Thromboembolism In Inflammatory Bowel Disease Research Articles

Biologics and Oral Small Molecules Are Not Associated With Increased Major Adverse Cardiovascular Events or Venous Thromboembolism in Inflammatory Bowel Disease.

Biologics and oral small molecules (OSM) effectively treat inflammatory bowel disease (IBD), but some are linked to higher risks of major adverse cardiovascular events (MACE) and venous thromboembolism (VTE). This study evaluates the MACE and VTE risks in IBD patients treated with biologics or OSM. Using the TrinNetX multi-institutional database, we examined MACE and VTE in adult IBD patients on biologics and compared them to IBD patients not on biologics. We also compared IBD patients on OSM to those not on OSM. We performed 1:1 propensity score matching. MACE (myocardial infarction [MI], stroke, and all-cause mortality) and VTE were assessed from 30 days to 3 years after drug prescription. After matching, IBD patients on biologics had reduced risk of MI, stroke, and all-cause mortality at 1 year, compared to those not on biologics (P < .05). No significant difference in VTE was observed (P = .5). At 3 years, biologic-treated patients had lower risks of MI, stroke, all-cause mortality, and VTE (P < .05). Inflammatory bowel disease patients on OSM showed no significant differences in MI, stroke, or VTE at 1 and 3 years, but had lower all-cause mortality (P < .05). In older IBD patients with at least 1 cardiovascular risk factor, OSM usage showed no significant difference in MI, stroke, or VTE risk compared to nonusers; however, all-cause mortality was decreased at 3 years (P < .05). Inflammatory bowel disease patients treated with biologics or OSM were not at increased risk of MACE or VTE. Although further studies and longer follow-up periods are needed to confirm these findings, our results provide reassurance regarding the safety of these medications in IBD.

Subtypes of Venous Thromboembolism in Inflammatory Bowel Disease: A Nationwide Assessment

Subtypes of Venous Thromboembolism in Inflammatory Bowel Disease: A Nationwide Assessment

P1029 Prevalance and risk factors of thromboembolism in Inflammatory Bowel Disease

Abstract Background Inflammatory bowel disease (IBD), as a chronic inflammatory condition, can affect atherosclerotic process, arterial events, and increase the formation of venous thromboembolism. The aim of this study was to determine the frequency of thromboembolism and the risk factors associated with acute thromboembolism in our IBD cohort. Methods A total of 3133 patients with 1414 Crohn's Disease (CD), 1667 Ulcerative Colitis (UC) and 52 Indeterminate Colitis who were admitted between 1999 and 2021 were retrospectively analyzed. Patients with acute arterial events and venous thromboembolism (n=39) during the follow-up period were compared with a control group (n=78) of the same gender and same diagnosis. Patients with Behçet's syndrome (n=126),systemic vasculitis (n=16) and hereditary thrombophilia (n=5) were excluded. Results Among 3133 IBD patients, number of patients with arterial events or venous thromboembolism at any time was 124, and the frequency was 3,95%. A total of 132 thromboembolic events, 86 arterial (65,2%) and 46 venous (34,8%) were recorded.Coronary artery disease was significantly higher in the UC group (2,3% vs. 1,2%; p=0.028). During follow-up, 40 acute thromboembolic events, 25 arterial and 15 venous, were seen in 39 patients (frequency 1,24%). There was no significant difference between the CD and UC groups in terms of acute thromboembolism (p=0.871). The presence of exacerbation, the presence of hospitalization, the number of priot hospitalizations and clinical activity at the last visit were associated with both arterial and venous thromboembolism; smoking history, age at diagnosis, body-mass index, non-mucosal CD (Montreal B2-B3) and higher basal CRP were associated with arterial thromboembolism only; higher CRP at the last visit, annual exacerbation frequency, presence of an additional inflammatory disease, presence of complications (surgery, abcess), longer total steroid traetment duration and also recent steroid therapy were associated only with venous thromboembolism. In regression analysis, recent steroid therapy and additional inflammatory disease were considered as independent risk factors for venous thromboembolism whereas age at diagnosis of IBD was considered as an independent risk factor for arterial events. Conclusion In addition to risk factors such as age, smoking and obesity, parameters indicating disease activity, inflammatory comorbidities and recent steroid therapy appear to be associated with acute thromboembolism in IBD patients.

