[Safely restarting antithrombotic treatment after a gastrointestinal bleed: evidence or gut feeling?]

Guidelines for the management of non-variceal upper gastrointestinal haemorrhage recommend restarting anticoagulant therapy after treatment of the haemorrhage in patients with an indication for anticoagulation, such as atrial fibrillation. This recommendation is based on findings in retrospective observational studies, and probably also on common sense: if the cause of the haemorrhage has been treated, the chance of a life-threatening second gastrointestinal haemorrhage when anticoagulation is restarted is likely to be smaller than the chance of a serious thromboembolic complication if anticoagulation is stopped indefinitely. A new, large observational study in patients with atrial fibrillation who had a gastrointestinal bleed while receiving antithrombotic treatment suggests that a restart of oral anticoagulation is associated with a lower risk of death and thromboembolic complications than not resuming anticoagulation, and that the risk of a recurrent bleed is slight. Unfortunately, methodological limitations inherent to most observational studies limit the usefulness of the findings to individual patient cases.