S3612 A Clotting and Bleeding Interplay in Ulcerative Colitis

Abstract

Introduction: Inflammatory bowel disease (IBD) patients are at increased risk of venous thromboembolic (VTE) events. Here we present a case of a patient with ulcerative colitis (UC) with incidental findings of pulmonary embolism (PE) and, further complications on anticoagulation. Case Description/Methods: A 50-year-old female with a past medical history of anxiety and recently diagnosed UC on steroid taper presented to the hospital with complaints of intractable diarrhea, diffuse abdominal discomfort, and worsening fatigue. Lab findings were consistent with previously diagnosed iron deficiency anemia, downtrending C-reactive protein, ESR, negative C.diff, and gastric pathogen panel. A repeat CT abdomen pelvis with contrast showed improving inflammation of the colon, mesalamine was added to steroid regimen . There was an incidental finding of PE in the bilateral segmental arteries without right heart strain, treated with heparin infusion and transitioned to rivaroxaban.Later, patient had two episodes of hospital admission for rectal bleeding complicating the treatment course. Rivaroxaban was resumed after first episode of bleeding, but since the further episode of rectal bleeding required cardiopulmonary resuscitation, anticoagulation was discontinued. During this time for UC, mesalamine was discontinued and infliximab was initiated. She developed another episode of bilateral deep vein thrombosis off anticoagulation, hence IVC filter was placed to avoid new PE and plan to restart anticoagulation after resolution of bleeding was made. Discussion: Patients with IBD are at higher risk ( 2 to 3 fold) of developing the extraintestinal complication of VTE compared to general population with incidence varying from 1.3% to 6.2% and mortality from 8% to 25%. The exact pathophysiology of thrombosis in IBD is not fully understood and is considered to be a complex interplay of inflammation and coagulation, affecting the procoagulant, anticoagulant and fibrinolytic factors of the coagulation cascade. Patients in an acute flare of IBD are associated with highest risk of VTE compared to patients in remission. Patients admitted for IBD flare should be on pharmacological prophylaxis for VTE and can be safely administered for patients with minor hematochezia. Treatment of VTE in IBD patients is the same as patients without IBD, but duration of therapy is not well established. Risk is lower in patients in remission, another important reason for providers to have IBD patients in endoscopic and clinical remission.