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Rifkin AS, Shi Z, Wei J, Zheng SL, Helfand BT, Cordova JS, Biank VF, Tafur AJ, Khan O, Xu J. Risk assessment of venous thromboembolism in inflammatory bowel disease by inherited risk in a population-based incident cohort. World J Gastroenterol 2023; 29:5494-5502. [PMID: 37900992 PMCID: PMC10600809 DOI: 10.3748/wjg.v29.i39.5494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/18/2023] [Accepted: 09/28/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND 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. AIM To estimate the proportion of VTE among IBD patients and assess genetic risk factors (monogenic and polygenic) for VTE. METHODS 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). RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Andrew S Rifkin
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL 60201, United States
| | - Zhuqing Shi
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL 60201, United States
| | - Jun Wei
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL 60201, United States
| | - Siqun Lilly Zheng
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL 60201, United States
| | - Brian T Helfand
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL 60201, United States
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL 60201, United States
- Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, United States
| | - Jonathan S Cordova
- Department of Pediatrics, NorthShore University HealthSystem, Evanston, IL 60201, United States
| | - Vincent F Biank
- Department of Pediatrics, NorthShore University HealthSystem, Evanston, IL 60201, United States
| | - Alfonso J Tafur
- Cardiovascular Institute, NorthShore University HealthSystem, Evanston, IL 60201, United States
| | - Omar Khan
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL 60201, United States
| | - Jianfeng Xu
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL 60201, United States
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL 60201, United States
- Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, United States
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Harindranath S, Varghese J, Afzalpurkar S, Giri S. Standard and Extended Thromboprophylaxis in Patients with Inflammatory Bowel Disease: A Literature Review. Euroasian J Hepatogastroenterol 2023; 13:133-141. [PMID: 38222957 PMCID: PMC10785145 DOI: 10.5005/jp-journals-10018-1401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 10/04/2023] [Indexed: 01/16/2024] Open
Abstract
Patients with inflammatory bowel disease (IBD), both Crohn's disease and ulcerative colitis, frequently experience venous thromboembolism (VTE), a potentially fatal consequence. The pathophysiological mechanisms contributing to VTE include inflammation, modifications in coagulation factors, endothelial dysfunction, and platelet activation. Numerous pro-inflammatory cytokines and markers, such as tumor necrosis factor-alpha and interleukin-6, have a significant impact on the thrombotic cascade. Patients with IBD are more likely to suffer VTE for a variety of causes. Exacerbations of preexisting conditions, admission to the hospital, surgical intervention, immobilization, corticosteroid usage, central venous catheterization, and hereditary susceptibility all fit into this category. The mainstay of therapy for VTE in IBD patients includes anticoagulation that is individualized for each patient depending on the thrombosis site, severity, bleeding risk, and interaction with other drugs. In some high-risk IBD patients, such as those having major surgery or hospitalized with severe flare, preventive anticoagulation may play a role. However, the acceptance rate for this recommendation is low. Additionally, there is a subset of patients who would require extended thromboprophylaxis. The majority of the studies that looked into this question consisted of patients in the surgical setting. Emerging data suggest that risk factors other than surgery can also dictate the duration of anticoagulation. While extending anticoagulation in all patients may help reduce VTE-related mortality, identifying these risk factors is important. Hence, the decision to initiate prophylaxis should be individualized, considering the overall thrombotic and bleeding risks. This review explores the relationship between IBD and VTE, including risk factors, epidemiology, and prevention. A multifactorial approach involving aggressive management of underlying inflammation, identification of modifiable risk factors, and judicious use of anticoagulant therapy is essential for reducing the burden of VTE in this vulnerable population. How to cite this article Harindranath S, Varghese J, Afzalpurkar S, et al. Standard and Extended Thromboprophylaxis in Patients with Inflammatory Bowel Disease: A Literature Review. Euroasian J Hepato-Gastroenterol 2023;13(2):133-141.
