Atrial Fibrillation, Cerebral Amyloid Angiopathy, and Stroke-Related Dysphagia: A Case Report of Gastrointestinal Haemorrhage Following Percutaneous Endoscopic Gastrostomy (PEG) Placement

Atrial fibrillation and cerebral amyloid angiopathy often coexist in older adults and can make post-stroke management particularly challenging, especially when further complicated by comorbidities such as cirrhosis. We present the case of a 78-year-old man admitted with an acute ischaemic stroke and persistent dysphagia. He was initially fed via a nasogastric tube, but ongoing swallowing difficulties led to the insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The patient's background of atrial fibrillation, cerebral amyloid angiopathy, and cirrhosis created a significant dilemma around the use of anticoagulation and increased his risk of both recurrent stroke and major bleeding. After PEG placement, he developed recurrent gastrointestinal haemorrhage requiring multiple blood transfusions, but no clear source of bleeding was identified on endoscopy or imaging. Despite multidisciplinary management and supportive care, his condition gradually deteriorated, and he died several weeks later, with the precise cause of death remaining uncertain. This case highlights the real-world difficulty of managing anticoagulation in patients with both atrial fibrillation and cerebral amyloid angiopathy, particularly when PEG feeding and other co-morbidities are present. Careful risk assessment and close teamwork are crucial in these complex situations.