1) A 59-year-old male with a history of colonic Crohn's disease for 20 years presented with a flare-up and was found to have developed a deep vein thrombosis in his left leg. 2) Thromboembolic complications are potentially life-threatening occurrences that are less frequent but increased in individuals with inflammatory bowel disease. Prophylaxis is recommended for all hospitalized patients with IBD. 3) The patient is currently experiencing a thrombotic complication. Low molecular weight heparin would be the recommended treatment option over unfractionated heparin or a vena cava filter in this case.

1. DR. K. K. RAWAL
M.D. D.M.(GASTRO)
Consultant Gastroenterologist
Milestone Hospital
Vidyanagar main road
Rajkot (0281-2480843 / 44)

2. Thrombotic complications in IBD
DR K K RAWAL
MD,DM
MILESTONE HOSPITAL
VIDYANAGAR MAIN ROAD
RAJKOT

3. Case
 59 year old male, Colonic Crohn’s for 20 years
Developed lymphoma while on azathioprine
Recent flare-up; 6 stool/day with blood, cramp
Rx budesonide & metronidazole
Developed frank rectal bleeding and swollen left leg
 Ultrasound – Deep Venous Thrombosis (DVT) in left leg

4. Sigmoidoscopy

5. What would you suggest next?
A. Low Molecular Weight Heparin
B. Unfractionated Heparin
C. Vena cava filter
D. Other

6. Thrombotic complications in IBD
 1st
reported in 1936 by Bargen and Barter
 Thromboembolic complications are less frequent but potentially life-
threatening (mortality – 25%)
 “Preventable” complication of IBD
Barger J, Barker N. Arch Intern Med 1936;58:17-31
Mayo Clin Proc 1986;61:140-5

7. Thromboembolic complications
 70 % are venous 30% arterial
 UC > CD
 Female > Male
Naess IA et al, J Thromb Haemost 2007;5:692-9

8. Incidence
 3 times higher risk than general population
 Clinical studies = 1- 4% Post mortem studies = 40%
 Risk increased in both hospital based and population based cohorts
 Greatest increase in risk under 40 years
 Recurrence = 10 – 15%
Kappelman et al, Gut 2011;60:937
Solem CA Am J Gastroenterol 2004;99:97-101

9. Site
 Almost all the peripheral and even central vessels including aorta
reported to be involved
 Deep vein thrombosis (DVT) and pulmonary embolism (PE) –
Commonest
 Mesenteric / portal / hepatic veins
 Cerebrovascular accidents
 NO increase in ischemic heart disease ??
Mayo Clin Proc 1986;61;140-5

10. Nutritional factors
Inherited tendencies ?Increased platelet activation
Thrombocytosis
Endothelial
activation
Immobility
Central venous
cannulation
Dehydration
Smoking ( in Crohn’s
disease )
Thrombosis
Clotting factor
abnormalities
Inflammation
Surgery

11. Risk factors
 Obesity
 Extreme age
 Prior H/O TE
 Malignancy
 Bed rest > 5 days
 Major surgery

12. Risk factors
 Activity of the disease (30% in non-active disease)
 Extent of the disease
 Colectomy does not prevent risk of recurrence
Irving P et al, Clin Gastroenterol Hepatol. 2005;3;617-28

13. Clinical features
 DVT- Hot, tender, swollen areas ( Homans Sign)
 PE - Dyspnea, chest pain, Hemoptysis, cough
D-dimer
Doppler US
CT angio
Venography

14. Management
 Control of inflammatory process
 Azathioprine / infliximab – Stopped
 Correction of nutrition and vitamin deficiency
 Smoking / OC pills – stopped
 Avoidance of dehydration
 Early mobilization

15. Prophylaxis
 NO RCT exists or can be carried out
 Published guidelines advise Px in all indoor patients with IBD
Guidelines for the management of IBD in adults. Gut 2004;53:1-16
AGA Physician Performance Measures Set 2011
Razik R, Can J Gastroenterol 2012;21:795-8

16. TE Prophylaxis is Under-Utilized in IBD
Percentage of doses administered N = 113
<25% 60 (53%)
25-49% 7 (6%)
50-79% 12 (11%)
>80% 14 (12%)
100% 20 (18%)
Table 3. Nursing administration of prophylaxis
Pleet J et al , DDW 2013, S434
Number of hospital days with
TE prophylaxis ordered
‘None’
‘All’
Actual administration of
ordered doses by nurses

17. Prophylaxis
Methods
 Pharmacological - Low molecular weight heparin
(LMWH)
- Unfractionated Heparin (UFH)
 Mechanical

18. Prophylaxis
 LMWH - Ease of administration (S/C)
- No monitoring of APTT needed
- 40mg OD S/C (enoxaparin)
 UFH - Infusion pump (cheap, safe in Renal failure)
APTT 6hrly (1.5 - 2 times)
Duration – Till ambulation or discharge
ACCP Clinical Practice Guidelines. Chest 2012;141:e601S

19. What would you suggest now?
A. Low Molecular Weight Heparin
B. Unfractionated Heparin
C. Vena cava filter
D. Other

20. Prophylaxis
 Mechanical - Antithrombotic stockings
- Intermittent pneumatic compression
- Venous foot pump
- “Vena cava filters”

21. Conclusion
 Thromboembolic events, are rare but important cause of morbidity
and mortality in patients with IBD.
 Simple interventions decrease the risk and should be considered in
all patients with IBD admitted to hospital, whether their disease is
active or not.

22. Thank you