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Affiliation(s)
- Sidharth Harindranath
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Jijo Varghese
- Department of Gastroenterology, NS Hospital, Kollam, Kerala, India
| | - Shivaraj Afzalpurkar
- Department of Gastroenterology, Nanjappa Multispecialty Hospital, Davangere, Karnataka, India
| | - Suprabhat Giri
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
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3
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S Y, Kedia S, Teja V, Vuyyuru SK, Yadav N, Sahu P, Jain S, Yadav DP, Bopanna S, Mouli VP, Madhu D, Sharma R, Das P, Makharia G, Ahuja V. Thromboembolism is associated with poor prognosis and high mortality in patients with inflammatory bowel disease: A case-control study. Indian J Gastroenterol 2022; 41:325-335. [PMID: 36063357 DOI: 10.1007/s12664-021-01237-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/22/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND 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. METHODS 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, extraintestinal manifestations (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. RESULTS Prevalence of TE in IBD was 0.9% (UC-0.89%, CD-1.2%). Among TE patients (mean age: 34.9 ± 13.1 years, 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. CONCLUSION 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.
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Affiliation(s)
- Yadukrishna S
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Varun Teja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Sudheer Kumar Vuyyuru
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Nidhi Yadav
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Pabitra Sahu
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Saransh Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Dawesh P Yadav
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Sawan Bopanna
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Venigalla Pratap Mouli
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Deepak Madhu
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Raju Sharma
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Govind Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 029, India.
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Dilillo A, Del Giudice E, Cucchiara S, Viola F, Mallardo S, Isoldi S, Iorfida D, Bloise S, Marcellino A, Martucci V, Sanseviero M, De Luca E, Protano C, Marotta D, Ventriglia F, Lubrano R. Evaluation of Risk for Thromboembolic Events in Pediatric Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2022; 74:599-604. [PMID: 35129153 DOI: 10.1097/mpg.0000000000003398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The occurrence of thrombotic events in adult patients with inflammatory bowel disease (IBD) is linked to multiple interactions between hereditary and acquired risk factors. There are few published data concerning children with iBD. The aim of this study was to investigate the presence of thromboembolic risk factors also in children with iBD. METHODS We enrolled three groups of children: one with Crohn disease (cD), one with ulcerative colitis (Uc), and a control group of healthy subjects. For all the participants the potential thromboembolic risk was evaluated clinically and with laboratory tests. RESULTS We studied: 30 children (25.6%) with CD, 28 (23.9%) with UC, and 59 (50.4%) healthy control subjects. Regarding Pediatric Crohn Disease Activity Index, no significant differences between thromboembolic risk factors and disease activity were detected. Instead, in the patients with UC, stratified with the Pediatric Ulcerative Colitis Activity Index, there was a statistically significant difference in serum fibrinogen levels between patients with mild and moderate/severe disease [3.8 (3.2-4.5) g/L vs 5.7 (4.8-6.2) g/L, P < 0.0032]. serum homocysteine levels were lower in healthy controls than in CD (P = 0.176) and UC (P = 0.026). An increased level ofhomocysteine in UC with a homozygous mutation in the methylene tetrahydrofolate reductase C677T gene was also observed. CONCLUSIONS Our study showed that children with IBD have clinical features, acquired and congenital factors that can increase thrombotic risk, similarly to adults.
