Thromboembolism as an important complication of inflammatory bowel disease

Venous Thromboembolism in Patients with Inflammatory Bowel Disease

Patients diagnosed with inflammatory bowel disease (IBD), which encompasses Crohn's disease and ulcerative colitis, experience chronic inflammation of the gastrointestinal tract. Those with IBD face a higher risk of developing venous thromboembolism (VTE) compared to individuals without IBD. This escalated risk is associated with various factors, some modifiable and others non-modifiable, with disease activity being the primary concern. Interestingly, Janus Kinase inhibitors approved for the treatment of IBD may be associated with an increased risk of VTE but only in patients that have other underlying risk factors leading to an overall increased VTE risk. Several recognized medical societies have recommended the use of VTE prophylaxis for hospitalized individuals with IBD. The association between VTE and IBD and the need for pharmacologic prophylaxis remains under-recognized. Increased awareness of this complication can hopefully protect patients from a potentially deadly complication.

Risk of venous thromboembolism in autoimmune diseases: A comprehensive review

Autoimmune diseases have specific pathophysiologic mechanisms leading to an increased risk of arterial and venous thrombosis. The risk of venous thromboembolism (VTE) varies according to the type and stage of the disease, and to concomitant treatments. In this review, we revise the most common autoimmune disease such as antiphospholipid syndrome, inflammatory myositis, polymyositis and dermatomyositis, rheumatoid arthritis, sarcoidosis, Sjogren syndrome, autoimmune haemolytic anaemia, systemic lupus erythematosus, systemic sclerosis, vasculitis and inflammatory bowel disease. We also provide an overview of pathophysiology responsible for the risk of VTE in each autoimmune disorder, and report current indications to anticoagulant treatment for primary and secondary prevention of VTE.

Positive antiphospholipid antibodies and pulmonary embolism in a patient with adalimumab-induced lupus

It is known that administration of tumor necrotic factor (TNF) inhibitors induces lupus. The case of a Crohn's disease patient who had been treated with adalimumab (ADA) and showed positive anti-DNA and antiphospholipid antibodies and developed pulmonary embolism is presented. Fortunately, early diagnosis and intervention helped her survive. Although ADA was withdrawn, the Crohn's disease did not recur, and the autoantibodies became negative without any steroid therapy. It is important to recognise that administration of TNF inhibitors may be associated with antiphospholipid syndrome. It is necessary to perform therapeutic interventions such as TNF inhibitor withdrawal and prompt anticoagulant therapy when such pathology is suspected.

Venous Thromboembolism Prophylaxis in Inflammatory Bowel Disease: A Two-year Retrospective Study of Patients Presenting With Inflammatory Bowel Disease to a Community Hospital

Objective

We set out to determine the rate of pharmacological venous thromboembolism (VTE) prophylaxis among patients admitted with inflammatory bowel disease (IBD) and indirectly compare it to national trends. We also assessed the demographic and clinical correlates for non-prescription of pharmacologic VTE prophylaxis among IBD patients with and without a flare.

Methods

We extracted data from 123 patients admitted to our facility with IBD from September 2018 to August 2020 retrospectively. Out of this cohort, 26 patients were excluded and 96 were included in our analysis. Baseline characteristics were analyzed using descriptive statistics. Multiple logistic regression was used to evaluate the correlates of pharmacological VTE prophylaxis use in individuals with IBD and to analyze the predictors of VTE prophylaxis use in patients with IBD flares.

Results

Out of the 96 patients with IBD included in this study, 61 (63.5%) presented with an IBD flare, and among those with a flare, 26/61 (42.6%) received VTE prophylaxis. IBD patients aged ≥ 65 years and of Black race were less likely to be placed on pharmacological VTE prophylaxis (adjusted odds ratio (AOR) 0.20, 95% CI (0.06 - 0.70), p-value 0.012) and (AOR 0.16, 95% CI (0.05 - 0.50), p-value 0.002) respectively. Among those with a flare, the presence of bright red bleeding per rectum was associated with a low rate of pharmacologic VTE use (AOR 0.01, 95% CI (0.00 -1.78), p-value 0.001). Overall the rate of VTE prophylaxis use in the IBD patient cohort was 56.3% and this was irrespective of flare status.

