Oral anticoagulation in patients with short-bowel syndrome

A 55-year-old woman was transferred to our institution from another hospital. The history of her present illness began 17 days earlier with a right-sided cerebral vascular accident (CVA). Three days later she had a superior mesenteric artery (SMA) embolus with infarcted bowel. Her small bowel was resected leaving about 20-25 centimeters of small bowel. A cardiac echo on hospital day 6 documented the presence of a left ventricular embolus, which was considered to be the cause of her CVA and SMA embolus. The cardiologists recommended lifelong anticoagulation, preferably with warfarin when technically feasible. After one month of warfarin therapy, with doses as high as 25 mg/d, the patient's prothrombin times (PTs) were not changed from baseline; however, this was probably due to concomitant therapy with vitamin K. Heparin was incorporated into her total parenteral nutrition (TPN) in preparation for her discharge. Because the TPN was cycled, she required subcutaneous heparin twice daily while off TPN. This patient's clinical course while she was maintained on heparin therapy was complicated by bleeding episodes and extensive thigh and abdominal hematomas, which led to erratic heparin absorption and widely fluctuating partial thromboplastin times. Ten months after the initiation of anticoagulation the patient was again tried on an oral warfarin regimen. She was successfully titrated to achieve the desired PT ratio. This case led to a review of the literature of patients with short-bowel syndrome requiring anticoagulation.