What is the diagnosis and management plan for an elderly patient presenting with upper gastrointestinal bleeding, neurological deficits, and a complex medical history?

Clinical Teaching Case: Elderly Male with Upper Gastrointestinal Bleeding and Neurological Deficits

1. Presentation and Investigation

This elderly male presented with a 5-day history of coffee-ground vomiting (multiple episodes daily), which by definition represents altered black blood from the upper gastrointestinal tract proximal to the ligament of Treitz 1. The coffee-ground appearance results from gastric acid converting hemoglobin to hematin, indicating blood has been in the stomach for several hours 1. Concurrent symptoms included a productive cough and constipation for one week, alongside a more chronic 2-week history of lower back pain radiating to the right leg, bilateral lower extremity weakness/rigidity, urinary incontinence, and decreased sensation 1.

The patient also exhibited rhythmic jerking movements of the arms that were action-induced and resolved with restraint, without loss of consciousness—a presentation more consistent with myoclonus or movement disorder rather than seizure activity. Previous brain MRI revealed a right small vestibular schwannoma with intramural microhemorrhage, mild-moderate global cerebral atrophy, and mild chronic small vessel ischemic changes 2.

Initial vital signs demonstrated relative hypotension (BP 100/60 mmHg) with tachypnea (RR 23) and borderline hypoxemia (SpO2 92%), suggesting hemodynamic compromise from blood loss 2. The heart rate of 83 bpm was inappropriately normal for the degree of hypotension, raising concern for either autonomic dysfunction or beta-blocker use (though none documented) 3. Physical examination revealed abdominal distension without tenderness, impacted stool on digital rectal examination, and asymmetric lower extremity motor strength (4/5 right lower extremity versus 5/5 elsewhere), consistent with possible spinal cord or nerve root compression 1.

Serial vital signs over subsequent days showed fluctuating blood pressures (120-145 mmHg systolic) and a concerning episode of desaturation to 85% on room air, suggesting either aspiration risk from recurrent vomiting or underlying pulmonary pathology 2. The patient was appropriately kept NPO (nothing by mouth) given active upper GI bleeding 3.

2. Problem List (Prioritized by Acuity)

1. Acute non-variceal upper gastrointestinal bleeding with hemodynamic compromise (coffee-ground emesis, anemia, hypotension) 1, 2
2. Hypovolemic shock (BP 100/60, positive fluid balance of +1500 mL suggesting aggressive resuscitation) 3
3. Aspiration pneumonia risk (productive cough, recurrent vomiting, desaturation to 85%) 2
4. Acute kidney injury (elevated creatinine 1.03, elevated urea 95.1, likely prerenal from hypovolemia) 2
5. Anemia (Hgb 10.6 g/dL, Hct 33.0%, likely from GI blood loss) 2
6. Hypokalemia (K+ 3.16 mmol/L, from vomiting and inadequate replacement) 2
7. Possible spinal cord compression or cauda equina syndrome (bilateral lower extremity weakness, urinary incontinence, saddle anesthesia, back pain radiating to leg) 1
8. Severe constipation with fecal impaction (1 week duration, impacted stool on PR exam) 2
9. Movement disorder (rhythmic arm jerking, possibly myoclonus related to cerebral atrophy or metabolic derangement) 2
10. Systemic inflammatory response (CRP 20, neutrophilia 86.5%, lymphopenia 6.5%) 2
11. Chronic conditions: Vestibular schwannoma with microhemorrhage, cerebral atrophy, small vessel ischemic disease, Grade I/II LV diastolic dysfunction, mild aortic regurgitation 2

3. Interpretation

Hematological Findings

The hemoglobin of 10.6 g/dL and hematocrit of 33.0% represent moderate anemia in the context of acute upper GI bleeding 2. In elderly patients, mortality from upper GI bleeding increases significantly with age, and this patient's anemia—while not meeting criteria for massive hemorrhage—still represents substantial blood loss given the 5-day duration 1. The elevated red cell distribution width (RDW) of 16.1% suggests anisocytosis, indicating a mixed population of older normocytic cells and newer reticulocytes attempting to compensate for blood loss 2. This finding typically appears 3-5 days after acute bleeding begins, consistent with the 5-day history 2.

The marked neutrophilia (86.5%) with severe lymphopenia (6.5%) creates a stress leukogram pattern, reflecting both the physiological stress of hemorrhage and possible concurrent infection (given the productive cough and elevated CRP of 20) 2. The normal platelet count of 283 × 10^9/L and normal coagulation parameters (PT, INR) are reassuring, as they exclude thrombocytopenia and coagulopathy as contributors to bleeding 2.

