Case Presentation: A sixty-six-year-old male with a history of Monoclonal Gammopathy of Undetermined Significance (MGUS), Atrial Fibrillation, and Rheumatic Heart Disease requiring aortic and mitral valvuloplasty, was on warfarin with an INR goal of 3.5-4 due to multiple hypercoagulable factors and recurrent Transient Ischemic Attacks (TIAs) at INR 2.5-3.5. Post prostate cancer radiation, he developed radiation proctitis and subsequent GI bleed, initially managed by ablative therapy and coumadin bridging. Three weeks later, he returned with hematochezia and anemia necessitating two units of RBCs. With the recent ablative therapy failing, a multi-disciplinary team adjusted the INR goal to 2.5-3.5 and introduced inpatient hydrocortisone enema and rectal suppositories for radiation proctitis.

Discussion: Mechanical mitral valve patients traditionally aim for an INR of 3.0 (Range, 2.5-3.5). However, the European Society of Cardiology advises a 3.0-4.0 range for dual mechanical valve recipients. For patients who experience systemic embolism despite adequate anticoagulation, the guidelines suggest augmenting Warfarin or adding Aspirin. In cases of major bleeding, defined as requiring transfusion of two or more units of red blood cells, the American College of Cardiology mandates stopping anticoagulation and initiating bleeding control measures. With radiation proctitis, a post-radiation therapy complication for prostate cancer, being observed in up to 20% of patients and a significant portion developing gastrointestinal (GI) bleeding, management intricacies amplify.

Conclusions: Navigating anticoagulation amidst radiation proctitis, especially with aggressive warfarin regimens for dual mechanical valve recipients, presents significant challenges. The frequent occurrence of radiation proctitis, found in up to 20% of post-radiation prostate cancer patients, combined with the complexities of anticoagulation, reveals a layered clinical dilemma: managing bleeding while preventing thrombosis. Halting warfarin in dual mechanical valve patients enhances thromboembolic dangers, emphasizing the delicate clinical balance in such situations. After the prior colonoscopic ablation proved unsuccessful due to the patient’s ongoing GI bleeding from radiation proctitis, our approach shifted towards using steroid enemas to counter inflammation and bleeding. Since steroids take time to exhibit therapeutic efficacy, and with the inability to discontinue warfarin due to bleeding and thrombotic risks, relying on supportive care, notably blood transfusions, became essential. This case underscores the need for innovative, collaborative, and patient-specific strategies when addressing the challenges posed by radiation proctitis combined with crucial anticoagulation.