THAMER A. BIN TRAIKIDEMONSTRATOR GS

PGY-1

KKUH

SMV Thrombosis in IBD Patients

1- CASE PRESENTATION

2-SMV THROMBOSIS PRESENTATION

3-LITERATURE REVIEW OF

1. IBD &THROMBOSIS2.IBD & SMV THROMBOSIS

Content

Case Presentation

26 y/o male from eastern region Dx to have UC since 3 years.

Admitted 9 times with acute exacerbation of his illness & labeled as steroid dependant .

He was on: Prednisolone 30 mg PO ODImuran 75 mg PO OD Pentasa 800 mg PO QIDPentasa 1 g Supp. BD

Cont.…

Admitted now forElective Laparoscopic

proctocolectomy with Ileostomy

Cont.…

Upon admission Imuran & Pentasa were held.The pt. started on soft diet.Heparinization with LMWH 2 days later His operation day During the operation Pneuomatic

compressing device & TED stoking were applied .

Cont.…

Post operatively Antithrombotic measures of LMWH , TED stoking & Pneumatic device were cont…. .

And to start the pt. on clear fluid diet when fully awake as tolerated .

Cont.…

D 1 post opD 1 post op

Fluid diet was tolerated.V/S : stable afebrile .Abd. Soft & lax .Stoma looks good .Stoma output in 1st day was 200 cc .

Cont.…

D 2 D 2 Soft diet started BUT was not toleratedVomited once & abd. pain V/S stable, afebrile .Abd : soft , lax with +ve bowel sound .Stoma output : nil .

Cont.…

Abdominal pain disproportional to his abdominal examination,despite of proper analgesia

(PCA morphine )

All of his labs were within normal

Cont.…

5th day CT abdomen requested :

Filling defect occupying the SMV at the proximity with the PV most likely to be a

thrombus

SMV thrombosis

Cont.…

Hematology team was consultedTherapeutic dose of LMWH started (1mg/kg SQ

bid). Pain subsidedOn/Off attacks of vomiting . TPN startedStoma continued to look healthy & functioning

well with variable amount of output .

Cont.…

D 11D 11 the stoma was mildly congested & edematous .

D 12D 12 stoma bag was filled with gas only even though he was not complaining of pain & his abdomen was soft .

D 13D 13 stoma was draining well

D 15D 15 F/U CT was requested :

CT Result

Thrombus disappeared .

Ascitis present .

Mucosal enhancement of the distal ileum without pneumatosis intestinale .

Cont.…

D 17D 17 a severe attack of severe generalized

abdominal painStoma output was nill not even gas Folly's cath. was inserted & large amount

came out of the stoma ( > 1 L ) .The cath kept in place .

Cont.…

D 18 D 18

The stoma was continue to function in the presence of the catheter .

Retrograde enema was requested .

Cont.…

The result showed Strictured area @ 7 cm proximal to the stoma ? Kinck? Ischemic changes

Cont.…

Then the patient was taken to the theater For Minilaparotomy

For refashioning of his stoma withResection of strictured part .

Post op the patient was doing fine Tolerating oral feeding .V/S stable afebrile Stoma was functioning very well.

Cont.…

D 42 the patient was discharged home in good condition .

Superior Mesenteric Vein Thrombosis

SMV Thrombosis

SMV thrombosis causes 5%-10% of acute mesenteric ischemia .

Cause intestinal ischemia .

The mortality of SMV thrombosis is around 25% .

Symptoms

Abdominal pain in 85% usually severe and disproportionate to physical findings .

Anorexia in 50%.

GI bleeding in 45%.

Nausea and vomiting in 45%

Signs

Physical signs depend on the severity and stage of intestinal injury.

Peritoneal signs are late manifestations that indicate bowel infarction.

Diagnosis

Usually made by CT or Angiography .CT :

o Diagnostic in ~ 80% o Demonstrates thrombus in the mesenteric vein

as a central area of low density surrounded by an enhanced peripheral vascular rim.

Angiography :o Less sensitive in detecting superior mesenteric venopathy

than arteriopathy .

Treatment

Full course of anticoagulation with heparinProlonged anticoagulation with coumadin

post acute heparinization (6months - longer if thrombophilic condition present)

Surgery to resect nonviable bowel if peritoneal signs present.

Thrombolytic therapy success in small number of patients though still considered experimental

IBD & THROMBOSIS

Literature Review

Thromboembolic (TE) events in (IBD) patients were first described in 1936.

Arch. Intern. Med.1936; 58: 17–31.

Miehsler, W. et al. 2004. Large cohort study Showed overall incidence of TE events is ~6.5% in both

Crohn’s disease and ulcerative colitis patients. Gut 53: 542–548

The incidence rising to 39–41% in postmortem studies.

Gastroenterology 1968;54:(suppl):819–22

Bernstein et al 2001 Population-based study IBD patients have ~ 3 folds risk of DVT and PE.

than general population”J Clin Gastroenterol 2005;39:27–31

Cont.…

In IBD, systemic TE events occur mainly in the venous circulation . Gut 2004;53: 542–548

NOVACEK et al. reported Two cases Aortic mural thrombi in IBD patients

Inflamm. Bowel Dis. 2004 10: 430–435.