Renal and Metabolic Derangements

The elevated urea (95.1 mg/dL) disproportionate to the creatinine elevation (1.03 mg/dL) creates a BUN:creatinine ratio exceeding 20:1, which is pathognomonic for upper GI bleeding 2. This occurs because blood proteins are digested in the small intestine, absorbed as amino acids, and metabolized to urea in the liver—a process that elevates BUN without affecting creatinine 2. The concurrent creatinine elevation suggests prerenal azotemia from hypovolemia, as evidenced by the hypotension and positive fluid balance indicating aggressive resuscitation 3.

Hypokalemia (3.16 mmol/L) results from multiple mechanisms: vomiting causes direct potassium loss, metabolic alkalosis from gastric acid loss drives intracellular potassium shift, and inadequate replacement in IV fluids perpetuates the deficit 2. This is clinically significant because hypokalemia can exacerbate cardiac arrhythmias, particularly concerning given the patient's underlying diastolic dysfunction 2.

Hepatic Enzyme Elevation

The mildly elevated transaminases (ALT 40.9, AST 45) and alkaline phosphatase (103) likely reflect hepatic congestion from right heart dysfunction (given the diastolic dysfunction and mild AR) or shock liver from hypotension 2. The AST:ALT ratio near 1:1 argues against chronic liver disease or cirrhosis, which would typically show AST:ALT >2:1 2. This is crucial because it makes variceal bleeding from portal hypertension unlikely, supporting a non-variceal etiology 1, 2.

Cardiovascular Findings

The echocardiographic findings of Grade I/II LV diastolic dysfunction with mild aortic regurgitation indicate impaired ventricular relaxation and filling, which becomes critically important during hypovolemia 2. These patients cannot compensate for blood loss by increasing cardiac output through the Frank-Starling mechanism as effectively as those with normal diastolic function 2. The preserved biventricular systolic function is reassuring, but the diastolic dysfunction explains why this patient may decompensate more rapidly than expected for the degree of blood loss 2.

Inflammatory Markers

The CRP of 20 mg/L is moderately elevated, suggesting either an inflammatory response to the GI bleeding itself (as blood in the GI tract can trigger inflammation) or concurrent infection, particularly given the productive cough and desaturation episode 2. The neutrophilia and lymphopenia support this interpretation 2.

Neurological Considerations

The vestibular schwannoma with intramural microhemorrhage is an incidental finding unlikely to cause the current symptoms, as vestibular schwannomas typically present with hearing loss, tinnitus, and balance problems rather than motor deficits 2. The cerebral atrophy and small vessel ischemic changes may contribute to the movement disorder (rhythmic arm jerking) and could represent underlying vascular parkinsonism or myoclonus 2. However, the bilateral lower extremity weakness, urinary incontinence, and saddle anesthesia constitute red flags for cauda equina syndrome or spinal cord compression, which requires urgent MRI of the spine 1.

4. Diagnosis

Primary Diagnosis: Acute Non-Variceal Upper Gastrointestinal Bleeding, Most Likely Peptic Ulcer Disease

Rationale for peptic ulcer disease: Peptic ulcer disease accounts for 35-50% of all upper GI bleeding cases and is the most common cause in non-cirrhotic patients 1. The 5-day history of coffee-ground vomiting without hematemesis (fresh blood) suggests a slower, intermittent bleed rather than active arterial hemorrhage, consistent with a bleeding ulcer that has partially clotted 1, 4. The absence of cirrhosis stigmata (normal liver enzymes, no ascites, no splenomegaly) and the patient's age make peptic ulcer disease far more likely than varices 1, 2.

Ruling out alternative diagnoses:

• Esophageal varices: Unlikely given normal liver function tests, absence of portal hypertension signs, and the AST:ALT ratio near 1:1 rather than >2:1 1, 2. Varices typically present with massive hematemesis rather than coffee-ground emesis 5.
• Gastroduodenal erosions: Account for 8-15% of cases but typically cause less severe bleeding 1. Cannot be definitively excluded without endoscopy 4.
• Mallory-Weiss tear: Represents 15% of cases and occurs after forceful vomiting 1. The 5-day duration argues against this, as Mallory-Weiss tears typically present with hematemesis immediately after retching episodes 1.
• Malignancy: Accounts for <5% of acute upper GI bleeding and typically presents with chronic anemia and weight loss rather than acute bleeding 1. The absence of weight loss history makes this less likely 6.
• Dieulafoy's lesion: Rare cause (<5%) that presents with massive hematemesis from an aberrant submucosal artery 1. The coffee-ground appearance argues against this 1.