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Affiliation(s)
- Anna Dilillo
- Pediatric and Neonatology Unit, Maternal and Child Department, Sapienza University of Rome, Polo Pontino, Latina
| | - Emanuela Del Giudice
- Pediatric and Neonatology Unit, Maternal and Child Department, Sapienza University of Rome, Polo Pontino, Latina
| | - Salvatore Cucchiara
- Maternal Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza - University of Rome
| | - Franca Viola
- Maternal Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza - University of Rome
| | - Saverio Mallardo
- Pediatric and Neonatology Unit, Maternal and Child Department, Sapienza University of Rome, Polo Pontino, Latina
| | - Sara Isoldi
- Pediatric and Neonatology Unit, Maternal and Child Department, Sapienza University of Rome, Polo Pontino, Latina
| | - Donatella Iorfida
- Pediatric and Neonatology Unit, Maternal and Child Department, Sapienza University of Rome, Polo Pontino, Latina
| | - Silvia Bloise
- Pediatric and Neonatology Unit, Maternal and Child Department, Sapienza University of Rome, Polo Pontino, Latina
| | - Alessia Marcellino
- Pediatric and Neonatology Unit, Maternal and Child Department, Sapienza University of Rome, Polo Pontino, Latina
| | - Vanessa Martucci
- Pediatric and Neonatology Unit, Maternal and Child Department, Sapienza University of Rome, Polo Pontino, Latina
| | - Mariateresa Sanseviero
- Pediatric and Neonatology Unit, Maternal and Child Department, Sapienza University of Rome, Polo Pontino, Latina
| | - Enrica De Luca
- Pediatric and Neonatology Unit, Maternal and Child Department, Sapienza University of Rome, Polo Pontino, Latina
| | - Carmela Protano
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Daniela Marotta
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Flavia Ventriglia
- Pediatric and Neonatology Unit, Maternal and Child Department, Sapienza University of Rome, Polo Pontino, Latina
| | - Riccardo Lubrano
- Pediatric and Neonatology Unit, Maternal and Child Department, Sapienza University of Rome, Polo Pontino, Latina
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5
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Ollech JE, Waizbard A, Lubetsky A, Kopylov U, Goren I, Dotan I, Yanai H. Venous Thromboembolism Among Patients With Inflammatory Bowel Diseases is Not Related to Increased Thrombophilia: A Case-Control Study. J Clin Gastroenterol 2022; 56:e222-e226. [PMID: 34231498 DOI: 10.1097/mcg.0000000000001578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/12/2021] [Indexed: 01/01/2023]
Abstract
GOAL The aim was to assess whether thrombophilia significantly contributes to the risk of venous thromboembolic events (VTEs) in patients with inflammatory bowel disease (IBD). BACKGROUND Patients with IBD have a high risk of VTE. The underlying mechanism has been only partially defined. METHODS A case-control study in adults with IBD and an episode of VTE (IBD-VTE) were matched and compared with non-IBD patients with a VTE (non-IBD-VTE). The study population was comprised of patients seen in 2 tertiary medical centers in Israel between 2000 and 2013. Characteristics of IBD and risk factors for VTE were retrieved from medical charts, and a comprehensive thrombophilia panel was completed in all patients. RESULTS Forty-four IBD-VTE cases (27 Crohn's disease) were matched with 127 non-IBD-VTE controls. The majority of VTE had a clear etiology and were considered provoked events. Provoked and unprovoked VTE rates were not different between the 2 groups. Likewise, thrombophilia rates were similar among patients with IBD-VTE and controls (40.9% vs. 53.5%, respectively, P=0.14). However, among patients with unprovoked VTE, thrombophilia rates were significantly lower in the IBD-VTE group compared with controls (42.1% vs. 70.7%, respectively, P=0.03). Among patients with IBD-VTE, an unprovoked event, and negative thrombophilia, 77% had active inflammation at the time of VTE. CONCLUSION Thrombophilia rates are similar among patients with IBD-VTE and controls but are less common among patients with unprovoked IBD-VTE. This finding suggests that either inflammation or other novel pathways drive VTE in patients with IBD.
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Affiliation(s)
- Jacob E Ollech
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva
- Sackler Faculty of Medicine, Tel Aviv University
| | - Amir Waizbard
- Sackler Faculty of Medicine, Tel Aviv University
- Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv
| | - Aaron Lubetsky
- Sackler Faculty of Medicine, Tel Aviv University
- The Institute of Thrombosis and Hemostasis
| | - Uri Kopylov
- Sackler Faculty of Medicine, Tel Aviv University
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Idan Goren
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva
- Sackler Faculty of Medicine, Tel Aviv University
| | - Iris Dotan
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva
- Sackler Faculty of Medicine, Tel Aviv University
| | - Henit Yanai
- IBD Center, Division of Gastroenterology, Rabin Medical Center, Petah-Tikva
- Sackler Faculty of Medicine, Tel Aviv University
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6
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Moukalled NM, Hashash JG, Taher AT. Inflammatory Bowel Disease: An Indication to Screen for Thrombophilia? Diseases 2022; 10:diseases10010014. [PMID: 35323181 PMCID: PMC8947449 DOI: 10.3390/diseases10010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 11/30/2022] Open
Abstract
Inflammatory bowel diseases (IBD) are systemic conditions characterized by multiple intestinal and extra-intestinal manifestations related to the associated chronic inflammatory state. Among their diverse extra-intestinal complications, venous thromboembolism (VTE) remains one of the most under recognized causes of morbidity and mortality in these patients, highlighting the need for a better understanding of the underlying mechanism of hypercoagulability, in addition to the role of acquired and inherited risk factors that further increase the risk of thrombosis with its impact on patients’ outcomes. We hereby present a review of the data regarding thrombosis in the setting of IBD, elucidating the possible role for screening in this high-risk category of patients and specifically in areas where inherited thrombophilia is expected to be highly prevalent, reporting two patients with IBD, one who developed a cerebrovascular event and another one who had recurrent VTE events; nevertheless, both of them had inherited thrombophilic mutations. The identification of specific genetic abnormalities in those patients reintroduces the controversy related to the need to screen a specific category of patients with IBD for hereditary thrombophilia, especially in regions characterized by a higher prevalence of such thrombophilic alterations.
