Introduction and Methods:
Antiplatelets are routinely provided after a cerebral thrombotic event such as stroke or transient ischaemic attack. However, in patients on antiplatelet agents, acute bleeding presents a management dilemma due to the concurrent bleeding risk and risk of recurrent thrombosis. We describe a 72-year-old female who had a transient ischaemic attack in the setting of acute-on-chronic gastrointestinal bleeding due to portal hypertensive gastropathy and colonic angiodysplasia, managed with aspirin 100 mg weekly.
Results:The patient presented with acute onset of left-sided facial droop, dysarthria, hemiparesis and sensory deficit on the background of daily melena in the setting of non-alcoholic fatty liver disease complicated by early cirrhosis (Child Pugh A), with no remarkable oesophageal varices or coagulopathy, recurrent epistaxis and type 2 diabetes. Multimodal stroke computed tomography and magnetic resonance imaging of brain were normal. Haemoglobin levels were 78–95 g/L with ferritin 421 microg/L, and platelets of 94–134 x10⁶/L. Low dose aspirin 50 mg daily was started. Endoscopies showed portal hypertensive gastropathy without varices, multiple antral gastric vascular ectasia (GAVE), and a few colonic angiodysplasia, which were managed with argon plasma coagulation. Owing to ongoing bleeding despite endoscopic intervention, aspirin dose was further reduced to 100 mg weekly with no further ischaemic events at 3 months.
Conclusion :Acute on chronic gastrointestinal bleeding can pose significant management challenge in secondary prevention of stroke or transient ischaemic attack. Lower dose aspirin below conventional 100mg daily could be considered in individual cases in addition to appropriate endoscopic and pharmaceutical prevention.