Secondary Diagnoses Requiring Urgent Evaluation

Possible cauda equina syndrome or spinal cord compression: The constellation of bilateral lower extremity weakness, urinary incontinence, decreased sensation, and back pain radiating to the leg represents a neurosurgical emergency 1. The 2-week duration suggests a subacute process, possibly from spinal stenosis, epidural abscess, or metastatic disease compressing the spinal cord 1. Urgent MRI of the thoracolumbar spine is mandatory to exclude surgical pathology 1.

Aspiration pneumonia: The productive cough, desaturation to 85%, and recurrent vomiting create high risk for aspiration 2. The elevated CRP and neutrophilia support concurrent infection 2. Chest X-ray is needed to evaluate for infiltrates 2.

5. Management Rationale

Evaluation of Current Orders

Omeprazole 80 mg IV stat, then 40 mg IV BID ✓ APPROPRIATE

Rationale: High-dose proton pump inhibitor (PPI) therapy is the cornerstone of non-variceal upper GI bleeding management 2, 3. The American College of Gastroenterology recommends an initial 80 mg IV bolus followed by continuous infusion of 8 mg/hour for 72 hours, or alternatively 40 mg IV BID 2. PPIs work by irreversibly inhibiting the H+/K+-ATPase pump in gastric parietal cells, raising gastric pH above 6, which stabilizes clot formation on ulcer bases by preventing pepsin-mediated clot lysis 2, 4. This patient's regimen of 80 mg stat then 40 mg BID provides adequate acid suppression, though the guideline-preferred continuous infusion would be superior 2. The timing is correct—PPIs should be started immediately before endoscopy to potentially downstage high-risk lesions 3, 4.

Normal Saline 1L with 3 vials of 40% Dextrose IV BID ⚠️ PARTIALLY APPROPRIATE, NEEDS MODIFICATION

Rationale: Crystalloid resuscitation is appropriate for hypovolemia from GI bleeding 3. However, the addition of dextrose is unnecessary and potentially harmful in a non-diabetic patient without documented hypoglycemia 3. Dextrose-containing fluids can cause hyperglycemia, which impairs wound healing and increases infection risk 3. The fluid choice should be normal saline or lactated Ringer's solution without dextrose 3. Additionally, the rate of 1L BID (2L/24 hours) may be insufficient given the positive fluid balance of +1500 mL suggests ongoing losses 3. Fluid resuscitation should target urine output >30 mL/hour, normalization of blood pressure, and falling heart rate 3.

Critical omission: Potassium supplementation is urgently needed given the hypokalemia of 3.16 mmol/L 2. Each liter of IV fluid should contain 20-40 mEq of potassium chloride to correct the deficit and prevent cardiac arrhythmias 2.

Metoclopramide (Plasil) 10 mg IV TID ⚠️ QUESTIONABLE APPROPRIATENESS

Rationale: Prokinetic agents like metoclopramide are sometimes given 30-60 minutes before endoscopy to promote gastric emptying and improve visualization by clearing blood and clots 4. However, metoclopramide is contraindicated in patients with GI obstruction or perforation 4. This patient's severe constipation with fecal impaction raises concern for partial bowel obstruction, making metoclopramide potentially dangerous 4. Additionally, metoclopramide can cause extrapyramidal side effects, including dystonia and akathisia, which could exacerbate this patient's existing movement disorder (rhythmic arm jerking) 4. The risk-benefit ratio does not favor continuing this medication 4.

Alternative: If prokinesis is desired before endoscopy, erythromycin 250 mg IV given 30-60 minutes pre-procedure is safer and more effective 4. Erythromycin acts as a motilin receptor agonist, promoting gastric emptying without the extrapyramidal risks of metoclopramide 4.

Clonazepam 0.25 mg PO daily ❌ INAPPROPRIATE

Rationale: Clonazepam is a benzodiazepine typically used for seizures, anxiety, or movement disorders 2. While it might be intended to treat the rhythmic arm jerking, benzodiazepines are relatively contraindicated in elderly patients with cerebral atrophy due to increased risk of falls, confusion, respiratory depression, and paradoxical agitation 2. In a patient with active GI bleeding who is NPO, oral medications should be avoided 3. Furthermore, benzodiazepines can mask signs of hepatic encephalopathy if the patient were to develop liver dysfunction 2. The movement disorder should be evaluated by neurology after stabilization, and if treatment is needed, non-benzodiazepine options like levetiracetam for myoclonus would be safer 2.

