What is the management approach for an elderly male patient with Rheumatoid Arthritis (RA), scleroderma, and Hypertension (HTn) presenting with recurrent hematemesis?

Management of Hematemesis in an Elderly Male with RA, Scleroderma, and Hypertension

Immediate Resuscitation and Stabilization

This patient requires immediate aggressive resuscitation with IV fluids and blood products, targeting a mean arterial pressure >65 mmHg, followed by emergency endoscopy given the high-risk presentation of recurrent hematemesis in an elderly patient with multiple comorbidities. 1

Initial Resuscitation Protocol

• Rapidly infuse 1-2 liters of normal saline initially to achieve hemodynamic stability 1
• Transfuse red cell concentrate when hemoglobin <100 g/L in the setting of active bleeding and hemodynamic instability 1
• Target mean arterial pressure >65 mmHg during resuscitation 1
• Admit to high-dependency unit given elderly age, multiple comorbidities (RA, scleroderma, hypertension), and serious hemorrhage 1

Critical Medication Management

Immediately discontinue NSAIDs if the patient is taking them, as continuation increases mortality risk substantially 1. This is particularly important given the patient's RA, where NSAIDs are commonly prescribed but must be stopped in the setting of gastrointestinal injury 2.

Start high-dose IV proton pump inhibitor therapy immediately, before endoscopy 1. This should be continued for a minimum of 72 hours after therapeutic endoscopy 1.

Endoscopy Timing Decision Algorithm

The timing of endoscopy depends on hemodynamic response to resuscitation:

If Patient Remains Hemodynamically Unstable Despite Aggressive Resuscitation:

• Perform emergency "out of hours" endoscopy immediately 1
• Do not delay for stabilization if the patient is not responding to fluids and blood products 1

If Patient Stabilizes After Resuscitation:

• Perform early elective endoscopy ideally the morning after admission (within 24 hours) 1
• This timing balances the need for urgent intervention with allowing adequate resuscitation 1

Pre-Endoscopy Optimization

Correct coagulopathy if INR >1.5 with fresh frozen plasma 1

Correct thrombocytopenia if platelets <50,000/µL with platelet transfusion 1

Special Considerations for This Patient's Comorbidities

Scleroderma-Specific Concerns

This patient with scleroderma and hypertension is at risk for scleroderma renal crisis (SRC), which can be triggered by intravascular volume depletion 3. However, the immediate priority remains controlling the life-threatening upper GI bleeding.

• Monitor blood pressure closely during resuscitation, as aggressive fluid administration is necessary for hemorrhage control but must be balanced against hypertension management 3
• Continue ACE inhibitors or ARBs if the patient is on them for scleroderma renal crisis prevention, as these should not be discontinued 2
• Be vigilant for signs of SRC: rapidly rising creatinine, worsening hypertension, or microangiopathic hemolytic anemia during the acute illness 3, 4

Rheumatoid Arthritis Medication Review

If the patient is on glucocorticoids for RA, recognize that these increase the risk of both GI bleeding and scleroderma renal crisis 3. However, do not abruptly discontinue chronic steroids during acute illness due to adrenal suppression risk.

Prognosis and Risk Stratification

Mortality in elderly patients with NSAID-induced upper GI bleeding is substantial (potentially 30%) given advanced age, shock at presentation, and multiple comorbidities 1. The presence of confusion, hemodynamic instability, and NSAID-induced ulcer all portend worse outcomes 1.

Post-Endoscopy Management

• Continue IV PPI for minimum 72 hours after therapeutic endoscopy 1
• Monitor hemoglobin, vital signs, and urine output closely in the high-dependency unit 1
• Reassess need for blood products based on ongoing bleeding and hemodynamic parameters 1

Long-Term Pain Management After Recovery

Given this patient's RA and the contraindication to NSAIDs after GI bleeding:

• Acetaminophen is the preferred first-line analgesic for arthritis pain, as it has minimal nephrotoxic potential and does not worsen hypertension or renal function 5
• Consider TNF inhibitors for active inflammatory arthritis if disease activity warrants, as they lack significant renal toxicity concerns 5
• Avoid NSAIDs permanently given the severe GI complication and the patient's hypertension and potential renal vulnerability from scleroderma 5