1519 Portal Vein Thrombosis as an Initial Presentation of Crohn's Disease

Abstract

INTRODUCTION: Inflammatory bowel diseases (IBD) are chronic and progressive conditions that can increase the risk of thromboembolism, including portal vein thrombosis (PVT). PVT are exclusively described in cases with confirmed IBD diagnosis and are more commonly related to ulcerative colitis. This report highlights a case of PVT as an initial manifestation of Crohn's disease. CASE DESCRIPTION/METHODS: A 38-year-old gentleman presented with worsening abdominal pain, watery diarrhea and weight loss of the last three months. His initial diagnosis was diverticulitis and a course of oral ciprofloxacin was prescribed. As symptoms persisted, a colonoscopy was performed and showed diverticulitis in the descending colon. The pathology demonstrated acute cryptitis from rectum to cecum. Due to ongoing symptoms, a computed tomography (CT) of the abdomen without contrast was obtained and showed wall thickening and inflammatory changes in the small bowel. Despite another course of antibiotics with the addition of oral steroids, his pain worsened and thus repeat imaging was performed as an abdominal CT with contrast. He was found to have a chronic PVT extending into the superior mesenteric vein (SMV) and was transferred to our institution for further management. Physical exam was notable for mild tenderness in upper abdominal quadrants. Laboratory studies revealed mildly elevated CRP and ESR but his liver function was normal. Hematologic workups including hypercoagulability and clonal disorders were noncontributory. He endorsed a history of tobacco abuse, but no history of abdominal surgery nor family history of IBD. A CT enterography showed skip lesions suggestive of Crohn's enteritis along with thrombus in the right main portal vein and SMV. The pathology report from a repeat colonoscopy showed chronic active colitis. The patient then improved with high dose oral steroids and he was discharged on a tapered steroid regimen with oral anticoagulation. Follow-up appointments were scheduled with hematology and gastroenterology. DISCUSSION: In summary, this case represents one of the handful reported cases of PVT being the initial presentation of Crohn's disease. In those with an established IBD diagnosis, PVT should be considered with persistent abdominal pain in the absence of active inflammation. Early recognition of portal vein thrombosis may expedite treatment and prevent the consequences of portal hypertension.