Proximal Crohnʼs Disease in a Patient with Hypercoagulable State

Abstract

Background: Inflammatory bowel disease (IBD) is a known risk factor for venous thromboembolism. Proximal small bowel involvement is uncommon pattern of Crohn's disease. We are reporting a case of unexplained recurrent venous thromboembolism, diagnosed later with proximal Crohn's disease. Case: A 39-year-old female presented with epigastric pain and indigestion, the patient is known to have unexplained hypercoagulable state with recurrent DVTs, failed coumadin treatment and on chronic enoxaparin injections with Greenfield filter placement for more than 1 year. Upper endoscopy showed multiple distal duodenal aphthous ulcers. Biopsy showed duodenitis with no granuloma and a negative H. pylori staining. Gastrin level ordered and was normal. Suspicion of Crohn's disease led to colonoscopy which showed normal colon with scattered ileal aphthous ulcers. The endoscopic features supported diagnosis of Crohn's disease and the patient was started on prednisone and mesalamine with good response. Video capsule endoscopy was done later and showed multiple aphthous deep and irregular ulcers from distal duodenum to ileum, mainly in the jejunum with multiple strictures. Discussion: Crohn's disease is a well known risk factor for venous thromboembolism. Previous studies have shown that increased risk of venous thromboembolism in inflammatory bowel disease is multifactorial, which may include endothelial dysfunction, increased platelet aggregation, hyperhomocysteinemia, antiphospholipid antibodies and can involve all components of the clotting system. Our patient was diagnosed with unexplained resistant hypercoagulable state with recurrent DVTs. The patient was found to have extensive proximal Crohn's disease from distal duodenum to the terminal ileum. This could be the underlying cause of her unexplained hypercoagulable state. She has proximal Crohn's, which is uncommon and could be related to the severity of her hypercoagulable state. Conclusion: Crohn's disease and IBD in general should be investigated in any case of unexplained hypercoagulable state. There could be an association between the pattern of Crohn's disease and the severity of hypercoagulability.Figure