What is the immediate management of a patient presenting with massive upper gastrointestinal hemorrhage and profuse hematemesis, and how should aspirin (or dual antiplatelet therapy) be discontinued and later restarted?

Immediate Management of Massive Upper GI Bleed with Hematemesis

For a patient presenting with massive hematemesis, immediately resuscitate with crystalloids and blood products targeting hemoglobin >7 g/dL, withhold all oral anticoagulants and correct coagulopathy without delaying endoscopy, continue aspirin if on dual antiplatelet therapy (stopping only the P2Y12 inhibitor), and perform endoscopy within 24 hours after hemodynamic stabilization. 1, 2, 3

Initial Resuscitation and Stabilization

Fluid and Blood Product Management:

• Transfuse red blood cells at a threshold of 7 g/dL to balance oxygen delivery with risk of rebleeding from excessive transfusion 4
• Resuscitate with appropriate crystalloids and blood products as necessary to achieve hemodynamic stability 2, 3
• Hemodynamic stabilization takes priority before endoscopic intervention, though endoscopy should not be excessively delayed 3

Pharmacologic Interventions:

• Administer high-dose intravenous proton pump inhibitors immediately in the acute setting to decrease the probability of high-risk stigmata at endoscopy 2, 4
• Consider erythromycin infusion 30-60 minutes before endoscopy to improve visualization by promoting gastric emptying 2, 4

Management of Anticoagulation During Active Bleeding

For Patients on Warfarin:

• Withhold oral anticoagulant immediately and administer intravenous vitamin K plus four-factor prothrombin complex concentrate (PCC) if hemodynamically unstable 1, 5
• Use fresh frozen plasma only if PCC is unavailable 1
• Correction of coagulopathy should not delay endoscopy or radiological intervention 1, 5

For Patients on Direct Oral Anticoagulants (DOACs):

• Interrupt DOAC therapy immediately at presentation 1, 5
• For life-threatening hemorrhage with hemodynamic instability, administer specific reversal agents: idarucizumab for dabigatran or andexanet alfa for anti-factor Xa inhibitors 1, 5
• If reversal agents are unavailable, consider four-factor PCC 1, 5

Critical Management of Antiplatelet Therapy

For Patients on Aspirin Monotherapy (Secondary Prevention):

• Continue aspirin throughout hospitalization—do not stop it 1, 5, 6
• A prospective RCT demonstrated mortality of 1.3% with continued aspirin versus 12.9% when stopped, despite a modest increase in rebleeding (10.3% vs 5.4%) 1, 6
• If aspirin must be temporarily stopped due to life-threatening hemorrhage, restart immediately once hemostasis is achieved 1, 5, 6

For Patients on Dual Antiplatelet Therapy (DAPT):

• Continue aspirin and temporarily interrupt only the P2Y12 receptor antagonist (clopidogrel, ticagrelor, prasugrel) during the acute bleeding phase 1, 5, 6
• This approach is critical for patients with coronary stents, where aspirin discontinuation carries an odds ratio up to 89 for major cardiac events 1, 6
• Urgent liaison with a consultant interventional cardiologist is mandatory in this setting 1, 5

Endoscopic Intervention

Timing and Approach:

• Perform endoscopy within 24 hours of presentation after initial stabilization 2, 4
• Do not delay endoscopy for coagulopathy correction unless INR is supratherapeutic 7
• Endoscopic therapy is the definitive treatment and should be available 7 days per week 1

Endoscopic Techniques:

• Use combination therapy for high-risk lesions (active spurting, oozing, or visible vessels) 4
• Epinephrine injection should always be combined with another modality (thermal, mechanical, or additional injection) to achieve durable hemostasis 2, 4
• Consider hemostatic powder spray (TC-325) for actively bleeding ulcers or over-the-scope clips for recurrent bleeding 4

Post-Hemostasis Management

Defining Hemostasis:

• Hemostasis is achieved when hemoglobin remains stable for 12-24 hours with no ongoing transfusion requirements and no endoscopic or clinical evidence of active bleeding 6, 7

Restarting Antiplatelet Therapy:

• Restart aspirin within 24-48 hours once hemostasis is confirmed for secondary prevention patients 5, 6
• Restart P2Y12 inhibitors within 5 days maximum due to exponentially increasing stent thrombosis risk beyond this timeframe 1, 5, 6, 7
• Delays beyond 5-7 days are associated with hazard ratio of 5.77 for thrombotic events and 3.32 for mortality 1, 6

Restarting Anticoagulation:

• For high thrombotic risk patients (mechanical heart valves, recent VTE <3 months), restart anticoagulation within 3 days of achieving hemostasis, potentially with bridging LMWH at 48 hours 5, 7
• For low thrombotic risk patients (atrial fibrillation without valvular disease), restart anticoagulation at 7 days after hemorrhage stops 1, 5, 7
• DOACs achieve full anticoagulant activity within 3 hours of the first dose, so timing must account for rapid re-anticoagulation 1, 5

Acid Suppression:

• After endoscopic hemostasis, administer high-dose PPI therapy continuously or intermittently for 3 days, followed by twice-daily oral PPI for the first 2 weeks 4
• Prescribe high-dose PPI at discharge for all patients resuming antiplatelet therapy to mitigate rebleeding risk 6, 8

Common Pitfalls to Avoid

• Never permanently discontinue aspirin in secondary prevention patients without cardiology consultation, as this markedly raises mortality risk 1, 5, 6
• Do not stop aspirin in patients with recent coronary stents (<12 months) even during massive bleeding—only interrupt the P2Y12 inhibitor 1, 6
• Do not delay P2Y12 inhibitor resumption beyond 5 days in high-risk cardiac patients, as stent thrombosis risk becomes prohibitive 1, 5, 6, 7
• Do not delay endoscopy while correcting coagulopathy unless INR is markedly supratherapeutic, as early endoscopy with hemostatic therapy is more important 7
• Do not use epinephrine injection monotherapy, as it must be combined with thermal or mechanical modalities for durable hemostasis 2, 4

Institutional Requirements

• All hospitals admitting patients with GI bleeding should have a designated GI bleeding lead and agreed management pathways 1
• Access to 7-day on-site colonoscopy and endoscopic therapy facilities is mandatory 1
• 24/7 interventional radiology access (on-site or via formalized referral) should be available for cases where endoscopic therapy fails 1, 4