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Affiliation(s)
- Nour M. Moukalled
- Division of Hematology and Oncology, Department of Internal Medicine, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El Solh, Beirut 1107 2020, Lebanon;
- Correspondence:
| | - Jana G. Hashash
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Ali T. Taher
- Division of Hematology and Oncology, Department of Internal Medicine, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El Solh, Beirut 1107 2020, Lebanon;
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7
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Olivera PA, Zuily S, Kotze PG, Regnault V, Al Awadhi S, Bossuyt P, Gearry RB, Ghosh S, Kobayashi T, Lacolley P, Louis E, Magro F, Ng SC, Papa A, Raine T, Teixeira FV, Rubin DT, Danese S, Peyrin-Biroulet L. International consensus on the prevention of venous and arterial thrombotic events in patients with inflammatory bowel disease. Nat Rev Gastroenterol Hepatol 2021; 18:857-873. [PMID: 34453143 PMCID: PMC8395387 DOI: 10.1038/s41575-021-00492-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 12/11/2022]
Abstract
Patients with inflammatory bowel disease (IBD) are at increased risk of thrombotic events. Therapies for IBD have the potential to modulate this risk. The aims of this Evidence-Based Guideline were to summarize available evidence and to provide practical recommendations regarding epidemiological aspects, prevention and drug-related risks of venous and arterial thrombotic events in patients with IBD. A virtual meeting took place in May 2020 involving 14 international IBD experts and 3 thrombosis experts from 12 countries. Proposed statements were voted upon in an anonymous manner. Agreement was defined as at least 75% of participants voting as 'fully agree' or 'mostly agree' with each statement. For each statement, the level of evidence was graded according to the Scottish Intercollegiate Guidelines Network (SIGN) grading system. Consensus was reached for 19 statements. Patients with IBD harbour an increased risk of venous and arterial thrombotic events. Thromboprophylaxis is indicated during hospitalization of any cause in patients with IBD. Disease activity is a modifiable risk factor in patients with IBD, and physicians should aim to achieve deep remission to reduce the risk. Exposure to steroids should be limited. Antitumour necrosis factor agents might be associated with a reduced risk of thrombotic events.
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Affiliation(s)
- Pablo A Olivera
- Gastroenterology Section, Department of Internal Medicine, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Stephane Zuily
- Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Centre Hospitalier Régional Universitaire de Nancy, Vandoeuvre-lès-Nancy, France
- University of Lorraine, INSERM, DCAC, Nancy, France
| | - Paulo G Kotze
- IBD outpatient clinics, Colorectal Surgery Unit, Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | | | - Sameer Al Awadhi
- Gastroenterology Division, Rashid Hospital, Dubai Health Authority, Dubai, UAE
| | - Peter Bossuyt
- Imelda GI Clinical Research Center, Imelda General Hospital, Bonheiden, Belgium
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Subrata Ghosh
- NIHR Biomedical Research Centre, University of Birmingham and University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo, Japan
| | | | - Edouard Louis
- Department of Gastroenterology, CHU Liège University Hospital, Liège, Belgium
| | - Fernando Magro
- Department of Gastroenterology, Centro Hospitalar São João, Porto, Portugal
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Alfredo Papa
- Division of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
- Catholic University of Rome, Rome, Italy
| | - Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - David T Rubin
- University of Chicago Medicine, Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and INSERM NGERE U1256, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France.
