In a middle‑aged hypertensive patient with a prior ischemic stroke two years ago, currently taking aspirin 75 mg, atorvastatin 20 mg, and cilnidipine 10 mg, with a history of acute gastroenteritis‑related acute kidney injury, who now presents with fresh per‑rectal bleeding, what is the next step in management?

Management of Per-Rectal Bleeding in a Post-Stroke Patient on Aspirin

Stop aspirin immediately and initiate urgent evaluation for the source of gastrointestinal bleeding, while simultaneously starting high-dose proton pump inhibitor therapy and arranging emergent endoscopy within 24 hours. 1

Immediate Management Steps

Discontinue Aspirin Temporarily

• Aspirin must be stopped immediately given the active per-rectal bleeding, as aspirin increases gastrointestinal bleeding risk with an odds ratio of 1.59 and specifically increases lower GI bleeding risk (OR 1.8 for 75mg dose). 1, 2
• The bleeding risk is dose-dependent and can occur from both upper and lower GI sources in patients on chronic aspirin therapy. 2, 3
• Fresh per-rectal bleeding in an aspirin user represents a serious adverse event requiring immediate drug cessation. 1

Initiate High-Dose PPI Therapy

• Start intravenous proton pump inhibitor therapy immediately (e.g., omeprazole 80mg IV bolus followed by 8mg/hour infusion) to reduce bleeding risk and facilitate hemostasis if an upper GI source is identified. 1
• PPI therapy is mandatory for any patient with GI bleeding who will eventually resume aspirin for secondary stroke prevention. 1

Urgent Diagnostic Evaluation

• Arrange emergent endoscopy (upper and/or lower) within 24 hours to identify and potentially treat the bleeding source. 4
• Obtain complete blood count, coagulation studies, renal function (given history of AKI), and type and cross-match blood products. 5
• Assess hemodynamic stability and initiate IV fluid resuscitation if needed. 5

Risk Assessment in This Patient

High-Risk Features Present

• History of prior AKI increases bleeding risk as renal impairment is a known risk factor for aspirin-related bleeding complications. 1
• Chronic aspirin use (75mg daily) for 2 years increases cumulative bleeding risk, with bleeding more likely early in treatment but remaining elevated throughout therapy. 2
• Hypertension (on cilnidipine) is a risk factor for bleeding complications if uncontrolled. 1

Cardiovascular Risk Considerations

• This patient has very high cardiovascular risk given prior ischemic stroke 2 years ago, making aspirin essential for secondary prevention. 5
• Long-term aspirin therapy in high-risk vascular patients prevents 36-50 major vascular events per 1,000 patients treated. 1
• The cardiovascular mortality benefit of aspirin outweighs bleeding risk when proper gastroprotection is used. 1

Plan for Resuming Antiplatelet Therapy

After Bleeding Source Controlled

• Aspirin should be resumed once the bleeding source is identified and definitively treated, as withholding aspirin in secondary stroke prevention carries unacceptable cardiovascular risk. 1
• Resume aspirin at the lowest effective dose (75-81mg daily) to minimize GI bleeding risk while maintaining cardiovascular protection. 1, 6
• Mandatory concurrent PPI therapy (omeprazole 20mg daily or equivalent) must be prescribed when aspirin is restarted. 1, 5

Additional Protective Measures

• Test for and eradicate Helicobacter pylori if present, as this further reduces bleeding risk in aspirin users (recurrent bleeding rate only 1.9% with eradication). 1, 4
• Avoid NSAIDs, which dramatically increase bleeding risk when combined with aspirin. 1
• Ensure blood pressure is well-controlled (target <140/90 mmHg) as uncontrolled hypertension increases bleeding risk. 1, 5

Common Pitfalls to Avoid

Do Not Substitute Clopidogrel

• Clopidogrel should not be substituted for aspirin in this scenario, as it carries similar or higher GI bleeding risk compared to aspirin plus PPI. 1
• Clopidogrel monotherapy does not eliminate bleeding risk and removes the proven benefit of aspirin plus PPI in this population. 7

Do Not Use Enteric-Coated Aspirin

• Enteric-coated or buffered aspirin formulations do not reduce GI bleeding risk compared to plain aspirin and should not be used as a risk mitigation strategy. 1

Do Not Permanently Discontinue Aspirin

• Aspirin must not be permanently withheld due to bleeding history alone in a patient with prior ischemic stroke, as the cardiovascular mortality benefit outweighs bleeding risk with proper gastroprotection. 1
• The risk of recurrent stroke without antiplatelet therapy far exceeds the managed risk of GI bleeding with aspirin plus PPI. 5

Monitoring After Aspirin Resumption

• Educate the patient about signs and symptoms of GI bleeding (dark stools, vomiting blood, bright red blood per rectum, syncope, lightheadedness). 1
• Regular monitoring for signs of bleeding is recommended, especially given this patient's history. 1
• Ensure adherence to daily PPI therapy as long as aspirin is continued. 5, 1
• Monitor renal function periodically given history of AKI, as worsening renal function increases bleeding risk. 1