Haematemesis in a 68-year-old on ibuprofen and low-dose aspirin

A 68-year-old woman presented to the emergency department with a two-hour history of vomiting blood and passing black stools. She reported epigastric pain for the past six weeks, for which she had been taking over-the-counter ibuprofen 400 mg three times daily, started six weeks ago. She had been taking low-dose aspirin 75 mg once daily for the past five years for secondary prevention of stroke. She had no prior history of gastrointestinal bleeding or peptic ulcer disease. She did not smoke and drank minimal alcohol. On examination, she was pale, tachycardic at 110 beats per minute, blood pressure 90/60 mmHg, and had epigastric tenderness. Laboratory tests showed haemoglobin 72 g/L, platelet count 230 x10^9/L, creatinine 110 µmol/L, urea 15 mmol/L. Upper gastrointestinal endoscopy revealed a 1 cm gastric ulcer with a visible vessel and recent bleeding, but no active oozing at the time of the procedure. She was resuscitated with intravenous fluids and blood transfusion, and an intravenous proton pump inhibitor was started. Ibuprofen was discontinued. Her haemoglobin stabilised, and she had no further episodes of haematemesis or melaena. Subsequent testing for H. pylori was negative. She was managed conservatively and discharged on oral proton pump inhibitor therapy. Aspirin was continued after discussion with the cardiology team. She was advised to avoid all NSAIDs. No rechallenge with ibuprofen was performed.