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8
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Lagrange J, Lacolley P, Wahl D, Peyrin-Biroulet L, Regnault V. Shedding Light on Hemostasis in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2021; 19:1088-1097.e6. [PMID: 31972287 DOI: 10.1016/j.cgh.2019.12.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 12/19/2019] [Accepted: 12/31/2019] [Indexed: 02/07/2023]
Abstract
Patients with inflammatory bowel diseases (IBD) have an increased risk of thrombosis, possibly due to changes in blood cells and molecules involved in hemostasis. They have increased platelet counts and reactivity as well as increased platelet-derived large extracellular vesicles. Coagulation is continuously activated in patients with IBD, based on measured markers of thrombin generation, and the anticoagulant functions of endothelial cells are damaged. Furthermore, fibrinogen is increased and fibrin clots are denser. However, pathogenesis of thrombosis in patients with IBD appears to differ from that of patients without IBD. Patients with IBD also take drugs that might contribute to risk of thrombosis, complicating the picture. We review the features of homeostasis that are altered in patients with IBD and possible mechanisms of this relationship.
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Affiliation(s)
- Jeremy Lagrange
- INSERM U1116, Faculté de Médecine, Université de Lorraine, Vandœuvre-lès-Nancy, France; Université de Lorraine, Nancy, France; Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.
| | - Patrick Lacolley
- INSERM U1116, Faculté de Médecine, Université de Lorraine, Vandœuvre-lès-Nancy, France; Université de Lorraine, Nancy, France; Centre Hospitalier Régionale Universitaire de Nancy, Vandœuvre-lès-Nancy, France
| | - Denis Wahl
- INSERM U1116, Faculté de Médecine, Université de Lorraine, Vandœuvre-lès-Nancy, France; Université de Lorraine, Nancy, France; Division of Vascular Medicine, Centre Hospitalier Régionale Universitaire de Nancy, Vandœuvre-lès-Nancy, France
| | - Laurent Peyrin-Biroulet
- Université de Lorraine, Nancy, France; INSERM U1256, Faculté de Médecine, Université de Lorraine, Vandœuvre-lès-Nancy, France; Department of Gastroenterology, Centre Hospitalier Régionale Universitaire de Nancy, Vandœuvre-lès-Nancy, France
| | - Véronique Regnault
- INSERM U1116, Faculté de Médecine, Université de Lorraine, Vandœuvre-lès-Nancy, France; Université de Lorraine, Nancy, France; Centre Hospitalier Régionale Universitaire de Nancy, Vandœuvre-lès-Nancy, France
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9
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Abstract
OBJECTIVES Inflammatory bowel disease (IBD) is associated with increased risk of venous thromboembolism (VTE). Despite this recognized risk, there are limited data and no anticoagulation guidelines for hospitalized pediatric IBD patients. The objectives of this study were to characterize pediatric IBD patients with VTE and determine risk factors. METHODS This was a nested case-control study comparing hospitalized children with IBD diagnosed with VTE to those without VTE over a decade at a large referral center. Standard descriptive statistics were used to describe the VTE group. Multivariable conditional logistic regression was used to assess risk factors. RESULTS Twenty-three cases were identified. Central venous catheter (CVC) presence (odds ratio [OR] 77.9; 95% confidence interval [CI]: 6.9--880.6; P < 0.001) and steroid use (OR 12.7; 95% CI: 1.3--126.4; P = 0.012) were independent risk factors. Median age at VTE was 17 years (interquartile range [IQR] 13.5--18.2), and in 48%, VTE was the indication for admission. Median duration of anticoagulation was 3.8 months (IQR 2.3--7.6), and there were no major bleeding events for patients on anticoagulation. There were no patients with known sequelae from VTE, though 22% had severe VTE that required interventions. CONCLUSIONS Pediatric patients with IBD are at risk for VTE, although the absolute risk remains relatively low. The safety and efficacy of pharmacologic thromboprophylaxis needs to be further evaluated in this population with attention to risk factors, such as steroid use and presence of CVC.
