What is the inpatient management for an elderly male patient with chronic atrial fibrillation (AFib) on Eliquis (apixaban) presenting with small bowel obstruction (SBO) and active bilious vomiting?

Inpatient Management of Elderly Male with Chronic AFib on Eliquis Presenting with SBO and Bilious Vomiting

Immediate Management and Orders

Hold Eliquis immediately upon admission given active bilious vomiting, NPO status, and potential need for surgical intervention. 1

Initial Resuscitation and Monitoring

• NPO status with aggressive IV crystalloid resuscitation to correct dehydration and electrolyte abnormalities 2, 3
• NG tube placement for gastric decompression and prevention of aspiration pneumonia (already placed per surgery) 2, 3
• Foley catheter for strict intake/output monitoring and assessment of hydration status 3
• Continuous telemetry for heart rate and rhythm monitoring given chronic AFib 4

Laboratory Workup

• CBC to assess for leukocytosis >10,000/mm³ suggesting peritonitis or ischemia 3, 5
• Complete metabolic panel including electrolytes (especially potassium and magnesium), BUN/creatinine to assess dehydration 2, 3
• Lactate level - elevation suggests intestinal ischemia and requires urgent surgical intervention 3, 5
• CRP - values >75 may indicate peritonitis 3
• Coagulation profile (PT/INR, aPTT) - critical given Eliquis use and potential need for emergency surgery 3
• Liver function tests 3

Imaging

• CT abdomen/pelvis with IV contrast (if not already obtained) - diagnostic accuracy >90% for SBO and can identify high-risk features including bowel wall thickening, abnormal enhancement, mesenteric edema, ascites, pneumatosis, or mesenteric venous gas 4, 2, 3
• Water-soluble contrast study (Gastrografin) after gastric decompression - 96% sensitivity and 98% specificity for predicting resolution with conservative therapy; obtain abdominal X-ray at 24 hours to assess contrast progression 2

Medications

• Anti-emetics (ondansetron or metoclopramide) 3
• IV antibiotics if signs of peritonitis, ischemia, or sepsis (elevated lactate, marked leukocytosis, fever) 5
• Pain control - avoid opioids if possible as they worsen ileus; if necessary, use sparingly 2

AFib Management During Acute SBO

Rate Control Strategy

Transition from Eliquis to IV rate control agents while maintaining NPO status, avoiding oral medications entirely during active obstruction. 4

• IV metoprolol (2.5-5 mg every 6 hours) OR IV diltiazem (5-10 mg bolus, then 5-15 mg/hr infusion) for rate control, targeting heart rate 80-110 bpm at rest 4
• Avoid IV calcium channel blockers if patient develops hemodynamic instability or heart failure 4
• IV digoxin (0.25 mg loading dose, then 0.125 mg daily) can be added if rate control inadequate with beta-blocker alone, especially if patient has heart failure 4
• Monitor for bradycardia when combining agents 4

Anticoagulation Management

Do not restart Eliquis while patient remains NPO with NG tube in place and potential surgical intervention pending. 1

Key decision points:

• If conservative management successful and patient tolerating PO: Resume Eliquis 5 mg BID (or 2.5 mg BID if patient meets dose reduction criteria: age ≥80, weight ≤60 kg, or creatinine ≥1.5 mg/dL) once adequate oral intake established 1
• If surgery required: Hold Eliquis at least 48 hours prior to surgery (already held on admission); restart postoperatively once adequate hemostasis established 1
• Bridging anticoagulation is NOT generally required during the 24-48 hour period after stopping Eliquis 1

Critical Monitoring for Surgical Intervention

Obtain urgent surgical consultation if any of the following develop: 4, 2, 3

• Peritoneal signs (rebound tenderness, rigidity, involuntary guarding)
• Rising lactate or WBC count
• Worsening abdominal distension despite NG decompression
• Failure of water-soluble contrast to reach colon by 24 hours
• CT findings of closed-loop obstruction, bowel ischemia, or perforation
• Clinical deterioration despite 48-72 hours of conservative management

Special Considerations

Be aware that anticoagulation with Eliquis can cause intramural small bowel hematoma leading to obstruction - this is a rare but documented complication that may present identically to adhesive SBO 6, 7. If CT shows circumferential wall thickening with intramural hyperdensity and the patient has supratherapeutic anticoagulation effect, consider intramural hemorrhage as the etiology 7.

Most adhesive SBOs (approximately 70-80%) resolve with conservative management within 48-72 hours 4, 5. However, mortality increases from 10% to 30% if bowel necrosis or perforation develops, making close monitoring essential 5.

Avoid oral AFib medications entirely until bowel function returns - attempting to crush and administer medications via NG tube in the setting of active obstruction risks aspiration and is contraindicated 1.