Anticoagulation-Amplified Recurrent Esophageal Hemorrhage in Triple-Positive Antiphospholipid Syndrome: The Inescapable Anticoagulation Dilemma.

INTRODUCTION: Antiphospholipid syndrome (APS) is an acquired thrombophilia. Triple-positive APS, defined by lupus anticoagulant, anticardiolipin, and anti-β2-glycoprotein I antibody positivity, usually requires long-term vitamin K antagonist therapy; direct oral anticoagulants are discouraged, and low-molecular-weight heparin is reserved for selected situations.

CASE PRESENTATION: A 52-year-old female with systemic lupus erythematosus and triple-positive APS on warfarin (International Normalized Ratio [INR] 2.9) presented with massive hematemesis requiring intubation. Serial esophagogastroduodenoscopy showed extensive esophageal clot burden followed by circumferential friability, sloughing, and necrotic/exudative esophagitis without varices or gastric/duodenal bleeding. Hemostatic powder was applied, fresh frozen plasma partially corrected the INR to 1.8, and anticoagulation was held. Therapeutic heparin bridging on hospital day 8 was followed by recurrent melena, hemoglobin decline from 8.3 to 5.5 g/dL, and gross hematuria; INR at rebleeding was 2.2. Hematology evaluation showed factor VIII activity 87% and negative Bethesda assay, arguing against acquired hemophilia A. Repeat endoscopy showed Los Angeles grade C esophagitis with clean-based linear ulcers and a 7-cm sliding hiatal hernia.

CONCLUSION: Severe diffuse esophageal mucosal injury can cause recurrent major bleeding when anticoagulation is resumed before mucosal recovery. In high-risk APS, anticoagulation resumption should be individualized with hematology and gastroenterology input, and repeat endoscopy may help guide timing.