Thrombosis with inflammatory bowel disease--bleed, clot or break

Abstract

A 35-year-old male presented with 2-month history of bloody diarrhoea. Sigmoidoscopy followed by rectal biopsy confirmed changes consistent with a diagnosis of inflammatory bowel disease (IBD). He was commenced on mesalazine, but required further immune-suppression with prednisolone for continuing symptoms. Six months after the initial episode, he presented with left pleuritic chest pain. Ventilation/perfusion scan showed bilateral pulmonary emboli and he was started on anticoagulant therapy [low molecular weight heparin (LMWH) followed by warfarin]. Two days following his discharge, however, he was readmitted with haematuria. Investigations revealed a large haematoma in the bladder wall possibly related to anticoagulation, which was withheld. His urinary symptoms settled soon and he was discharged after recommencement of warfarin (due to previous high-risk thrombosis) with a plan for strict anticoagulant control and shorter follow-ups. A further 2 months later, he presented to the hospital with abdominal pain. A laparoscopy was performed which showed an extensive retroperitoneal haematoma. Immediate warfarin reversal was achieved with intravenous vitamin K and anticoagulation was withheld temporarily. Despite this, he developed a right breast haematoma 2 days later which extended into his right axilla. The possibility of vasculitis was considered and high dose of prednisolone (i.e. 40 mg daily) was …