SHM Converge Scientific Abstract ePoster Gallery-Therapuetic Tightrope: Reccurent Gastrointestinal Bleeding Amidst Dual Mechanical Valve Anticoagulation

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This case highlights the difficulty of balancing bleeding risk and thrombosis prevention in a patient with dual mechanical heart valves who developed radiation proctitis after prostate cancer radiation therapy. The 66-year-old man had multiple thromboembolic risk factors, including atrial fibrillation, rheumatic heart disease, MGUS, and prior TIAs despite therapeutic anticoagulation, so he was maintained on high-intensity warfarin with an INR goal of 3.5–4.0.  <br /><br />After developing gastrointestinal bleeding from radiation proctitis, he initially underwent colonoscopic ablation and warfarin bridging, but bleeding recurred three weeks later with hematochezia and symptomatic anemia requiring transfusion of two units of red blood cells. Because stopping warfarin posed a major thromboembolic risk and prior ablation was unsuccessful, the multidisciplinary team lowered the INR goal to 2.5–3.5 and started inpatient hydrocortisone enemas and rectal suppositories to treat inflammation from radiation proctitis.  <br /><br />The discussion emphasizes that radiation proctitis can occur in up to 20% of patients after prostate radiation and often leads to GI bleeding. In patients with mechanical valves, especially mitral or dual-valve recipients, anticoagulation decisions are especially complex because higher INR targets reduce thromboembolism but increase bleeding. The report underscores that when standard endoscopic therapy fails, management may require individualized, collaborative care, supportive transfusions, and careful adjustment of anticoagulation rather than full cessation.

Asset Subtitle

Michael Sabina

Meta Tag

Author List Andrew Lamb, Corey Thurman, Michael Sabina, Yusuf Buxtamusa, Zein Barakat

Category Clinical Vignettes

Concept INR Target

Concept Anticoagulation

Concept Warfarin

Concept Radiation Proctitis

Concept Major Bleeding

Distinguished Non-Finalist

Presenter Organization Lakeland Regional Health Medical Center

Presenting Author Michael Sabina

Track Adult

Keywords

radiation proctitis

mechanical heart valves

warfarin anticoagulation

gastrointestinal bleeding

prostate cancer radiation

atrial fibrillation

thromboembolic risk

INR target adjustment

hematochezia

hydrocortisone enemas

INR Target

Anticoagulation

Warfarin

Radiation Proctitis

Major Bleeding