Abstract 15381: Phlegmasia Cerulea Dolens and Concurrent Gastrointestinal Bleeding: A Dangerous Combination With Challenging Management

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Introduction: Phlegmasia cerulea dolens (PCD) is a rare and life-threatening complication related to extensive deep venous thrombosis (DVT) resulting in acute limb ischemia. Treatment options include anticoagulation, thrombolysis and thrombectomy. Case: A 31-year-old female with a history of ulcerative colitis (UC) on chronic steroids presented with acute dyspnea and tachycardia. She was hemodynamically stable. The initial workup included a lower extremity (LE) Doppler ultrasound (US) which showed an acute occlusive thrombus involving the left posterior tibial and popliteal veins, and a computerized tomography angiography (CTA) of her chest which showed bilateral pulmonary emboli. She was placed on heparin drip for 48 hours but due to an episode of acute gastrointestinal (GI) bleeding due to severe UC, anticoagulation was discontinued after an inferior vena cava filter placement and she was discharged from the hospital. After 1 month, she presented with severe diarrhea, hypotension and tachycardia. A chest CTA showed reduced clot burden compared to prior. On hospital day 2, the patient experienced acute onset of severe left LE pain, bluish skin discoloration and rapidly progressing edema. A repeat US showed progression of DVT to the left common femoral vein. The findings were consistent acute limb ischemia in the setting of PCD. She was managed with emergent thrombectomy, with significant amount of thrombus retrieved. Gastroenterology was consulted and GI bleeding did not recur. Discussion: Due to its rarity, there are limited data available to guide PCD management in the setting of elevated bleeding risk such as severe UC. However, after a risk-benefit assessment, we determined that this young patient should be treated with anticoagulation and undergo emergent thrombectomy, which resulted in significant improvement of her symptoms. We highlight the importance of multidisciplinary approach, early diagnosis and prompt treatment in these complex patients.