Conclusion

Our study showed the low rate of pharmacologic VTE prophylaxis use in IBD patients at this center and this finding was in line with national trends. Interestingly age and the race of patients played a major role in the decision to provide pharmacological VTE prophylaxis but the reason for this finding was not explored by our study. A larger multi-center study is needed to further evaluate these relationships.

Inflammatory bowel disease and thromboembolic events: a c'lot to learn

BACKGROUND

Inflammatory bowel disease (IBD) is associated with a variety of extraintestinal manifestations including arterial and venous thromboembolism. Research evidences that IBD patients have about a 2- to 3-fold increase in the risk of venous thromboembolism when compared with the general population.

OBJECTIVES

We intended to evaluate the coagulation parameters and the prevalence of thromboembolic events (TE) in IBD patients. It was also our aim to investigate the correlation between coagulation parameters and disease phenotype and activity in this population.

METHODS

This single center prospective observational study was performed between November 2016 and April 2020. The cohort included patients with 18 years of age or older, diagnosed with IBD and followed at a gastroenterology consultation, during a follow-up period of 36 months. Patients were evaluated in terms of IBD type, extent and disease behavior, clinical scores of IBD activity, medication, smoking history, family and personal history of TE, coagulation parameters, fecal calprotectin levels, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), hospitalization due to TE, IBD-related hospitalization or surgery, pregnancy, or diagnosis of malignancy.

RESULTS

The study included 149 IBD patients (67 males and 82 females). Coagulation parameters were similar in CD and UC patients and only plasminogen was increased in CD patients [97.4 (17.0) versus 91.6 (13.3), p = 0.035], when comparing with UC patients. The determined values were in the range of the reference values described in literature for the standard population. During the follow-up period, none of the patients experienced a TE that demanded hospitalization.

CONCLUSION

In our study, acquired and inherited risk factors for TE and changes in coagulation parameters did not show to influence prothrombotic predisposition in IBD patients. As such, the clinical relevance of measuring coagulation parameters in this population is questionable.

TRIAL REGISTRY

NCT05162339 (ClinicalTrials.gov ID).

Venous thromboembolism in chronic gastrointestinal disorders

INTRODUCTION

Chronic gastrointestinal disorders (including autoimmune gastritis, celiac disease, inflammatory bowel disease, and diverticular disease) are highly prevalent disorders, that may be associated with unpredictable, life-threatening complications, such as thromboembolic events. Venous thromboembolism (VTE) is one of the major causes of morbidity and mortality worldwide. Several conditions, including cancer, major trauma, surgery, prolonged immobilization, are well-established risk factors for VTE. Over the past decade, chronic inflammation has also been identified as an independent risk factor for VTE due to the prothrombotic effects of inflammatory cytokines and oxidative stress on the coagulation cascade. Other several mechanisms were shown to be associated with a higher incidence of VTE in patients with gastrointestinal disorders.

AREAS COVERED

We critically discuss the latest insights into the mechanisms responsible for thromboembolic manifestations in chronic gastrointestinal disorders, also focusing on the recognition of risk factors and treatment.

EXPERT OPINION

The occurrence of thrombotic complications is underestimated in patients with chronic gastrointestinal disorders. Identifying potential risk factors and concomitant predisposing conditions and to prevent VTE and guide treatment require a multidisciplinary approach, and this is critically important for clinicians, in order to provide the best care for such patients.

Venous Thromboembolic Complications in Pediatric Gastrointestinal Diseases: Inflammatory Bowel Disease and Intestinal Failure