Risk assessment of venous thromboembolism in inflammatory bowel disease by inherited risk in a population-based incident cohort.

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is a chronic inflammatory disease of the digestive tract with increasing prevalence globally. Although venous thromboembolism (VTE) is a major complication in IBD patients, it is often underappreciated with limited tools for risk stratification. To estimate the proportion of VTE among IBD patients and assess genetic risk factors (monogenic and polygenic) for VTE. Incident VTE was followed for 8465 IBD patients in the UK Biobank (UKB). The associations of VTE with F5 factor V leiden (FVL) mutation, F2 G20210A prothrombin gene mutation (PGM), and polygenic score (PGS003332) were tested using Cox hazards regression analysis, adjusting for age at IBD diagnosis, gender, and genetic background (top 10 principal components). The performance of genetic risk factors for discriminating VTE diagnosis was estimated using the area under the receiver operating characteristic curve (AUC). The overall proportion of incident VTE was 4.70% in IBD patients and was similar for CD (4.46%), UC (4.49%), and unclassified (6.42%), and comparable to that of cancer patients (4.66%) who are well-known at increased risk for VTE. Mutation carriers of F5/F2 had a significantly increased risk for VTE compared to non-mutation carriers, hazard ratio (HR) was 1.94, 95% confidence interval (CI): 1.42-2.65. In contrast, patients with the top PGS decile had a considerably higher risk for VTE compared to those with intermediate scores (middle 8 deciles), HR was 2.06 (95%CI: 1.57-2.71). The AUC for differentiating VTE diagnosis was 0.64 (95%CI: 0.61-0.67), 0.68 (95%CI: 0.66-0.71), and 0.69 (95%CI: 0.66-0.71), respectively, for F5/F2 mutation carriers, PGS, and combined. Similar to cancer patients, VTE complications are common in IBD patients. PGS provides more informative risk information than F5/F2 mutations (FVL and PGM) for personalized thromboprophylaxis.

Prevalence, risk factors and implication of venous thromboembolism in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic inflammatory disease that affects the gastrointestinal system and includes Crohn's disease and ulcerative colitis. Globally IBD accounts for approximately 84.3 cases per 100,000 persons. A well-known extraintestinal manifestation of IBD that increases morbidity and mortality in IBD patients is venous thromboembolism additionally its association with IBD is growing in importance as a result of the global incidence and prevalence of IBD being on the rise. Patients with IBD have a higher risk of developing venous thromboembolism. Prothrombotic mechanisms that include triggering activation of coagulation, which is partially mediated by weakening of the intestinal barrier and released bacterial components, predispose people with IBD to arterial and venous thrombosis. Clinical characteristics of venous thromboembolism in IBD include an earlier onset, high rates during active and remission stages, greater recurrence rates, and a poor prognosis. Surgery, old age and the use of drugs like corticosteroids or tofacitinib may raise the risk of venous thromboembolism in IBD patients. Post-thrombotic syndrome and a high recurrence incidence following hospital discharge are two long-term effects of venous thromboembolism. IBD outpatients frequently develop venous thromboembolism, hence it is advised that high-risk patients have prophylactic treatment timely. It is essential to keep emphasising on preventing and treating venous thromboembolism in IBD patients appropriately for which further research can be beneficial. The purpose of this research is to review the available information about prevalence, risk factors and implication of venous thromboembolism in IBD.

