Unusual Thrombotic Complications in Severe Ulcerative Colitis

Abstract

Introduction: Thromboembolic complications, both venous and arterial, are serious extra intestinal manifestations complicating the course of inflammatory bowel disease (IBD), and can lead to significant morbidity and mortality. Left ventricular thrombus formation, as well as peripheral arterial complications, are rarely reported events. We report a case with multiple arterial and venous complications in a patient with severe ulcerative colitis complicated by Clostridium difficile infection. Case description: A 38-year-old male with known severe universal ulcerative colitis, was admitted with increasing abdominal pain, bloody diarrhea, and shock. Temperature was 36.7, P 138, BP 85/57. Hemoglobin was 9.0 mg/dl, WBC 24,899 with left shift. CRP was 65.8. Clostridium difficile PCR was positive. Initial resuscitation was successful, but after 10 days of aggressive medical therapy, total colectomy was required. With initial EKG changes and borderline troponin elevations, CV work-up including transesophageal echocardiography had revealed a left ventricular thrombus, and nuclear stress testing showed a small fixed inferoapical defect, and EF of 45%. He also had developed increasing leg pain and evident arterial occlusive changes by Doppler studies/ABI. Gangrenous deterioration of the right foot developed, requiring partial amputation. Later in his course, he developed pulmonary emboli, confirmed by CTA. Thrombophilia work up was negative, including cardiolipin antibodies. He had been fully anti-coagulated early in his hospitalization. His status gradually improved after a two-month hospitalization, and he was discharged temporarily to skilled nursing facility. Discussion: This case demonstrates both arterial and venous complications of severe ulcerative colitis, including rarely previously reported left ventricular thrombus. His overall condition improved following total colectomy, and likely diminished diathesis for arterial and venous thrombotic manifestations, including distal extremity gangrenous changes requiring amputation, and potential for embolic stroke. Early colectomy may be warranted in those presenting in this fashion.