Ulcerative Colitis Complicated with Left Ventricular Thrombus and Extensive Arterio-Venous Thromboembolism

Abstract

Purpose: Background: Inflammatory bowel disease is an idiopathic condition of gastrointestinal tract with complex interaction of genetic susceptibility and environmental influences. Patients have high incidence of thromboembolic events, accountable as the major cause of mortality and morbidity. We describe a case with ulcerative colitis flare, complicated with left ventricular thombosis, embolising into the arterial system and extensive venous thromboembolism. Case: A 52-year-old white male, was brought to the emergency department, confused, having multiple loose bowel movements per day. He had a history of ulcerative colitis for 30 years, with last exacerbation three years ago and no treatment for two years. On exam, he was disheveled, dehydrated and cachectic; febrile, tachycardic and orthostatic. Admitted for dehydration and altered mental status, treated with fluids and antibiotics for community acquired pneumonia, MSSA bacteremia and mesalamine for ulcerative colitis and transfusion for low hemoglobin. During the subsequent hospital course, transthoracic echo performed showed a large, mobile, echogenic 2.6x1.2 cm left apical mass with central translucency, in an otherwise structurally and functionally normal heart. CAT scan of the chest and abdomen performed showed diffuse colitis, extensive bilateral venous thrombosis and pulmonary embolism for which he was heparinised. Subsequently, he developed cold and mottled right lower extremity, revealing popliteal artery atheroembolism, confirmed with angiogram and surgical resection. A trans esophageal echo performed later revealed no remnants of thrombus, suggesting its migration to the legs. Summary: English literature reviewed thus far, from 1985 to present, using PubMed search revealed only one other case reporting intracardiac thrombosis with ulcerative colitis flare. Though thromboembolic events contribute to the majority of mortality and morbidity of patients with ulcerative colitis, etiology is yet to be established. Risk factor modification, treatment of the underlying disease and chronic anticoagulation with heparin are the treatment choices.Table: No Caption available.Figure: Transthoracic Echocardiogram.