Management and Therapy of Venous Thromboembolism in Inflammatory Bowel Disease

Aim: Venous thromboembolism (VTE) guidelines issued by American College of Chest Physicians do not address individuals having inflammatory bowel illness, the class that is at extreme danger of both VTE also gastrointestinal hemorrhagic complications. Individuals with inflammatory bowel disease (IBD) should follow our guidelines for prevention and treatment of the VTE. Methods: VTE in IBD samples were reviewed by a comprehensive literature review. As per the Grading of suggestion analysis, formulation, and analysis methodology, the methodological quality and the strength of recommendations were graded. The occupied committee of general and specialty gastroenterologists in addition to thrombosis experts finalized and voted on the principles after they remained established concluded an iterative online platform. Results: Patients suffering with the IBD have just a roughly 3-fold extreme danger of VTE than non-IBD patients. The illness of this disease causes more danderous effacyts tan anyother disease. Anticoagulant thrombo prophylaxis remains suggested for IBD individual whom remain hospitalized having severe IBD flares but no active bleeding, but it remains also indicated once the bleeding is not serious. Anticoagulant thromboprophylaxis is recommended in outpatient clinics through the record of VTE caused through an IBD flare or an senseless VTE, but not or else. The period of anticoagulation afterward the first VTE is determined by existence of inciting variables. There are special considerations for preventing and treating VTE in pediatric in addition pregnant IBD individuals. Conclusion: By following the principles of American College of Chest Physicians as the framework, researchers used findings from IBD research to generate key suggestions for therapy of VTE in our current massive population. Keywords: VTE guidelines, American College of Chest Physicians, inflammatory bowel illness.

Thromboembolism is associated with poor prognosis and high mortality in patients with inflammatory bowel disease: Acase-control study.

The information on the risk of thromboembolism (TE) in inflammatory bowel disease (IBD) and its predictors are lacking, especially from developing countries. The present study evaluated the prevalence, predictors, and prognosis of TE in IBD. This case-control study included 35 patients with IBD (ulcerative colitis [UC, n = 25]; Crohn's disease [CD], n = 10) and history of TE, from a cohort of 3597 patients (UC n = 2752, CD n = 845) under follow-up from 2005 to 2018. Details on demographics, extraintestinalmanifestations (EIMs), patient status, type and outcomes of TE, treatment details, and disease course were compared with IBD patients without TE (age, gender, and duration of follow-up matched) in the ratio of 1:4. Prevalence of TE in IBD was 0.9% (UC-0.89%, CD-1.2%). Among TE patients (mean age: 34.9 ± 13.1years, 48.6% males), median duration from diagnosis to TE was 12 (inter-quartile range [IQR]: 3-36) months, 37% had other EIMs, 94.1% had moderate/severe disease at time of TE, 62.8% had steroid-dependent/refractory disease, and 5 patients (14.2%) died because of disease-related complications. Lower limb was the commonest site (57.1%), 14.3% had pulmonary TE, and 31.4% had involvement of multiple sites. Phenotypically, more patients with TE (among UC) had steroid-dependent disease (60% vs. 25%, p = 0.001), pancolitis (76% vs. 36%, p = 0.002), chronic continuous disease course (44% vs. 19%, p = 0.009), and acute severe colitis (48% vs. 18%, p = 0.002), of which the latter three were also independent predictors of TE. Approximately 1% of patients with IBD develop thromboembolism relatively early during their disease course, and TE is associated with severe disease and higher disease-related complications including mortality.

Validity of Caprini Score in Postoperative Venous Thromboembolism in Inflammatory Bowel Disease

Validity of Caprini Score in Postoperative Venous Thromboembolism in Inflammatory Bowel Disease

A nationwide survey concerning the mortality and risk of progressing severity due to arterial and venous thromboembolism in inflammatory bowel disease in Japan

BackgroundThe mortality and risk factors of severe disease and death due to arterial and venous thromboembolism (ATE and VTE, respectively) in patients with inflammatory bowel disease (IBD) remain unclear, especially in Asia.AimsThis study aimed to reveal the mortality and risk factors of TE in IBD patients in Japan.MethodsIn the primary surveillance, responses to questionnaires regarding the number of cases of severe TE and TE-associated death in IBD patients in a span of over the past 10 years were obtained from 32 institutions in Japan. In the secondary surveillance, detailed data about IBD patients with TE were collected. The characteristics, laboratory data, therapy status, and situation at the time of TE development were retrospectively collected, and the data were compared between the patients with and without severe TE and TE-associated death.ResultsThe incidence of TE was 1.89% among 31,940 IBD patients. The frequencies of severe TE and TE-associated mortality were 10.7% and 1.0% among the total IBD and TE with IBD patients, respectively. The only risk factor for severe ATE and ATE-associated death was ischemic heart disease. The independent risk factors for severe VTE and VTE-associated death were age (≤ 45 years old), the site of VTE, and disease severity, with anti-TNF therapy as a potential negative risk factor. Patients with severe VTE had a high risk of developing persistent VTE and sequelae.ConclusionUnlike ATE, the incidence of VTE was comparable in Asian and Western countries. Therapeutic and prophylactic strategies for managing IBD-associated TE in Asia are urgently needed.