In children with gastrointestinal disorders such as inflammatory bowel disease (IBD) and intestinal failure (IF), the risk of venous thromboembolism (VTE) is increased. VTE may lead to pulmonary embolism, sepsis and central line infection, stroke and post-thrombotic syndrome. The purpose of this review is to summarize current knowledge and recent advances around VTE management in pediatric gastroenterology with a focus on IBD and IF. The VTE incidence in children with IBD is reported to be around 4-30 per 10,000 patient-years, with higher incidences for hospitalized children. While in general, IF is less common than IBD, the VTE incidence in children with IF is around 750 per 10,000 patient-years. The most common risk factors for development of VTE involve deviations leading to Virchow's triad (endothelial damage, stasis, and hypercoagulability) and include active inflammation, particularly with colonic involvement, presence of a central venous catheter, underlying thrombophilia, reduced mobility, surgery, and hospitalization. Classes of anticoagulants used for treatment of VTE are low molecular weight heparins and vitamin K antagonists. However, the use of direct oral anticoagulants for treatment or prevention of VTE has not been studied in this pediatric population yet. Pediatric gastroenterologists apply different VTE prevention and treatment strategies due to lack of literature and lack of consensus. We discuss the role of primary and secondary prophylactic use of anticoagulants, and provide tools and recommendations for screening, prevention and management for the specific pediatric populations.

International consensus on the prevention of venous and arterial thrombotic events in patients with inflammatory bowel disease

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.

Venous and arterial thromboembolism in patients with inflammatory bowel diseases

The risk of thromboembolism (TE) is increased in patients with inflammatory bowel disease (IBD), mainly due to an increased risk of venous TE (VTE). The risk of arterial TE (ATE) is less pronounced, but an increased risk of cardiovascular diseases needs to be addressed in IBD patients. IBD predisposes to arterial and venous thrombosis through similar prothrombotic mechanisms, including triggering activation of coagulation, in part mediated by impairment of the intestinal barrier and released bacterial components. VTE in IBD has clinical specificities, i.e., an earlier first episode in life, high rates during both active and remission stages, higher recurrence rates, and poor prognosis. The increased likelihood of VTE in IBD patients may be related to surgery, the use of medications such as corticosteroids or tofacitinib, whereas infliximab is antithrombotic. Long-term complications of VTE can include post-thrombotic syndrome and high recurrence rate during post-hospital discharge. A global clot lysis assay may be useful in identifying patients with IBD who are at risk for TE. Many VTEs occur in IBD outpatients; therefore, outpatient prophylaxis in high-risk patients is recommended. It is crucial to continue focusing on prevention and adequate treatment of VTE in patients with IBD.

The Incidence and Characteristics of Venous Thromboembolisms in Paediatric-Onset Inflammatory Bowel Disease: A Prospective International Cohort Study Based on the PIBD-SETQuality Safety Registry

BACKGROUND AND AIMS

Guidelines regarding thromboprophylaxis for venous thromboembolisms [VTEs] in children with inflammatory bowel disease [IBD] are based on limited paediatric evidence. We aimed to prospectively assess the incidence of VTEs in paediatric-onset IBD [PIBD], characterize PIBD patients with a VTE and identify potential IBD-related risk factors.

METHODS

From October 2016 to September 2020, paediatric gastroenterologists prospectively replied to the international Safety Registry, monthly indicating whether they had observed a VTE case in a patient <19 years with IBD. IBD details [type, Paris classification, clinical and biochemical disease activity, treatment] and VTE details [type, location, treatment, outcome] were collected. To estimate VTE incidence, participants annually reported the number of PIBD patients, data source and catchment area of their centre. A systematic literature review and meta-analysis was performed to calculate the VTE incidence in the general paediatric population.

RESULTS

Participation of 129 PIBD centres resulted in coverage of 24 802 PIBD patients. Twenty cases of VTE were identified [30% Crohn's disease]. The incidence of VTEs was 3.72 (95% confidence interval [CI] 2.27-5.74) per 10 000 person-years, 14-fold higher than in the general paediatric population (0.27 [95% CI 0.18-0.38], p < 0.001). Cerebral sinus venous thrombosis was most frequently reported [50%]. All but one patient had active IBD, 45% were using steroids and 45% were hospitalized. No patient received thromboprophylaxis, whereas according to current PIBD guidelines, this was recommended in 4/20 patients.

CONCLUSION

There is an increased risk of VTEs in the PIBD population compared to the general paediatric population. Awareness of VTE occurrence and prevention should be extended to all PIBD patients with active disease, especially those hospitalized.

