DR. K. K. RAWALM.D. D.M.(GASTRO)

Consultant GastroenterologistMilestone Hospital Vidyanagar main roadRajkot (0281-2480843 / 44)

Thrombotic complications in IBD

DR K K RAWAL MD,DM MILESTONE HOSPITAL VIDYANAGAR MAIN ROAD RAJKOT

Case

59 year old male, Colonic Crohn’s for 20 years Developed lymphoma while on azathioprine Recent flare-up; 6 stool/day with blood, cramp Rx budesonide & metronidazole

Developed frank rectal bleeding and swollen left leg

Ultrasound – Deep Venous Thrombosis (DVT) in left leg

Sigmoidoscopy

What would you suggest next?

A. Low Molecular Weight HeparinB. Unfractionated HeparinC. Vena cava filterD. Other

Thrombotic complications in IBD

1st reported in 1936 by Bargen and Barter Thromboembolic complications are less frequent but potentially life-

threatening (mortality – 25%) “Preventable” complication of IBD

Barger J, Barker N. Arch Intern Med 1936;58:17-31

Mayo Clin Proc 1986;61:140-5

Thromboembolic complications

70 % are venous 30% arterial UC > CD Female > Male

Naess IA et al, J Thromb Haemost 2007;5:692-9

Incidence

3 times higher risk than general population Clinical studies = 1- 4% Post mortem studies = 40% Risk increased in both hospital based and population based cohorts Greatest increase in risk under 40 years Recurrence = 10 – 15%

Kappelman et al, Gut 2011;60:937

Solem CA Am J Gastroenterol 2004;99:97-101

Site

Almost all the peripheral and even central vessels including aorta reported to be involved

Deep vein thrombosis (DVT) and pulmonary embolism (PE) – Commonest

Mesenteric / portal / hepatic veins Cerebrovascular accidents NO increase in ischemic heart disease ??

Mayo Clin Proc 1986;61;140-5

Nutritional factors

Inherited tendencies ?Increased platelet activation

Thrombocytosis

Endothelial activation

Immobility

Central venous cannulation

Dehydration

Smoking ( in Crohn’s disease )

Thrombosis

Clotting factor abnormalities

Inflammation

Surgery

Risk factors

Obesity Extreme age Prior H/O TE Malignancy Bed rest > 5 days Major surgery

Risk factors

Activity of the disease (30% in non-active disease) Extent of the disease Colectomy does not prevent risk of recurrence

Irving P et al, Clin Gastroenterol Hepatol. 2005;3;617-28

Clinical features

DVT- Hot, tender, swollen areas ( Homans Sign) PE - Dyspnea, chest pain, Hemoptysis, cough D-dimer Doppler US CT angio Venography

Management

Control of inflammatory process Azathioprine / infliximab – Stopped Correction of nutrition and vitamin deficiency Smoking / OC pills – stopped Avoidance of dehydration Early mobilization

Prophylaxis

NO RCT exists or can be carried out Published guidelines advise Px in all indoor patients with IBD

Guidelines for the management of IBD in adults. Gut 2004;53:1-16

AGA Physician Performance Measures Set 2011

Razik R, Can J Gastroenterol 2012;21:795-8

TE Prophylaxis is Under-Utilized in IBD

Pleet J et al , DDW 2013, S434

Number of hospital days with TE prophylaxis ordered

‘None’‘All’

Actual administration of ordered doses by nurses

Prophylaxis

Methods Pharmacological - Low molecular weight heparin (LMWH) - Unfractionated Heparin (UFH)

Mechanical

Prophylaxis

LMWH - Ease of administration (S/C) - No monitoring of APTT needed - 40mg OD S/C (enoxaparin)

UFH - Infusion pump (cheap, safe in Renal failure) APTT 6hrly (1.5 - 2 times) Duration – Till ambulation or discharge

ACCP Clinical Practice Guidelines. Chest 2012;141:e601S

What would you suggest now?

A. Low Molecular Weight HeparinB. Unfractionated HeparinC. Vena cava filterD. Other

Prophylaxis

Mechanical - Antithrombotic stockings - Intermittent pneumatic compression - Venous foot pump - “Vena cava filters”

Conclusion

Thromboembolic events, are rare but important cause of morbidity and mortality in patients with IBD.

Simple interventions decrease the risk and should be considered in all patients with IBD admitted to hospital, whether their disease is active or not.

Thank you