Bisacodyl 5 mg PO daily ⚠️ INAPPROPRIATE TIMING, CORRECT INDICATION

Rationale: Addressing the fecal impaction is important, but bisacodyl is contraindicated in patients who are NPO because stimulant laxatives require oral intake to work effectively and can cause cramping in an empty bowel 2. Additionally, in the acute phase of GI bleeding, aggressive bowel stimulation could theoretically worsen bleeding 2. The appropriate management for fecal impaction is manual disimpaction followed by enemas (e.g., phosphate or mineral oil enemas) 2. Once the patient resumes oral intake and bleeding is controlled, a bowel regimen with stool softeners (docusate) and osmotic laxatives (polyethylene glycol) would be more appropriate than stimulant laxatives 2.

NPO Status ✓ APPROPRIATE

Rationale: Keeping the patient NPO is standard practice in acute upper GI bleeding to reduce aspiration risk during potential emergency endoscopy and to allow gastric emptying 3. Oral intake can be safely resumed 4-6 hours after endoscopy in hemodynamically stable patients 2, 3.

Additional Recommendations

URGENT: Upper Endoscopy within 24 Hours 7, 2, 3

Indication: The American Society for Gastrointestinal Endoscopy and American College of Gastroenterology mandate upper endoscopy within 24 hours for all patients with upper GI bleeding 7, 2, 3. This patient is now beyond 24 hours from presentation (5 days of symptoms), making endoscopy overdue and urgent 7.

Rationale: Endoscopy serves dual purposes: (1) diagnostic—identifying the bleeding source with 97.5% accuracy 5, and (2) therapeutic—achieving hemostasis through injection therapy, thermal coagulation, or mechanical clips 2, 4. Combined therapy (epinephrine injection plus thermal or mechanical method) is superior to monotherapy 2. The endoscopy must be performed by an experienced endoscopist in a fully equipped endoscopy unit with trained nursing staff, not on the general ward 7, 3.

Risk stratification: Using the Rockall score, this patient has multiple high-risk features: age >60 years, comorbidity (diastolic dysfunction, renal impairment), and hemodynamic compromise (hypotension) 3. A Rockall score >3 indicates need for intensive monitoring and early endoscopy 3.

Blood Product Transfusion Strategy 2, 3

Indication: Current hemoglobin of 10.6 g/dL is above the transfusion threshold of 7.0 g/dL for most patients 2, 3. However, this patient has cardiovascular disease (diastolic dysfunction, aortic regurgitation), which raises the transfusion threshold to 8.0-9.0 g/dL 2.

Recommendation: Transfuse 1-2 units of packed red blood cells to maintain hemoglobin >8.0 g/dL 2, 3. The patient's blood type is O Rh-negative (universal donor), so crossmatching should be straightforward 2. Restrictive transfusion strategy (Hgb target 7-9 g/dL) is associated with lower mortality than liberal strategy (Hgb target >10 g/dL) in upper GI bleeding 2, 3.

Correct Hypokalemia Aggressively 2

Indication: Potassium of 3.16 mmol/L requires urgent correction, especially given the cardiac comorbidities 2.

Recommendation: Add 40 mEq KCl to each liter of IV fluid and administer additional 20-40 mEq KCl IV over 2-4 hours with cardiac monitoring 2. Recheck potassium in 4-6 hours and continue supplementation until K+ >4.0 mmol/L 2.

URGENT: MRI Thoracolumbar Spine 1

Indication: Bilateral lower extremity weakness, urinary incontinence, decreased sensation, and back pain radiating to the leg constitute red flags for cauda equina syndrome or spinal cord compression 1.

Rationale: Cauda equina syndrome is a neurosurgical emergency requiring decompression within 48 hours to prevent permanent neurological deficit 1. The 2-week duration suggests subacute compression, possibly from spinal stenosis, epidural abscess, or metastatic disease 1. MRI is the gold standard for diagnosing spinal cord compression, with sensitivity >90% 1.

Timing: This should be performed urgently (within 24 hours) but can be delayed until after endoscopy if the patient is hemodynamically unstable 1. If MRI shows cord compression, immediate neurosurgical consultation is mandatory 1.

