S2290 Venous and Arterial Thromboembolism: Unusual Harbinger of Ulcerative Colitis in a 64-Year-Old

Abstract

INTRODUCTION: Arterial and venous thromboembolic events are known extraintestinal manifestations of inflammatory bowel disease (IBD). Since elderly patients with IBD require tailored treatment strategies, establishing the initial diagnosis and assessing the etiology of future symptoms are critical. We present a 64-year-old male who underwent left iliofemoral vein and artery thrombectomy for phlegmasia with subsequent diagnosis of severe active ulcerative colitis. CASE DESCRIPTION/METHODS: A 64-year-old otherwise healthy white male presented with a 3-month history of abdominal pain, hematochezia, 20 lb unintentional weight loss, and left lower extremity pain. He quit smoking one year prior to presentation and denied family history of IBD or colon cancer. Vital signs were stable and physical exam revealed left leg swelling and tenderness, cyanosis of the left great toe, and positive fecal occult blood test. Labs showed mild normocytic anemia and elevated fecal calprotectin. The abdominal CT showed thrombosis of the left femoral vein, right sided subsegmental pulmonary embolus, distal abdominal aorta mural thrombus, and left iliac artery occlusion (Figure 1). Anticoagulation was not initiated given concerns for lower gastrointestinal bleed. An Inferior Vena Cava filter was placed the following day with stenting of the left common and external iliac arteries, and thrombectomy of the left common femoral, superficial femoral, and external iliac veins. A colonoscopy showed severe inflammation from the rectum to the descending colon (Figure 2). Colonic biopsies showed active chronic colitis with cryptitis and crypt abscesses consistent with ulcerative colitis (UC). Patient was started on steroids, discharged on hospital day 5, and readmitted 5 days later for right leg pain. The Doppler ultrasound showed an occlusive acute Deep Vein Thrombosis (DVT) of the right posterior-tibial vein, nonocclusive DVT of the right common femoral, superficial femoral, and popliteal veins, and occlusion of right proximal superficial femoral artery. He was started on heparin drip, switched to apixaban on hospital day 5, and discharged on hospital day 8. DISCUSSION: The risk of venous thromboembolism is quite high in elderly adults with UC. The literature suggests that thrombosis and hypercoagulability are features of IBD involved in the occurrence of thromboembolic events. Therefore, it is imperative to consider IBD as a differential diagnosis in elderly patients presenting with unprovoked thromboembolism and gastrointestinal bleeding.Figure 1.: Mural thrombus of the distal abdominal aorta and high-grade left iliac artery occlusion.Figure 2.: Colitis up to the descending colon.