BACKGROUND
Direct oral anticoagulants (DOACs) are increasingly being prescribed to prevent thromboembolic events. They are preferred over warfarin due to their rapid action and because they do not require routine blood monitoring. However, they are associated with a risk of severe bleeding, particularly in elderly patients with multiple comorbidities. Managing major gastrointestinal hemorrhage in such patients remains challenging, especially when standard reversal agents are unavailable (due to high costs) or contraindicated based on hypersensitivity reactions.
CASE REPORT
We present the case of a 68-year-old man with an extensive cardiovascular and vascular surgical history who developed severe lower gastrointestinal bleeding while receiving rivaroxaban therapy (20 mg daily). He had a history of colonic diverticular disease. Conventional resuscitative and endoscopic measures were insufficient to control the hemorrhage, and emergency surgery was deemed extremely high risk. Our center did not have the specific reversal agent (andexanet alfa) for rivaroxaban on site due to its high cost, and the patient’s condition was deteriorating rapidly, with evidence of ongoing bleeding. Hemoperfusion therapy using CytoSorb in combination with continuous renal replacement therapy was initiated as a rescue strategy. The patient achieved rapid hemodynamic stabilization and cessation of bleeding within hours, thus avoiding emergent colectomy.
CONCLUSIONS
This case study illustrates the potential of extracorporeal hemoperfusion as an adjunctive or alternative treatment for patients experiencing life-threatening bleeding associated with direct oral anticoagulants, particularly when reversal agents are unavailable. It provides rapid action and reduces the need for blood transfusions, potentially leading to a significantly shorter hospital stay for patients.

Keywords: Case Reports; Gastroenterology; Hemostasis; Rivaroxaban