Defining the Economic Burden of Perioperative Venous Thromboembolism in Inflammatory Bowel Disease in the United States.

Patients with IBD are at increased risk of venous thromboembolism. This study aims to define the economic burden associated with inpatient venous thromboembolism after surgery for IBD that presently remains undefined. This study is a retrospective, cross-sectional analysis using the National Inpatient Sample from 2004 to 2014. Participating hospitals across the United States were sampled. The International Classification of Diseases, 9th Revision codes were used to identify patients with a primary diagnosis of IBD. Major abdominopelvic bowel surgery was performed. The primary outcome measured was the occurrence of inpatient venous thromboembolism. Univariate and multivariable patient- and hospital-level logistic regression models were used to compare patient characteristics, hospital characteristics, and outcomes between venous thromboembolism and non-venous thromboembolism cohorts. Total average direct costs were then compared between cohorts, and the resulting difference was extrapolated to the national population. Of 26,080 patients included, inpatient venous thromboembolism was identified in 581 (2.2%). On multivariable analysis, diagnosis of ulcerative colitis, transfer status, length of preoperative hospitalization, and insurance status were independently associated with inpatient venous thromboembolism. Patients with venous thromboembolism were observed to be associated with an increased median length of stay (17.6 vs 6.7 days; p < 0.001) and higher inpatient mortality (5.0% vs 1.1%; OR 4.7, SE 3.2-7.0; p < 0.001). After adjusting for clinically relevant covariates, the additional cost associated with each inpatient venous thromboembolism was $31,551 (95% CI, $29,136-$33,965). Our study is limited by the administrative nature of the National Inpatient Sample database, which limits our ability to evaluate the impact of clinical covariates (eg, use of venous thromboembolism chemoprophylaxis, steroid use, and nutrition status). Inpatient venous thromboembolism in abdominopelvic surgery for IBD is an infrequent, yet costly, morbid complication. Given the magnitude of patient morbidity and economic burden, venous thromboembolism prevention should be a national quality improvement and research priority. See Video Abstract at http://links.lww.com/DCR/B544. ANTECEDENTES:Pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de tromboembolismo venoso (TEV).OBJETIVO:Definir el impacto económico de TEV hospitalaria después de la cirugía por EII, que en la actualidad permanece indefinida.DISEÑO:Un análisis transversal retrospectivo utilizando la Muestra Nacional de Pacientes Internos (NIS) de 2004 a 2014.ENTORNO CLINICO:Hospitales participantes muestreados en los Estados Unidos.PACIENTES:Se utilizaron los códigos de la 9ª edición de la Clasificación Internacional de Enfermedades (ICD-9) para identificar a los pacientes con diagnóstico primario de EII.INTERVENCIONES:Cirugía mayor abdominopélvica intestinal.PRINCIPALES MEDIDAS DE VALORACION:Incidencia de TEV en pacientes hospitalizados, utilizando modelos de regresión logística univariado y multivariable a nivel de pacientes y hospitales para comparar las características de los pacientes, las características del hospital y los resultados entre las cohortes de TEV y no TEV. Se compararon los costos directos promedio totales entre cohortes y la diferencia resultante extrapolando a la población nacional.RESULTADOS:De 26080 pacientes incluidos, se identificó TEV hospitalario en 581 (2,2%). En análisis multivariable, el diagnóstico de colitis ulcerosa, el estado de transferencia (entre centros hospitalarios), la duración de la hospitalización preoperatoria y el nivel de seguro medico se asociaron de forma independiente con la TEV hospitalaria. Se observó que los pacientes con TEV se asociaron con un aumento de la duración media de la estancia (17,6 versus a 6,7 días; p <0,001) y una mayor mortalidad hospitalaria (5,0% versus a 1,1%; OR 4,7, SE 3,2 -7,0; p <0,001). Después de ajustar las covariables clínicamente relevantes, el costo adicional asociado con cada TEV para pacientes hospitalizados fue de $ 31,551 USD (95% C.I. $ 29,136 - $ 33,965).LIMITACIONES:Estudio limitado por la naturaleza administrativa de la base de datos del NIS, que limita nuestra capacidad para evaluar el impacto de las covariables clínicas (por ejemplo, el uso de quimioprofilaxis de TEV, el uso de esteroides y el estado nutricional).CONCLUSIÓN:TEV hospitalaria en la cirugía abdominopélvica para la EII es una complicación mórbida infrecuente, pero costosa. Debido a la magnitud de la morbilidad el impacto económico, la prevención del TEV debería ser una prioridad de investigación y para mejoría de calidad a nivel nacional. Consulte Video Resumen en http://links.lww.com/DCR/B544.