Microbiota Gut-Brain Axis in Ischemic Stroke: A Narrative Review with a Focus about the Relationship with Inflammatory Bowel Disease

The gut microbiota is emerging as an important player in neurodevelopment and aging as well as in brain diseases including stroke, Alzheimer’s disease, and Parkinson’s disease. The complex interplay between gut microbiota and the brain, and vice versa, has recently become not only the focus of neuroscience, but also the starting point for research regarding many diseases such as inflammatory bowel diseases (IBD). The bi-directional interaction between gut microbiota and the brain is not completely understood. The aim of this review is to sum up the evidencesconcerningthe role of the gut–brain microbiota axis in ischemic stroke and to highlight the more recent evidences about the potential role of the gut–brain microbiota axis in the interaction between inflammatory bowel disease and ischemic stroke.

Right ventricular thrombus and pulmonary embolism after infliximab therapy for ulcerative colitis

Infliximab, an antitumour necrosis factor alpha (TNF-alpha)agent, is a cornerstone of treatment of inflammatory bowel disease with a favourable and well-tolerated side effect profile. While the majority of side effects associated with infliximab have been well established, the pathophysiology of infliximab-associated thrombosis remains controversial and poorly defined. We present a case of a young woman with ulcerative colitis who presented with a right ventricular thrombus and bilateral pulmonary emboli after initiation of infliximab and was subsequently found to have underlying factor V Leiden and prothrombin gene mutation. Clinicians should be aware of this potential adverse event associated with anti-TNF agents, especially in individuals with predisposing prothrombotic mutations such as factor V Leiden or prothrombin gene mutation.

Presentation with perforation of the terminal ileum and acute limb ischemia in Crohn's disease: A case report

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Crohn’s disease may be revealed by serious complications.

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Initial free peritoneum perforation in Crohn’s disease is uncommon and remains life threatening.

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Thromboembolic events revealing Crohn’s disease is exceptional.

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Our case is unique because of the association of two initial rare conditions revealing Crohn’s disease.

Introduction and importance

Crohn’s disease is a chronic inflammatory bowel disease with complex pathophysiology and multiple complications, some of which can be fatal. We report herein the management of an unusual case of Crohn’s disease revealed by two life-threatening complications.

Case presentation

A 59-year-old patient presented with an acute abdominal pain evolving for one day with a clinical presentation in favor of peritonitis by perforation of the last ileal loop and acute limb ischemia.

At emergency laparotomy, we found a fecal peritonitis by perforation of the last ileal loop. The patient underwent an ileo-caecal resection with rifle barrel ileo-colostomy associated with embolectomy using a Fogarty catheter of the femoral artery. Pathological examination of the specimen showed an aspect consistent with an ileo-caecal Crohn's disease and blood clot embolus of the femoral artery. Postoperative course was uneventful and the patient was kept in remission with immunosuppressants.

Discussion

Several complications may arise during the evolution of the disease. However, Life-threatening complication scarcely inaugurate crohn’s disease like in our patient. Free perforation of the small intestine in crohn’s disease occurs rarely, which makes its statistical study difficult. Risk factors for perforation are still poorly identified. Patients diagnosed with crohn's disease have a higher risk of thromboembolic complications. Indeed, there is an association between the activity of the disease and thromboembolic events. In our case, the severity of the clinical presentation as well as its inaugural character are unique.

Conclusion

The management of inaugural two uncommon acute conditions in Crohn’s disease is challenging.

Prevalence and Effect of Genetic Risk of Thromboembolic Disease in Inflammatory Bowel Disease

BACKGROUND AND AIMS

The largest cause of mortality in patients with inflammatory bowel disease (IBD) remains thromboembolic disease (TED). Recent reports have demonstrated that both monogenic and polygenic factors contribute to TED and 10% of healthy subjects are genetically at high risk for TED. Our aim was to utilize whole-exome sequencing and genome-wide genotyping to determine the proportion of IBD patients genetically at risk for TED and investigate the effect of genetic risk of TED in IBD.

METHODS

The TED polygenic risk score was calculated from genome-wide genotyping. Thrombophilia pathogenic variants were extracted from whole-exome sequencing. In total, 792 IBD patients had both whole-exome sequencing and genotyping data. We defined patients at genetically high risk for TED if they had a high TED polygenic risk score or carried at least 1 thrombophilia pathogenic variant.