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10
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Zöller B, Ohlsson H, Waehrens R, Sundquist J, Sundquist K. Association of irritable bowel syndrome and venous thromboembolism. Scand J Gastroenterol 2018; 53:784-789. [PMID: 29688100 DOI: 10.1080/00365521.2018.1465118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Inflammatory bowel disease (IBD) is associated with venous thromboembolism (VTE). Whether functional gastrointestinal disorders, such as irritable bowel syndrome (IBS), are associated with VTE has not been determined. This nationwide study aimed to determine the risk of VTE in IBS outpatients in primary and specialist care. DESIGN We performed two matched case-control studies. Cases (n = 90,502) were individuals in Sweden aged 18-80 years with a first hospital diagnosis of VTE between 2001 and 2010. Five controls (n = 452,510) from the Swedish Total Population Register were matched to each case for birth, sex, country of birth, and education level. Diagnosis of IBS was determined in the Swedish hospital outpatient register. This procedure was replicated for the primary care population. As the Primary Care data did not have nationwide coverage, we only included individuals that were registered in the Primary Care database. A total of 9766 cases of hospital diagnosed VTE individuals could be found in the Primary Care population and they were matched to 48,830 controls also from the Primary health care population. Conditional logistic regression was used to determine odds ratio (OR) for first VTE diagnosis. Results The adjusted OR for VTE when IBS was diagnosed in hospital outpatient care was 1.49 (95% confidence interval 1.33-1.67). The crude OR for VTE was 1.18 (0.94-1.48) when IBS was diagnosed in primary care. CONCLUSIONS This is the first study describing an association between VTE and IBS. The results suggest that specialist treated IBS patients have increased risk of VTE.
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Affiliation(s)
- Bengt Zöller
- a Center for Primary Health Care Research, Lund University, Region Skåne , Malmö , Sweden
| | - Henrik Ohlsson
- a Center for Primary Health Care Research, Lund University, Region Skåne , Malmö , Sweden
| | - Rasmus Waehrens
- a Center for Primary Health Care Research, Lund University, Region Skåne , Malmö , Sweden
| | - Jan Sundquist
- a Center for Primary Health Care Research, Lund University, Region Skåne , Malmö , Sweden
| | - Kristina Sundquist
- a Center for Primary Health Care Research, Lund University, Region Skåne , Malmö , Sweden
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11
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Cheng J, Zhu XQ. Progress in research of venous thromboembolism in hospitalized patients with digestive system diseases. Shijie Huaren Xiaohua Zazhi 2018; 26:1089-1094. [DOI: 10.11569/wcjd.v26.i18.1089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hospitalized patients with digestive system diseases are at high risk of venous thromboembolism (VTE) due to a variety of factors such as advanced age, prolonged bed rest, medication and so on. VTE can affect the quality of life of patients, the number of days of hospitalization, and the cost of treatment and even threaten their life. This article gives a brief overview of the pathogenesis, risk factors, assessment tools, and preventive methods for VTE to promote better prevention of this disease.
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Affiliation(s)
- Jie Cheng
- Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Xiu-Qin Zhu
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
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12
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Sarlos P, Szemes K, Hegyi P, Garami A, Szabo I, Illes A, Solymar M, Petervari E, Vincze A, Par G, Bajor J, Czimmer J, Huszar O, Varju P, Farkas N. Steroid but not Biological Therapy Elevates the risk of Venous Thromboembolic Events in Inflammatory Bowel Disease: A Meta-Analysis. J Crohns Colitis 2018; 12:489-498. [PMID: 29220427 DOI: 10.1093/ecco-jcc/jjx162] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 11/30/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Inflammatory bowel disease [IBD] is associated with a 1.5- to 3-fold increased risk of venous thromboembolism [VTE] events. The aim of this study was to determine the risk of VTE in IBD as a complication of systemic corticosteroids and anti-tumour necrosis factor alpha [TNFα] therapies. METHODS A systematic review and meta-analysis was conducted, which conforms to the Preferred Reporting Items for Systematic Reviews and Meta-analyses [PRISMA] statement. PubMed, EMBASE, Cochrane Library and Web of Science were searched for English-language studies published from inception inclusive of 15 April 2017. The population-intervention-comparison-outcome [PICO] format and statistically the random-effects and fixed-effect models were used to compare VTE risk during steroid and anti-TNFα treatment. Quality of the included studies was assessed using the Newcastle-Ottawa scale. The PROSPERO registration number is 42017070084. RESULTS We identified 817 records, of which eight observational studies, involving 58518 IBD patients, were eligible for quantitative synthesis. In total, 3260 thromboembolic events occurred. Systemic corticosteroids were associated with a significantly higher rate of VTE complication in IBD patients as compared to IBD patients without steroid medication (odds ratio [OR]: 2.202; 95% confidence interval [CI]: 1.698-2.856, p < 0.001). In contrast, treatment with anti-TNFα agents resulted in a 5-fold decreased risk of VTE compared to steroid medication [OR: 0.267; 95% CI: 0.106-0.674, p = 0.005]. CONCLUSION VTE risk should be carefully assessed and considered when deciding between anti-TNFα and steroids in the management of severe flare-ups. Thromboprophylaxis guidelines should be followed, no matter the therapy choice.
