in elderly) 2
• Transfuse red cell concentrate when hemoglobin <100 g/L with active bleeding and hemodynamic instability 2
• Insert urinary catheter and monitor hourly urine output (target >30 mL/hour) 2
• Continuous automated monitoring of pulse and blood pressure 2

Critical Risk Stratification

This patient has multiple high-risk Rockall criteria indicating 30% mortality risk: 1

• Age >80 years (if applicable based on "elderly")
• Shock (hypotension with likely tachycardia)
• Confusion indicating significant comorbidity and end-organ hypoperfusion
• Heavy NSAID use predisposing to peptic ulcer disease

Medication Management

• Immediately discontinue NSAIDs - continuation increases mortality, reinfarction, heart failure, and myocardial rupture risk 1
• Start high-dose IV proton pump inhibitor immediately (before endoscopy) 1
• Co-prescribe PPI prophylaxis if NSAIDs must be restarted (though strongly discouraged in elderly) 1

Endoscopy Timing and Preparation

Timing Decision Algorithm:

If patient remains hemodynamically unstable despite aggressive resuscitation:

• Emergency "out of hours" endoscopy required immediately 1
• Consider endotracheal intubation before endoscopy given confusion and risk of pulmonary aspiration 2
• Perform in operating theatre environment with anesthetic support available 1

If patient stabilizes after resuscitation:

• Early elective endoscopy ideally the morning after admission (within 24 hours) 1, 2
• Perform in fully equipped endoscopy unit with trained staff 1

Pre-Endoscopy Requirements:

• Keep patient fasted until hemodynamically stable 2
• Ensure experienced endoscopist skilled in therapeutic interventions available 1, 2
• Equipment for cardiorespiratory monitoring during and after procedure 1

Level of Care

• High-dependency unit admission is mandatory for elderly patients with multiple comorbidities and serious hemorrhage 1
• This patient requires high-intensity support unavailable on general wards 1

Addressing Confusion

The confusion likely represents:

• Hypovolemic shock with cerebral hypoperfusion 1
• Anemia with inadequate oxygen delivery 3
• Uremia from prerenal acute kidney injury (check BUN/creatinine) 3

Do not attribute confusion to age alone - it indicates severe physiologic derangement requiring aggressive intervention 1

Expected Endoscopic Findings

Given heavy NSAID use, anticipate: 4

• Peptic ulcer disease (gastric or duodenal) - most likely
• Esophageal ulcers (50% associated with NSAID use)
• Gastritis/duodenitis

Endoscopic Stigmata Predicting Rebleeding:

• Active bleeding from ulcer = 80% risk of continued bleeding/death in shocked patients 1
• Non-bleeding visible vessel = 50% risk of rebleeding 1
• Adherent clot = moderate risk 4
• Clean-based ulcer = very low risk 1

Post-Endoscopy Management

• Continue IV PPI for 72 hours minimum after therapeutic endoscopy 1
• Monitor for rebleeding with continuous pulse, blood pressure, and urine output observation 2
• Start oral intake only when hemodynamically stable 4-6 hours post-endoscopy 2
• Correct coagulopathy if INR >1.5 with fresh frozen plasma 1
• Correct thrombocytopenia if platelets <50,000/µL with platelet transfusion 1

Common Pitfalls to Avoid

• Do not delay resuscitation for diagnostic testing - resuscitation and assessment occur simultaneously 1, 2
• Do not perform endoscopy before adequate resuscitation - this increases procedural risk 2
• Do not restart NSAIDs in this elderly patient - alternative analgesia (acetaminophen) is safer 1
• Do not attribute all symptoms to GI bleeding - remember >33% of bleeding in elderly may have concurrent non-malignant treatable causes 5
• Do not use dextrose-only solutions for resuscitation - isotonic crystalloid (normal saline) is required 2

Prognosis

Mortality in this patient is substantial (potentially 30%) given: 1

• Advanced age
• Shock at presentation
• Confusion indicating comorbidity
• NSAID-induced ulcer (if confirmed)

Deaths are almost entirely restricted to patients with significant comorbid illness, which this patient demonstrates through confusion and likely cardiovascular/renal compromise 1