Resuming anticoagulant therapy after gastrointestinal bleeding is a frequent and critical clinical dilemma. Early resumption may increase recurrent bleeding, whereas delayed resumption raises thromboembolic risk. Prospective data evaluating timing and structured protocols remain limited.

We conducted a prospective single-center cohort study including 162 consecutive adult patients presenting with gastrointestinal bleeding over two years, confirmed endoscopically. Exclusion criteria were hereditary hemorrhagic telangiectasia, portal hypertensive gastropathy, radiation-induced vascular lesions, inflammatory bowel disease, post-endoscopic duodenal bleeding, and incomplete follow-up. Patients were managed according to a standardized anticoagulant resumption protocol, stratifying timing into <7 days, 7–14 days, and >14 days post-bleeding. Recurrent bleeding was defined as new hematochezia or melena, hemoglobin drop ≥2 g/dL, need for transfusion, or endoscopic confirmation. Follow-up included scheduled visits, electronic records, and structured telephone contact. Kaplan-Meier curves estimated recurrence-free survival and Cox proportional hazards models identified predictors.

Recurrent bleeding occurred in 28 patients (17.3 %). Recurrence was highest in patients resuming anticoagulants <7 days (12/42, 28.6 %), intermediate for 7–14 days (10/68, 14.7 %), and lowest for >14 days (6/52, 11.5 %; log-rank p = 0.03). Cox regression identified early resumption (<7 days, HR 2.3, 95 % CI 1.1–4.9, p = 0.03), chronic kidney disease (HR 1.9, 95 % CI 1.0–3.5, p = 0.04), and age >75 years (HR 1.8, 95 % CI 1.0–3.2, p = 0.05) as independent predictors of recurrence. No thromboembolic events were observed during follow-up in patients with delayed resumption (7–14 or >14 days). The standardized resumption protocol allowed individualized risk stratification and guidance for clinical management.

This prospective single-center study demonstrates that timing of anticoagulant resumption critically impacts recurrent gastrointestinal bleeding. Early resumption within 7 days is associated with the highest recurrence. A structured resumption protocol enables safer, evidence-based management, allowing clinicians to tailor therapy while minimizing bleeding risk. These findings provide practical guidance for daily clinical decision-making and can inform multicenter validation studies.