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Affiliation(s)
- Patricia Sarlos
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary.,Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Kata Szemes
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Peter Hegyi
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary.,Institute for Translational Medicine, University of Pécs, Pécs, Hungary.,Hungarian Academy of Sciences-University of Szeged, Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary
| | - Andras Garami
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Imre Szabo
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Anita Illes
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Margit Solymar
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Erika Petervari
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Aron Vincze
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Gabriella Par
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Judit Bajor
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Jozsef Czimmer
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Orsolya Huszar
- First Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Peter Varju
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary.,Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Nelli Farkas
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary.,Szentágothai Research Centre, University of Pécs, Pécs, Hungary.,Institute of Bioanalysis, University of Pécs, Pécs, Hungary
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13
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Alkim H, Koksal AR, Boga S, Sen I, Alkim C. Etiopathogenesis, Prevention, and Treatment of Thromboembolism in Inflammatory Bowel Disease. Clin Appl Thromb Hemost 2016; 23:501-510. [DOI: 10.1177/1076029616632906] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Huseyin Alkim
- Department of Gastroenterology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ali Riza Koksal
- Department of Gastroenterology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Salih Boga
- Department of Gastroenterology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ilker Sen
- Department of Gastroenterology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Canan Alkim
- Department of Gastroenterology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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14
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Koutroubakis IE. The relationship between coagulation state and inflammatory bowel disease: current understanding and clinical implications. Expert Rev Clin Immunol 2015; 11:479-88. [PMID: 25719625 DOI: 10.1586/1744666x.2015.1019475] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Inflammatory bowel disease (IBD) is associated with a hypercoagulable state and subsequently with an increased risk for venous thromboembolism (VTE). VTE in IBD is characterized by a high recurrence rate and is associated with the disease activity. Acquired endothelial dysfunction, abnormalities of platelets, activation of coagulation system and impaired fibrinolysis are the main changes in the coagulation state in IBD. The development of VTE in IBD has been considered to be the result of multiple interactions between acquired and inherited risk factors. The treatment of VTE in IBD patients is recommended to be similar and to follow the same protocols as for non-IBD patients. In the clinical practice, the management of IBD patients and especially the hospitalized patients should include thromboprophylaxis.
