Management of Rivaroxaban (Xarelto) in Patients Requiring Surgery for Small Bowel Obstruction

Rivaroxaban should be discontinued at least 24 hours before surgery for small bowel obstruction to reduce the risk of bleeding complications. 1

Assessment and Timing of Discontinuation

Rivaroxaban should be stopped at least 24 hours before the procedure to reduce bleeding risk, as stated in the FDA drug label 1
For patients with renal impairment (CrCl 30-50 mL/min), longer discontinuation periods should be considered due to delayed drug clearance 2
Obtain renal function tests to determine appropriate timing of discontinuation, as rivaroxaban is partially eliminated by the kidneys 3
Complete blood count should be ordered to assess baseline hemoglobin and platelet count before surgical intervention 4

Patients with small bowel obstruction requiring urgent surgery (signs of peritonitis, strangulation, or bowel ischemia) need immediate intervention regardless of anticoagulation status 2
CT scan is the preferred imaging technique to assess the need for urgent surgery in SBO and should be performed to guide management decisions 2
Signs of closed loop obstruction, bowel ischemia, and free fluid on imaging suggest the need for immediate surgery without delay 2
Non-operative management should be tried in patients with adhesive small bowel obstruction without signs of peritonitis, strangulation, or bowel ischemia 2

In cases requiring immediate surgery due to peritonitis or bowel ischemia, proceed with surgery despite anticoagulation 2
Consider administration of prothrombin complex concentrate for life-threatening bleeding situations during surgery 5
Temporary discontinuation of rivaroxaban is necessary, with supportive measures including blood product administration as needed 6

If surgery can be delayed for at least 24 hours, hold rivaroxaban to allow for drug clearance 1
No bridging anticoagulation is needed when discontinuing rivaroxaban 2
Assess renal function to determine if longer discontinuation period is needed in patients with impaired kidney function 7

For patients whose surgery can be delayed, discontinue rivaroxaban for at least 24-30 hours before the procedure 2
For patients with creatinine clearance between 30-50 mL/min, consider extending the discontinuation period to 48 hours 2

Rivaroxaban should be restarted after surgical intervention as soon as adequate hemostasis has been established 1
For patients with low bleeding risk and adequate hemostasis, rivaroxaban can be resumed at least 6 hours after the end of the procedure 4
If bleeding risk remains high or hemostasis is incomplete, consider delaying full anticoagulation and using prophylactic doses of anticoagulants 2

Failing to assess renal function before determining the appropriate discontinuation period can increase bleeding complications 7
Unnecessary bridging with heparin products can increase bleeding risk without reducing thrombotic risk 2
Resuming full-dose anticoagulation too early in cases with incomplete hemostasis can lead to significant bleeding complications 4
Delaying anticoagulation for too long postoperatively increases thrombotic risk, especially in high-risk patients 6