Venous thromboembolism in inflammatory bowel disease.

Patients with inflammatory bowel disease (IBD) are at an increased risk for venous thromboembolism (VTE). VTE events carry significant morbidity and mortality, and have been associated with worse outcomes in patients with IBD. Studies have suggested that the hypercoagulable nature of the disease stems from a complex interplay of systems that include the coagulation cascade, natural coagulation inhibitors, fibrinolytic system, endothelium, immune system, and platelets. Additionally, clinical factors that increase the likelihood of a VTE event among IBD patients include older age (though some studies suggest younger patients have a higher relative risk of VTE, the incidence in this population is much lower as compared to the older IBD patient population), pregnancy, active disease, more extensive disease, hospitalization, the use of certain medications such as corticosteroids or tofacitinb, and IBD-related surgeries. Despite the increased risk of VTE among IBD patients and the safety of pharmacologic prophylaxis, adherence rates among hospitalized IBD patients appear to be low. Furthermore, recent data suggests that there is a population of high risk IBD patients who may benefit from post-discharge prophylaxis. This review will provide an overview of patient specific factors that affect VTE risk, elucidate reasons for lack of VTE prophylaxis among hospitalized IBD patients, and focus on recent data describing those at highest risk for recurrent VTE post-hospital discharge.

Venous thromboembolism in IBD: Increased risk for women in CD?

Although coagulation disturbances have been described in inflammatory bowel disease (IBD), it remains unclear how common venous thromboembolism (VTE) is in IBD, and what factors influence VTE frequency. We evaluated VTE in Crohn's disease (CD) and ulcerative colitis (UC) at LSUHSC-S, a southern US medical center with an approximately equal White: African-American (AA) (1.12:1) patient base. This retrospective study evaluated VTE as a co-morbidity in IBD as a function of age, gender and race based on ICD-10 coding (2011−2015.) Results. Of 276 IBD diagnostic records, 213 were for CD (77.17%) and 63 for UC (22.8%). 52% of the CD patients were white, 42% were AA, and 6% were other. 42% of CD patients were male, with 58% were female. 6.1% (13 patients) of the 213 CD patients had a VTE. Of these 13 CD patients, 9 had active disease and 4 were in remission. 9 of 13 were female and 4 were male, with 5 white patients and 4 A A patients. 63 patients were diagnosed with UC, 3.38-fold fewer cases than CD. 25 UC patients were white, 25 were AA and 13 were in other ethnic groups. Of 63 UC cases, 2 UC patients had a VTE, both with active disease. At our institution, VTE appears to be 3x more frequently associated with CD than UC and was more common in white female patients. The recognition of VTE risk in CD, particularly in women, may be an important observation which may guide therapy and limit potentially life-threatening consequences.

