Coffee Brown Vomitus in Elderly Patient on Aspirin After Ischemic Stroke
The coffee brown vomitus represents upper gastrointestinal bleeding, most likely from aspirin-induced gastric mucosal injury causing gastritis or peptic ulcer disease, which manifests as hematemesis with blood that has been partially digested by gastric acid. 1
Pathophysiology of Aspirin-Induced Upper GI Bleeding
Aspirin causes direct gastric mucosal damage through inhibition of cyclooxygenase (COX), reducing protective prostaglandin synthesis in the gastric mucosa, leading to erosions, ulcers, and bleeding. 1, 2
The principal toxicity of aspirin is gastrointestinal hemorrhage, with an annual risk of serious GI bleeding of approximately 0.4% in patients on low-dose aspirin (≤325 mg), which is 2.5 times the risk for nonusers. 1
Coffee-ground appearance occurs when hemoglobin in blood is converted to hematin by gastric acid, indicating the blood has been in the stomach long enough for this chemical transformation. 2
Risk Factors Present in This Patient
Advanced age (elderly) is a significant independent risk factor for aspirin-induced GI bleeding. 1, 2, 3
Recent restart of aspirin after stroke represents a critical period where the gastric mucosa may not have adapted to aspirin exposure. 2, 3
History of ischemic stroke itself is associated with increased GI bleeding risk, as cardiovascular and neurological disorders appear to enhance GI toxicity. 3
The dose-dependent nature of aspirin GI toxicity means even low-dose aspirin (75-325 mg) carries substantial bleeding risk, though higher doses increase this risk further. 1, 2
Immediate Clinical Management
Continue aspirin without interruption, as the mortality benefit from preventing recurrent stroke outweighs bleeding risk in this patient only 20 days post-ischemic stroke. 4
Initiate high-dose intravenous proton pump inhibitor immediately (80 mg IV bolus followed by 8 mg/hour infusion) to reduce gastric acid and promote hemostasis. 4
Perform urgent upper endoscopy within 12 hours while continuing aspirin to identify the bleeding source and achieve endoscopic hemostasis. 4
Resuscitate with intravenous fluids and transfuse packed red blood cells only if hemodynamic instability persists. 4
Long-Term Prevention Strategy
Prescribe a proton pump inhibitor indefinitely to all patients continuing aspirin after GI bleeding, as this substantially reduces risk of recurrent bleeding to near zero (0.7%). 1, 4, 2
Use pantoprazole or esomeprazole preferentially, as omeprazole may reduce effectiveness of other antiplatelet agents through CYP2C19 inhibition if dual therapy becomes necessary. 4
The combination of aspirin plus esomeprazole 20 mg twice daily is superior to switching to clopidogrel alone for preventing recurrent GI bleeding (0.7% vs 8.6% recurrence rate). 1
Critical Pitfalls to Avoid
Never discontinue aspirin abruptly in this patient, as withdrawal increases cardiovascular and recurrent stroke risk, which would be catastrophic at 20 days post-ischemic stroke. 4, 5
Do not switch from aspirin to clopidogrel as a bleeding prevention strategy, as clopidogrel alone actually increases bleeding risk (8.6%) compared to aspirin plus PPI (0.7%). 1, 5
Avoid adding NSAIDs or COX-2 inhibitors, as concomitant use dramatically increases GI bleeding risk. 1, 3
Do not use dual antiplatelet therapy (aspirin plus clopidogrel) long-term for stroke prevention alone, as it significantly increases bleeding risk without additional benefit beyond the acute period. 4
Additional Considerations
Test for and eradicate Helicobacter pylori if present, as this further reduces risk of upper GI bleeding in patients on chronic aspirin therapy. 2, 3
The first 90 days post-stroke carry the highest risk of recurrence, making aspirin continuation absolutely essential despite the bleeding episode. 4
Enteric-coated aspirin does not reduce GI bleeding risk despite common belief. 1, 3
Monitor hemoglobin at 1 week and 1 month post-discharge to detect occult recurrent bleeding. 4