RESULTS

We identified 122 of 792 IBD patients (15.4%) as genetically high risk for TED. Among 715 of 792 subjects whose documented TED status were available, 63 of the 715 patients (8.8%) had TED events. Genetic TED risk was significantly associated with increased TED event (odds ratio, 2.5; P = .0036). In addition, we confirmed an additive effect of monogenic and polygenic risk on TED (P = .0048). Patients with high TED genetic risk more frequently had thrombosis at multiple sites (78% vs 42%, odds ratio, 3.96; P = .048).

CONCLUSIONS

Genetic risk (both poly- and monogenic) was significantly associated with TED history. Our results suggest that genetic traits identify approximately 1 in 7 patients with IBD who will experience 2.5-fold or greater risk for TED.

Multiple Cerebral Infarction Associated with Cerebral Vasculitis in a Patient with Ulcerative Colitis

A 40-year-old man was admitted to the hospital due to both a worsening of symptoms associated with ulcerative colitis (UC), which had been diagnosed 3 years previously, and limb paralysis. Colonoscopy revealed severe pancolitis-type UC. He was diagnosed with cerebral vasculitis with multiple white matter infarctions associated with the disease activity of UC by contrast-enhanced head magnetic resonance imaging. Mesalazine at 4,000 mg/day and prednisolone at 60 mg/day were started, and the prednisolone dosage was thereafter gradually reduced and switched to golimumab. He achieved a long-term remission from UC, and thereafter his neurological abnormalities improved significantly. He had no recurrence of cerebral infarction.

Thrombosis in IBD in the Era of JAK Inhibition

Patients with inflammatory bowel diseases (IBD) have an increased risk of thrombosis. The interaction between inflammation and coagulation has extensively been studied. It is well-- known that some drugs can influence the haemostatic system, but several concerns on the association between therapies and increased risk of thrombosis remain open. While biologics seem to have a protective role against thrombosis via their anti-inflammatory effect, some concerns about an increased risk of thrombosis with JAK inhibitors have been raised. We conducted a literature review to assess the association between biologics/small molecules and venous/arterial thrombotic complications. An increased risk of venous and arterial thrombosis was found in patients treated with corticosteroids, whereas anti-TNFα were considered protective agents. No thromboembolic adverse event was reported with vedolizumab and ustekinumab. In addition, thromboembolic events rarely occurred in patients with ulcerative colitis (UC) after therapy with tofacitinib. The overall risk of both venous and arterial thrombosis was not increased based on the available evidence. Finally, in the era of JAK inhibitors, the treatment should be individualized by evaluating the pre-existing potential thrombotic risk balanced with the intrinsic risk of the medication used.

Inflammatory Bowel Disease Therapy and Venous Thromboembolism

Purpose of review

To explore the relationship between IBD (inflammatory bowel diseases) therapy and VTE (venous thromboembolism) risk, as well as the safety, barriers, and utility of VTE prophylaxis.

Recent findings

In 2019, the Food and Drug Administration (FDA) issued a black box warning concerning the use of tofacitinib among ulcerative colitis (UC) patients with a post hoc analysis revealing that all patients had additional risk factors for VTE. Additionally, although IBD patients experiencing a disease flare often present with hematochezia, these patients are less likely to receive VTE prophylaxis, despite data showing that pharmacologic prophylaxis has not been associated with clinically significant signs of bleeding.

Summary

Among IBD patients, corticosteroid use has been associated with an increased risk of VTE, whereas anti-TNF therapy does not appear to increase this risk. High-dose tofacitinib has also been shown to increase the likelihood of VTE in patients with additional risk factors. In order to prevent future VTE events, pharmacologic thromboprophylaxis should be emphasized, particularly in hospitalized IBD patients, with recent data suggesting that a select population at risk may benefit from continued prophylaxis.

Thromboembolic events in inflammatory bowel disease

GOAL OF THE STUDY

Inflammatory bowel disease (IBD) is associated with an increased risk of thromboembolic events (TEE) during outbreaks, increasing morbidity and mortality. The aim of our study was to specify the prevalence of TEE in IBD patients and to determine their epidemiological, clinical and evolutionary characteristics.