Etiopathogenesis, Prevention, and Treatment of Thromboembolism in Inflammatory Bowel Disease

The close relationship between inflammation and thrombosis affects the progression and severity of inflammatory bowel disease (IBD). The prevalence of venous thromboembolism (VTE) varies between 1% and 7% among patients with IBD. The VTE risk in patients with IBD is at least 3 times higher than that in the normal general population. The absolute risk is very high during hospitalization, active disease, and surgery. The IBD-related VTE occurs at younger ages and recurs more frequently. The development of thrombosis in IBD is due to the interaction of many hereditary and acquired risk factors. Each patient diagnosed with IBD should be evaluated for a personal and family history of thrombosis and for prothrombotic drug use. Although procoagulant factors are increased during the natural course of inflammation, natural anticoagulants and fibrinolytic activity are decreased. Although IBD is accepted as a prothrombotic condition, there is no treatment that can remove this risk from daily practice. Patient training is required to control important factors, such as long-term immobilization and smoking. Oral contraceptives and hormone replacement therapy should be avoided. Inducing permanent disease remission must be the key approach for the prevention of thrombosis. Low-molecular-weight heparin (LMWH) is the basis of prophylactic treatment, which reduces the thrombosis risk by 50%. Prophylaxis with LMWH should be administered to all patients with IBD hospitalized due to disease attack or surgery. Long-term or even life-long anticoagulation therapy should be planned if there is insufficient disease control, recurrent VTE attacks, positive thrombophilia tests, or thrombosis in vital veins.

DOP022. Incidence of and risk factors for thromboembolism in Inflammatory Bowel Disease: Results from a population-based inception cohort

DOP022. Incidence of and risk factors for thromboembolism in Inflammatory Bowel Disease: Results from a population-based inception cohort

Incidence of thromboembolism in inflammatory bowel disease: Results from a population-based inception cohort

Background: Patients with Inflammatory Bowel Disease (IBD) were reported to have an increased risk for venous thromboembolism (VTE), particularly when hospitalized. The estimated risk varies considerably among studies, primarily due to differences in cohort type and methodology. The aim of the present study was to analyze the incidence and risk factors of VTE in a population based inception cohort in the Veszprem province database between 1977 and 2012.

Thromboembolism in inflammatory bowel disease: results from a prospective, population-based European inception cohort

Background. Patients with inflammatory bowel disease (IBD) have proven an increased risk of venous thromboembolism (VTE), particularly when hospitalized. The estimate of the true risk varies considerably between studies, primarily due to differences in methodology. We set out to determine the incidence of VTE in a population-based European inception cohort. Methods. IBD patients were incepted into a cohort that was prospectively followed from the early 1990s to the early 2000s. A total of 1145 patients were followed for a total of 10,634 patient-years (p.y.). Results. A total of 19 thromboembolic events were identified – 13 deep vein thrombosis and 6 with pulmonary embolism. The incidence rate of VTE was 1.8 per 1000 p.y. Conclusion. The risk of VTE was elevated in this IBD cohort but lower than previously reported. The highest risk was seen in hospitalized patients, but corticosteroids-requiring disease in outpatients also conferred some risk.

Consensus Statements on the Risk, Prevention, and Treatment of Venous Thromboembolism in Inflammatory Bowel Disease: Canadian Association of Gastroenterology

Guidelines for the management of venous thromboembolism (VTE) from the American College of Chest Physicians do not address patients with inflammatory bowel disease (IBD), a group with a high risk of both VTE and gastrointestinal bleeding. We present recommendations for the prevention and treatment of VTE in patients with IBD. A systematic literature search was performed to identify studies on VTE in IBD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Statements were developed through an iterative online platform, then finalized and voted on by a working group of adult and pediatric gastroenterologists and thrombosis specialists. IBD patients have an approximately 3-fold higher risk of VTE compared with individuals without IBD, and disease flares further increase this risk. Anticoagulant thromboprophylaxis is recommended for IBD patients who are hospitalized with IBD flares without active bleeding and is suggested when bleeding is nonsevere. Anticoagulant thromboprophylaxis is suggested during moderate-severe IBD flares in outpatients with a history of VTE provoked by an IBD flare or an unprovoked VTE, but not otherwise. The recommended duration of anticoagulation after a first VTE is based on the presence of provoking factors. Specific suggestions are made for the prevention and treatment of VTE in pediatric and pregnant IBD patients. Using the American College of Chest Physicians' guidelines as a foundation, we have integrated evidence from IBD studies to develop specific recommendations for the management of VTE in this high-risk population.

