Multidisciplinary management of Grade III circumferential mixed hemorrhoids in a patient with Marfan syndrome receiving long-term anticoagulation: a case report.

Management of advanced hemorrhoidal disease in patients with Marfan syndrome (MFS) who require lifelong anticoagulation is clinically complex because perioperative care must balance prosthetic valve thrombosis against postoperative anorectal bleeding. We report the case of a 33-year-old male with MFS, status post-aortic dissection repair (Sun's procedure and Bentall operation) on continuous warfarin therapy, who presented with persistent Grade III circumferential mixed hemorrhoids that had not responded adequately to prior conservative outpatient management. Physical examination confirmed characteristic MFS musculoskeletal signs and severe hemorrhoidal prolapse. A structured multidisciplinary team (MDT) pathway involving colorectal surgery, cardiovascular medicine, vascular surgery, anesthesia, pharmacy, and nutrition was used to individualize perioperative management. After cardiology consultation, and based on the patient's high thromboembolic risk, preoperative warfarin interruption was shortened to 3 days with enoxaparin bridging, and the INR decreased to 1.01 on the day before surgery. Rubber band ligation was avoided because of concern for delayed bleeding after sloughing in an anticoagulated patient. Because the disease involved circumferential mixed hemorrhoids with a prominent external component and prolapse, repeated sclerotherapy alone was considered unlikely to provide adequate definitive control. The patient therefore underwent external dissection and internal ligation combined with liquid polidocanol injection sclerotherapy, with minimal intraoperative blood loss. Postoperatively, a 25-day inpatient observation period enabled close INR titration during warfarin reinitiation, controlled bowel management, staged low-residue enteral nutrition, avoidance of rectal suppositories, and direct monitoring for delayed bleeding. Following minor self-limiting hematochezia, the patient was discharged with an INR of 1.8 as a pragmatic compromise between bleeding and thrombotic risks. At 41 months of follow-up, the wounds remained well healed, with no recurrent prolapse or severe hemorrhagic complications. This case suggests that surgical intervention for advanced hemorrhoids in anticoagulated MFS patients may be feasible when embedded within a structured, individualized multidisciplinary pathway. The anticoagulation, nutritional, and inpatient-monitoring strategies described here should be interpreted as patient-specific measures requiring further validation.