DR. K. K. RAWALM.D. D.M.(GASTRO)
Consultant GastroenterologistMilestone Hospital Vidyanagar main roadRajkot (0281-2480843 / 44)
Thrombotic complications in IBD
DR K K RAWAL MD,DM MILESTONE HOSPITAL VIDYANAGAR MAIN ROAD RAJKOT
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
Sigmoidoscopy
What would you suggest next?
A. Low Molecular Weight HeparinB. Unfractionated HeparinC. Vena cava filterD. Other
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
Thromboembolic complications
70 % are venous 30% arterial UC > CD Female > Male
Naess IA et al, J Thromb Haemost 2007;5:692-9
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
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
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
Risk factors
Obesity Extreme age Prior H/O TE Malignancy Bed rest > 5 days Major surgery
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
Clinical features
DVT- Hot, tender, swollen areas ( Homans Sign) PE - Dyspnea, chest pain, Hemoptysis, cough D-dimer Doppler US CT angio Venography
Management
Control of inflammatory process Azathioprine / infliximab – Stopped Correction of nutrition and vitamin deficiency Smoking / OC pills – stopped Avoidance of dehydration Early mobilization
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
TE Prophylaxis is Under-Utilized in IBD
Pleet J et al , DDW 2013, S434
Number of hospital days with TE prophylaxis ordered
‘None’‘All’
Actual administration of ordered doses by nurses
Prophylaxis
Methods Pharmacological - Low molecular weight heparin (LMWH) - Unfractionated Heparin (UFH)
Mechanical
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
What would you suggest now?
A. Low Molecular Weight HeparinB. Unfractionated HeparinC. Vena cava filterD. Other
Prophylaxis
Mechanical - Antithrombotic stockings - Intermittent pneumatic compression - Venous foot pump - “Vena cava filters”
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.
Thank you