Chest X-Ray and Sputum Culture 2

Indication: Productive cough, desaturation to 85%, elevated CRP, and neutrophilia suggest possible aspiration pneumonia or community-acquired pneumonia 2.

Recommendation: Obtain portable chest X-ray to evaluate for infiltrates 2. If infiltrates are present, send sputum for Gram stain and culture and initiate empiric antibiotics covering aspiration pathogens (ampicillin-sulbactam 3g IV q6h or piperacillin-tazobactam 4.5g IV q8h) 2.

Discontinue Metoclopramide, Consider Erythromycin Pre-Endoscopy 4

Rationale: As discussed above, metoclopramide poses risks of extrapyramidal effects and is contraindicated with possible bowel obstruction 4.

Recommendation: Stop metoclopramide immediately 4. If prokinesis is desired before endoscopy, administer erythromycin 250 mg IV 30-60 minutes pre-procedure 4.

Discontinue Clonazepam, Neurology Consultation 2

Rationale: Benzodiazepines are inappropriate in elderly patients with cerebral atrophy and active GI bleeding 2.

Recommendation: Hold clonazepam 2. Consult neurology to evaluate the movement disorder (rhythmic arm jerking) after stabilization 2. If myoclonus is confirmed, levetiracetam 500 mg PO BID is a safer alternative 2.

Manual Disimpaction and Enemas for Fecal Impaction 2

Rationale: Fecal impaction requires mechanical removal, not oral laxatives in an NPO patient 2.

Recommendation: Perform manual disimpaction at bedside followed by phosphate enema or mineral oil enema 2. Once oral intake resumes, initiate bowel regimen with docusate 100 mg PO BID and polyethylene glycol 17g PO daily 2.

Helicobacter pylori Testing and Eradication 2

Indication: All patients with peptic ulcer disease should be tested for H. pylori and receive eradication therapy if positive 2.

Recommendation: Obtain gastric biopsy for H. pylori testing during endoscopy (rapid urease test, histology, or culture) 2. If positive, initiate triple therapy: clarithromycin 500 mg PO BID + amoxicillin 1g PO BID + PPI 40 mg PO BID for 14 days after acute bleeding resolves 2. H. pylori eradication reduces ulcer recurrence from 60% to <5% 2.

Intensive Monitoring for 72 Hours Post-Endoscopy 2, 3

Indication: High-risk patients (age >60, comorbidities, hemodynamic instability) require prolonged monitoring 2, 3.

Recommendation: Admit to high-dependency unit or ICU for continuous cardiac monitoring, hourly vital signs, and serial hemoglobin checks every 6 hours for 72 hours 2, 3. Rebleeding occurs in 10-20% of cases within 72 hours and is defined as fresh hematemesis, melena with hemodynamic instability, or hemoglobin drop >2 g/dL 2.

Post-Endoscopy PPI Regimen 2, 3

Indication: After endoscopic therapy for high-risk lesions (active bleeding, visible vessel, adherent clot), high-dose PPI reduces rebleeding risk 2.

Recommendation: Continue omeprazole 40 mg IV BID for 72 hours post-endoscopy, then transition to omeprazole 40 mg PO daily for 4-8 weeks 2, 3. High-dose PPI reduces rebleeding from 20% to 10% and mortality from 5% to 2% 2.

Nutritional Support 2

Indication: Prolonged NPO status and catabolic stress from bleeding require nutritional support 2.

Recommendation: If oral intake cannot resume within 48-72 hours, initiate enteral nutrition via nasogastric tube (if no contraindication) or consider parenteral nutrition 2. Early enteral nutrition reduces infectious complications and hospital length of stay 2.

Thromboprophylaxis 2

Indication: Elderly patient with prolonged immobility is at high risk for venous thromboembolism 2.

Recommendation: Once bleeding is controlled (>24 hours without rebleeding), initiate pharmacologic thromboprophylaxis with enoxaparin 40 mg SC daily or heparin 5000 units SC TID 2. Mechanical prophylaxis with sequential compression devices should be started immediately 2.

6. Learning Points

1. Coffee-Ground Emesis Indicates Upper GI Bleeding with Gastric Acid Exposure, Mandating Urgent Endoscopy within 24 Hours 1, 7, 3

Coffee-ground vomiting results from hemoglobin conversion to hematin by gastric acid, indicating blood has been in the stomach for several hours 1. This presentation is less urgent than fresh hematemesis but still requires endoscopy within 24 hours per American College of Gastroenterology guidelines 7, 3. The most common cause in non-cirrhotic patients is peptic ulcer disease (35-50% of cases), followed by gastroduodenal erosions (8-15%) and Mallory-Weiss tears (15%) 1. Mortality in elderly patients with upper GI bleeding reaches 11% for those admitted to hospital and 33% for those who develop bleeding while hospitalized for other reasons 1. Early endoscopy allows both diagnosis and therapeutic intervention, with combined therapy (epinephrine injection plus thermal or mechanical method) achieving hemostasis in >90% of cases 2, 4.

