[Rectal bleeding in a 60-year-old woman under anticoagulation and platelet aggregation inhibition]

We report on a woman with lower gastrointestinal bleeding under effective oral anticoagulation with both phenprocoumon and apixaban (with intention to switch to the latter) as well as the antiplatelet agent acetylsalicylic acid for aortic bifurcation kissing stents after stent thrombosis. Our patient presented with weakness and rectal bleeding. Upon examination, she looked anemic and had sinus tachycardia (104 beats per minute). The digital rectal examination revealed bright red blood mixed with clots. We established the diagnosis of lower gastrointestinal bleeding that originated from angiodysplasia in the cecum. The patient was stabilized with fluid resuscitation and transfusion. The bleeding source was treated endoscopically. Phenprocoumon had already been stopped and apixaban was paused immediately. Further intervention regarding coagulation was not needed.

Anticoagulation is an important risk factor for gastrointestinal bleeding. Switching from phenprocoumon (or warfarin) to a non-vitamin K oral anticoagulant (NOAC) should be monitored closely using the international normalized ratio. Apixaban or other NOAC are currently not approved for arterial stent thrombosis and there is no evidence for efficacy. Therefore, off-label use requires careful consideration of the risks and benefits.