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Affiliation(s)
- Ioannis E Koutroubakis
- Department of Gastroenterology, University Hospital Heraklion, P.O. Box 1352, 71110 Heraklion, Crete, Greece
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15
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Magro F, Soares JB, Fernandes D. Venous thrombosis and prothrombotic factors in inflammatory bowel disease. World J Gastroenterol 2014; 20:4857-4872. [PMID: 24803797 PMCID: PMC4009517 DOI: 10.3748/wjg.v20.i17.4857] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 01/12/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
Patients with inflammatory bowel disease (IBD) may have an increased risk of venous thrombosis (VTE). PubMed, ISI Web of Knowledge and Scopus were searched to identify studies investigating the risk of VTE and the prevalence of acquired and genetic VTE risk factors and prothrombotic abnormalities in IBD. Overall, IBD patients have a two- to fourfold increased risk of VTE compared with healthy controls, with an overall incidence rate of 1%-8%. The majority of studies did not show significant differences in the risk of VTE between Crohn’s disease and ulcerative colitis. Several acquired factors are responsible for the increased risk of VTE in IBD: inflammatory activity, hospitalisation, surgery, pregnancy, disease phenotype (e.g., fistulising disease, colonic involvement and extensive involvement) and drug therapy (mainly steroids). There is also convincing evidence from basic science and from clinical and epidemiological studies that IBD is associated with several prothrombotic abnormalities, including initiation of the coagulation system, downregulation of natural anticoagulant mechanisms, impairment of fibrinolysis, increased platelet count and reactivity and dysfunction of the endothelium. Classical genetic alterations are not generally found more often in IBD patients than in non-IBD patients, suggesting that genetics does not explain the greater risk of VTE in these patients. IBD VTE may have clinical specificities, namely an earlier first episode of VTE in life, high recurrence rate, decreased efficacy of some drugs in preventing further episodes and poor prognosis. Clinicians should be aware of these risks, and adequate prophylactic actions should be taken in patients who have disease activity, are hospitalised, are submitted to surgery or are undergoing treatment.
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16
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Nguyen GC, Bernstein CN, Bitton A, Chan AK, Griffiths AM, Leontiadis GI, Geerts W, Bressler B, Butzner JD, Carrier M, Chande N, Marshall JK, Williams C, Kearon C. Consensus statements on the risk, prevention, and treatment of venous thromboembolism in inflammatory bowel disease: Canadian Association of Gastroenterology. Gastroenterology 2014; 146:835-848.e6. [PMID: 24462530 DOI: 10.1053/j.gastro.2014.01.042] [Citation(s) in RCA: 216] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Anthony K Chan
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, Hepatology, and Nutrition, Sick Kids Hospital, Toronto, Ontario, Canada
| | | | - William Geerts
- Thromboembolism Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Brian Bressler
- Department of Medicine, Division of Gastroenterology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - J Decker Butzner
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Marc Carrier
- Clinical Epidemiology Program, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Nilesh Chande
- Division of Gastroenterology, Western University, London, Ontario, Canada
| | | | - Chadwick Williams
- Dalhousie University, Halifax, Nova Scotia; Memorial University, St John's, Newfoundland, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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17
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Owczarek D, Cibor D, Głowacki MK, Rodacki T, Mach T. Inflammatory bowel disease: epidemiology, pathology and risk factors for hypercoagulability. World J Gastroenterol 2014; 20:53-63. [PMID: 24415858 PMCID: PMC3886032 DOI: 10.3748/wjg.v20.i1.53] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 11/19/2013] [Accepted: 12/05/2013] [Indexed: 02/06/2023] Open
Abstract
Hypercoagulability observed in patients with inflammatory bowel diseases (IBD) may lead to thromboembolic events (TE), which affect the venous and arterial systems alike and are an important factor in patients' morbidity and mortality. The risk of TE in IBD patients has been demonstrated to be approximately three-fold higher as compared to the general population. The pathogenesis of thrombosis in IBD patients is multifactorial and not fully explained. The most commonly listed factors include genetic and immune abnormalities, disequilibrium between procoagulant and anticoagulant factors, although recently, the role of endothelial damage as an IBD-triggering factor is underlined. Several studies report that the levels of some coagulation enzymes, including fibrinogen, factors V, VII, VIII, active factor XI, tissue factor, prothrombin fragment 1 + 2 and the thrombin-antithrombin complex, are altered in IBD patients. It has been demonstrated that there is a significant decrease of tissue plasminogen activator level, a marked increase of plasminogen activator inhibitor type 1 and thrombin-activable fibrinolysis inhibitor, a significantly lower level of antithrombin III and tissue factor pathway inhibitor. IBD patients have been also observed to produce an increased amount of various anticoagulant antibodies. Hyperhomocysteinemia, which is a potential risk factor for TE was also observed in some IBD patients. Further studies are necessary to assess the role of coagulation abnormalities in IBD etiology and to determine indications for thromboprophylactic treatment in patients at high risk of developing TE.
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