Proximal Crohnʼs Disease in a Patient with Hypercoagulable State

Background: Inflammatory bowel disease (IBD) is a known risk factor for venous thromboembolism. Proximal small bowel involvement is uncommon pattern of Crohn's disease. We are reporting a case of unexplained recurrent venous thromboembolism, diagnosed later with proximal Crohn's disease. Case: A 39-year-old female presented with epigastric pain and indigestion, the patient is known to have unexplained hypercoagulable state with recurrent DVTs, failed coumadin treatment and on chronic enoxaparin injections with Greenfield filter placement for more than 1 year. Upper endoscopy showed multiple distal duodenal aphthous ulcers. Biopsy showed duodenitis with no granuloma and a negative H. pylori staining. Gastrin level ordered and was normal. Suspicion of Crohn's disease led to colonoscopy which showed normal colon with scattered ileal aphthous ulcers. The endoscopic features supported diagnosis of Crohn's disease and the patient was started on prednisone and mesalamine with good response. Video capsule endoscopy was done later and showed multiple aphthous deep and irregular ulcers from distal duodenum to ileum, mainly in the jejunum with multiple strictures. Discussion: Crohn's disease is a well known risk factor for venous thromboembolism. Previous studies have shown that increased risk of venous thromboembolism in inflammatory bowel disease is multifactorial, which may include endothelial dysfunction, increased platelet aggregation, hyperhomocysteinemia, antiphospholipid antibodies and can involve all components of the clotting system. Our patient was diagnosed with unexplained resistant hypercoagulable state with recurrent DVTs. The patient was found to have extensive proximal Crohn's disease from distal duodenum to the terminal ileum. This could be the underlying cause of her unexplained hypercoagulable state. She has proximal Crohn's, which is uncommon and could be related to the severity of her hypercoagulable state. Conclusion: Crohn's disease and IBD in general should be investigated in any case of unexplained hypercoagulable state. There could be an association between the pattern of Crohn's disease and the severity of hypercoagulability.Figure

Vascular Thrombosis and Vascular Thrombo-embolism in Inflammatory Bowel Disease: Systematic Evaluation of 52,855 Cases with Meta-analysis

Vascular Thrombosis and Vascular Thrombo-embolism in Inflammatory Bowel Disease: Systematic Evaluation of 52,855 Cases with Meta-analysis

Duration of Anticoagulation for the Management of Venous Thromboembolism in Inflammatory Bowel Disease: A Decision Analysis

There is practice variation in the duration of anticoagulation for venous thromboembolism (VTE) in inflammatory bowel disease (IBD) patients. Clinicians must weigh the high risk of recurrent VTE with the risk of gastrointestinal bleeding. We implemented Markov decision analysis to compare the costs and effectiveness of extended anticoagulation vs. time-limited anticoagulation (6 months) among IBD patients with first unprovoked VTE over a 5-year time horizon. In a secondary analysis, we added two strategies in which therapeutic-dose or prophylactic-dose anticoagulation was administered during IBD flares. Compared with time-limited anticoagulation, extended anticoagulation yielded slightly higher quality-adjusted life years (QALYs) (4.40 vs. 4.38) and costs ($21,158 vs. $20,825), and an incremental cost-effectiveness ratio (ICER) of $15,254/QALY over 5 years. In secondary analysis, pharmacological prophylaxis during IBD flares was associated with the highest QALYs (4.41) and costs ($28,177), but was not cost-effective when compared with extended anticoagulation (ICER=$1,158,717/QALY). Anticoagulation during flares yielded the lowest cost ($19,681) and same QALYs as extended anticoagulation. In probabilistic sensitivity analysis, extended anticoagulation yielded higher QALYs than time-limited anticoagulation in 91% of trials and was dominant or cost-effective (<$50,000/QALY) in 72% of trials. When analyzed over a lifetime, extended anticoagulation dominated time-limited anticoagulation with higher effectiveness (18.44 vs. 17.95 QALYs) and lower costs ($94,738 vs. $102,874) and was highly robust in sensitivity analyses. Our analyses suggest that extended anticoagulation may provide marginal benefit over time-limited anticoagulation and should be considered in the management of first unprovoked VTE in IBD. Anticoagulation and prophylaxis during IBD flares are alternative viable strategies.