.

DVT and PE are the most common types of TE.

HOWEVERThrombosis are also reported in unusual sites

such: Cerebral V. Innominate V. Retinal V. Hepatic V. Mesenteric veins.

Ann. N.Y. Acad. Sci. 2005 ;1051: 166–173.

Cont.…

TE was also shown to occur at a younger age in IBD patients .

Scand J Gastroenterol 2000;35:619-23

Papa et al , 2005 demonstrated IBD patients have a greater intima-

media thickness of the carotid arteries a marker of early atherosclerosis.

Aliment Pharmacol Ther 2005;22:839–46.

Why Do IBD Patient Develop Thrombosis?

1 – Inflammatory Reaction Activation of coagulation acts as a constituent of

the inflammatory response by directly mediating cytokine responses and some proinflammatory cytokines, such as IL-6, activate coagulation .

Hypofibrinolysis, a prothrombotic condition, is a typical feature of inflammation .

Am J Gastroenterol 2007;102:174–186

2- Related to the Disease itselfTE is a specific feature of IBD .

Gut 2004;53:542-8

Cont…

Abnormalities of coagulation↑ Fibrinogen↑ Factors V, VIII, IX↑ Fragment 1 + 2, fibrinopeptide

A&B TAT (thrombin antithrombin

complex)↓ Factor XIII/subunit A factor XIII↓ Protein C, protein S,

antithrombin III↓ TFPI (tissue factor pathway

inhibitor) Abnormalities of platelets↑ Number, activation, aggregation

Abnormalities of fibrinolysis↓ tPA (tissue-type plasminogen

activator)↑ PAI (plasminogen activator

inhibitor),TAFI (thrombin-activatable

fibrinolyis inhibitor)↑ D-dimer, FDP (fibrin

degradation products),FgDP (fibrinogen degradation

products) Endothelial abnormalities↑ Circulating thrombomodulin,

ECPR,and von Willebrand factor↓ Tissue thrombomodulin and

EPCR

Cont.…

Nutritional abnormalities↑ Homocysteinemia, lipoprotein A↓ Vitamin B6Immunological abnormalitiesAntibodies:Antiphospholipidantiprotein Santiendothelial cellsanti-tPA

Does The Disease Activity Have a Role?

Author/YearTotal # Pts# Active% Active

Talbot, 1996694768

Jackson, 1997523975

Guedon, 2001151066

Minjhout, 200411655

Cont.…

From these data :

One third of IBD patient can develop TE During disease quiescence .

IBD & SMV THROMBOSIS

Literature Review

Retrospective review of 545 patients with IBD 6 with MVT; 3 CD; 3 UC

All post surgery, 3 within 60 days of abdominal colectomy, 2 post OLT 1 post terminal ileal resection

Conclusion: MVT is an important clinical consideration in IBD patients, specifically during the perioperative setting .

Hatoum, O J clin Gastro 39, 2005; 27-31

83pt. consecutive with total colectomy for IBD (1999-2001)

New post-op abdominal pain Abdominal CT 4 MVT/2 PVT Interval 6-90 days, Median 10 days.

“Direct surgical trauma to the middle colic veins, with resulting thrombosis and clot propagation into the SMV and portal vein is likely to be the precipitating factor in a borderline intrinsically hypercoagulable environment ”

Fischera ,A Dis Colon Rectum 46,2003; 643-648

Incidence of MV thrombosis in IBD

Author/YearStudy TypeTotal TEVisceral/PVT

Graef, 1966100 consecutive autopsies 1943-1962 in IBD vs. Control

39% vs. 14.5%16% vs. 3-6%

Talbot, 1986Review of 7199 patients (1970-1980)

1.3%8 patients2 PVT

Hautoum, 2005Review of 545 patients

Not reported6(1.1% )2 PVT

Does Surgery Protect?

Solem et al. 2004 . Retrospective study of IBD pt. with TE events over 9 yrs 59 UC & 39 CD 16 of UC pt. underwent proctocolectomy 2 (13% )of them

develop recurrent thromboembolic event .

Conclusion: Proctocolectomy is not protective of recurrent TE events

Am J Gastroenterol. 2004 Jan;99(1):97-101

Conclusion

Clinical features of thrombosis in inflammatory bowel disease

Overall incidence of thrombosis 6.2% Risk ratio for TE event 3.0–3.6 Median time to occurrence of first TE event ~5 years Two-year mortality following a TE event 22–25% Evidence for bowel disease activity at the time of TE event CD: 60–89% UC: 45–

60%

Prevalence of DVT or PE 79–87% Ann. N.Y. Acad. Sci. 2005;1051: 166–173.

Take Home Message

Thrombosis post op in IBD patient isa Known Complication

With these data shall we Give therapeutic doses of anticoagulant peri-

operatively ?And if yes for how long ?

Thank You