What is the best management for a patient with osteoarthritis, presenting with coffee ground vomitus and black tarry stools, who has been taking naproxen (nonsteroidal anti-inflammatory drug) erratically, and has hypotension, tachycardia, and epigastric tenderness?

Management of NSAID-Induced Upper GI Bleeding

This patient must be admitted to the hospital and undergo urgent upper endoscopy (Option C). This presentation represents a life-threatening upper gastrointestinal hemorrhage requiring immediate inpatient management, hemodynamic stabilization, and diagnostic endoscopy.

Clinical Presentation Indicating Severe GI Bleeding

This patient demonstrates clear evidence of significant upper GI bleeding:

• Coffee ground vomitus indicates active or recent upper GI bleeding with gastric acid exposure to blood
• Melena (black tarry stools) for 2 days suggests ongoing hemorrhage with substantial blood loss
• Hemodynamic instability: Tachycardia (HR 118 bpm) with borderline blood pressure (100/80 mmHg) indicates compensated shock from volume depletion
• Pallor suggests significant anemia from blood loss
• Epigastric tenderness localizes the bleeding source to the upper GI tract

The combination of NSAID use (naproxen) and these findings strongly suggests NSAID-induced peptic ulcer disease with active bleeding 1.

Why Admission and Endoscopy Are Mandatory

Outpatient management (Options A and B) is contraindicated and potentially fatal in this clinical scenario:

• The patient has signs of hemodynamic compromise requiring IV fluid resuscitation and possible blood transfusion
• Active upper GI bleeding requires risk stratification through endoscopy to determine bleeding source, severity, and need for therapeutic intervention
• Endoscopic therapy (cauterization, clipping, injection) may be necessary to achieve hemostasis
• Mortality risk increases significantly without prompt intervention in patients with ongoing bleeding 1

Role of IV Proton Pump Inhibitor Therapy

While Option D (admit and give IV omeprazole) is partially correct, it is incomplete as the primary answer:

• IV PPI therapy should be initiated immediately upon presentation, even before endoscopy, as omeprazole is effective in healing NSAID-induced ulcers 1
• PPIs reduce rebleeding rates and may decrease the need for surgical intervention
• However, PPI therapy alone without endoscopy is inadequate management for a patient with active bleeding and hemodynamic changes

The complete management requires BOTH admission with endoscopy AND IV PPI therapy, making Option C the most accurate single best answer, with the understanding that IV omeprazole should be started concurrently 2, 3.

Immediate Management Algorithm

Upon presentation, the following steps should occur simultaneously:

1. Hemodynamic stabilization:

   • Establish large-bore IV access (two lines)
   • Initiate crystalloid resuscitation
   • Type and crossmatch blood for potential transfusion
   • Monitor vital signs continuously

2. Pharmacologic therapy:

   • Discontinue naproxen immediately 1
   • Start IV PPI (omeprazole 80 mg bolus, then 8 mg/hour infusion) 2, 3

3. Diagnostic evaluation:

   • Complete blood count to assess degree of anemia
   • Coagulation studies
   • Urgent upper endoscopy within 24 hours (ideally within 12 hours for high-risk patients with hemodynamic instability)

Common Pitfalls to Avoid

• Never discharge a patient with melena and hemodynamic changes, even if they appear stable at the moment—compensated shock can rapidly deteriorate 1
• Do not delay endoscopy for "elective" scheduling—this is an urgent indication requiring inpatient evaluation
• Oral PPI therapy is insufficient for active bleeding; IV administration achieves more rapid and sustained acid suppression 2, 3
• Do not restart NSAIDs after this episode; transition to acetaminophen (up to 4g daily) for osteoarthritis pain management 1

Post-Stabilization Considerations

After endoscopic evaluation and hemostasis:

• Continue high-dose PPI therapy (omeprazole 40 mg twice daily) for at least 8 weeks to allow ulcer healing 2, 3
• Test for Helicobacter pylori and eradicate if present, as this reduces rebleeding risk 2
• Permanently discontinue naproxen and substitute with acetaminophen as first-line therapy for osteoarthritis 1
• If NSAIDs are absolutely necessary in the future (which should be avoided given this history), use the lowest-risk agent (ibuprofen 1.2g daily) with continuous PPI prophylaxis 1
• This patient now has a documented history of NSAID-induced GI bleeding, placing them in the highest risk category for future complications 1, 2, 3