2. Disproportionately Elevated BUN Relative to Creatinine (BUN:Cr Ratio >20:1) is Pathognomonic for Upper GI Bleeding 2

When blood enters the GI tract, proteins are digested and absorbed as amino acids, then metabolized to urea in the liver, elevating BUN without affecting creatinine 2. This patient's urea of 95.1 mg/dL with creatinine of 1.03 mg/dL creates a ratio of approximately 92:1, far exceeding the diagnostic threshold 2. This finding helps distinguish upper GI bleeding from other causes of anemia and guides the urgency of endoscopy 2. The concurrent creatinine elevation suggests prerenal azotemia from hypovolemia, which improves with fluid resuscitation 3. Failure of BUN to normalize after bleeding cessation suggests ongoing occult bleeding or renal dysfunction 2.

3. High-Dose PPI Therapy (80 mg Bolus, Then 8 mg/Hour Infusion or 40 mg BID) Started Before Endoscopy Reduces High-Risk Stigmata and Rebleeding 2, 3, 4

PPIs irreversibly inhibit the H+/K+-ATPase pump in gastric parietal cells, raising gastric pH above 6, which stabilizes clot formation by preventing pepsin-mediated clot lysis 2, 4. Pre-endoscopy PPI administration downstages high-risk lesions in 30% of cases, reducing the need for endoscopic therapy 3, 4. Post-endoscopy, high-dose PPI for 72 hours reduces rebleeding from 20% to 10% and mortality from 5% to 2% in patients with high-risk stigmata (active bleeding, visible vessel, adherent clot) 2. The mechanism involves maintaining intragastric pH >6 continuously, which requires either continuous infusion (8 mg/hour) or high-dose intermittent dosing (40 mg BID) 2. Oral PPI therapy is insufficient in the acute phase because absorption is erratic in bleeding patients 2.

4. Bilateral Lower Extremity Weakness, Urinary Incontinence, and Saddle Anesthesia Constitute Cauda Equina Syndrome Until Proven Otherwise—Urgent MRI Spine is Mandatory 1

Cauda equina syndrome results from compression of the lumbosacral nerve roots below the conus medullaris, causing bilateral leg weakness, urinary retention or incontinence, decreased rectal tone, and saddle anesthesia 1. Surgical decompression within 48 hours is critical to prevent permanent neurological deficit, including irreversible bladder dysfunction and paraplegia 1. Common causes include massive central disc herniation, spinal stenosis, epidural abscess, or metastatic disease 1. MRI of the thoracolumbar spine with and without contrast is the gold standard, with sensitivity >90% 1. Red flags that mandate urgent imaging include: bilateral neurological symptoms, urinary retention or incontinence, fecal incontinence, saddle anesthesia, progressive motor weakness, and severe or progressive pain 1. Delay in diagnosis and treatment is the most common cause of medicolegal claims in spine surgery 1.

5. Restrictive Transfusion Strategy (Hemoglobin Target 7-9 g/dL) Reduces Mortality Compared to Liberal Strategy in Upper GI Bleeding, Except in Patients with Active Cardiovascular Disease 2, 3

Multiple randomized controlled trials demonstrate that restrictive transfusion (transfusing only when Hgb <7 g/dL, targeting 7-9 g/dL) reduces mortality, rebleeding, and hospital length of stay compared to liberal transfusion (transfusing when Hgb <9 g/dL, targeting >10 g/dL) 2, 3. The mechanism involves avoiding transfusion-related increases in portal pressure and splanchnic blood flow, which can precipitate rebleeding 2. However, patients with active cardiovascular disease (acute coronary syndrome, decompensated heart failure, symptomatic peripheral vascular disease) require a higher threshold of 8-9 g/dL to maintain oxygen delivery to ischemic tissues 2, 3. This patient's diastolic dysfunction and aortic regurgitation qualify as cardiovascular disease, justifying a target hemoglobin of 8-9 g/dL 2. Over-transfusion (Hgb >10 g/dL) increases mortality by 30% in upper GI bleeding 2.