Diagnosis of Crohnʼs Disease in a Patient with Pulmonary Embolism: A ‘Clotʼ to Think About

Abstract

Background: The risk of venous thromboembolism (VTE) amongst patients with inflammatory bowel disease (IBD) is increased by a 2-4 time fold compared to non-IBD patients. This case describes a patient who incidentally was diagnosed with Crohn's disease while investigated for a pulmonary embolism. History: A 66-year old woman was admitted to our hospital after a witnessed episode of loss of consciousness. She had recently been on a 2-hour aeroplane flight. She had lost weight recently but her medical history was otherwise non-contributory and was not on any regular medications. She was an ex-smoker. On physical examination a systolic heart murmur was diagnosed. She was pyrexial. The rest of the examination was unremarkable. Laboratory assessment revealed elevated inflammatory markers and a raised d-dimer. Her head CT was normal and echocardiogram showed severe aortic stenosis. A chest radiograph was normal but CT pulmonary angiogram confirmed a pulmonary embolism (PE). Gastroscopy was normal and cross sectional imaging of the thorax, abdomen and pelvis were showed terminal ileal thickening consistent with Crohn's disease. Ileo-colonoscopy with biopsies confirmed mild to moderately active ileitis but no colonic disease. With the possible exception of weight loss she had no other symptoms attributable to IBD. Her son was diagnosed some years ago with ulcerative colitis from which he as asymptomatic after investigations for pulmonary embolism. Management: She has been anticoagulated with warfarin and awaits surgery for aortic valve replacement. She is currently being managed with aminosalicylates despite limited evidence for 5-ASA's in Crohn's disease given the relatively short segment of otherwise asymptomatic disease with a plan to reassess disease after aortic valve replacement. Discussion: Venous thromboembolism (VTE) is a well-recognised complication of IBD with an overall mortality as high as 25% per episode. Despite emerging evidence that Inflammation and coagulation are interdependent processes that perpetuate and intensify each other, this important complication may not be appreciated as well as it should and a high index of suspicion and prompt treatment are necessary for optimal outcomes. Up to 75% of IBD patients may have no identifiable provoking factors but as many as a third of these will have recurrent VTE within 5 years. Between 55-80% have active IBD at diagnosis of VTE. There remains paucity of clinical data driving evidence- based decisions and although anticoagulation is the cornerstone of therapy, randomised trials testing catheter directed thrombolysis or anticoagulation are much needed.