MATERIEL AND METHODS

This is a retrospective study collecting all patients with IBD, who had a thromboembolic complication confirmed by imagery, between January 2012 and December 2018.

RESULTS

One hundred patients with IBD were diagnosed during the study period. A TEE occurred in 6 patients (5.9%). These patients had an average age of 41 years, divided into 4 women and 2 men. Five patients had Crohn's disease and one patient had ulcerative colitis. The IBD was active in all patients. Five patients were already hospitalized and under preventive heparin therapy. Patients had deep venous thrombosis of the lower limbs in 3 cases, associated with pulmonary embolism in 1 case, cerebral venous thrombosis in 2 cases and pulmonary embolism isolated in 1 case. Thrombophilia investigations were negative in all patients. Evolution under medical treatment was favorable in 4 patients and fatal in 2 patients.

CONCLUSION

In our study, the prevalence of TEE in patients with IBD was 5.9%. Thrombosis occurred during the active phase of IBD in all cases.

Presentation and Management of Arterial Thromboembolisms during Active Inflammatory Bowel Disease: Case Series and Literature Review

BACKGROUND

Active inflammatory bowel disease (IBD) is associated with considerable risk for thromboembolism; however, arterial thromboembolism is rare and associated with considerable morbidity and mortality. Their management requires careful coordination between multiple providers, and as a consequence, much of the published literature is limited to case reports published across specialties.

METHODS

We examined our recent institutional experience with aortoiliac, mesenteric, and peripheral arterial thromboembolisms in patients with either Crohn's disease or ulcerative colitis. To supplement our experience, a comprehensive literature review was performed using MEDLINE and EMBASE databases from 1966 to 2019. Patient demographics, flare/thromboembolism management, and outcomes were abstracted from the selected articles and our case series.

RESULTS

Fifty-two patients with IBD, who developed an arterial thromboembolism, were identified (49 from published literature and 3 from our institution). More than 82% of patients presented during an active IBD flare. Surgical intervention was attempted in 77% of patients, which included open thromboembolectomy, catheter-directed thrombolysis, or bowel resection. Thromboembolism resolution was achieved in 76% of patients with comparable outcomes with either catheter-directed thrombolysis or open thrombectomy (83.3% vs. 68.2%). Nearly one-third of patients underwent small bowel resection or colectomy. In 2 patients, thromboembolism resolution was achieved only after total abdominal colectomy for severe pancolitis. Multiple thromboembolectomies were associated with higher risk for amputation. Overall mortality was 11.5% but was greatest for occlusive aortoiliac and mesenteric thromboembolism (14.3% and 57%, respectively). All survivors of occlusive superior mesenteric artery thromboembolism suffered short gut syndrome requiring small bowel transplant.

CONCLUSIONS

Patients with IBD, who develop an arterial thromboembolism, can expect overall poor outcomes. Catheter-directed thrombolysis achieved comparable outcomes with open thromboembolectomy without undue bleeding risk. Total abdominal colectomy for moderate-to-severe pancolitis is an emerging strategy in the management of refractory arterial thromboembolism. Successful surgical management may include open thromboembolectomy, catheter-directed thrombolysis, and bowel resection when indicated.

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.

Cerebral venous sinus thrombosis in a young patient with ulcerative colitis: A case report

RATIONALE

Cerebral venous sinus thrombosis (CVST) represents one of the most alarming forms of hemostatic abnormalities that may occur in patients with inflammatory bowel diseases (IBDs).

PATIENT CONCERNS

Here we report a case of a 25-year-old male with ulcerative colitis, who developed such thromboembolic complication during flare of the disease. CVST in our patient was clinically manifested by headache and nausea.

DIAGNOSIS

Angio-magnetic resonance imaging scan of the head revealed segments of contrast filling defects/absence indicating right dural venous sinus thrombosis of the transverse sinus.

INTERVENTION

Immediate treatment with low-molecular-weight heparin has been introduced and led to full remission of symptoms and total recanalization of the thrombotic cerebral regions.

OUTCOMES

Currently (over 2 years after diagnosis) the patient is in remission of the disease, and no further thromboembolic complications have been observed.

LESSONS

Our case study highlights the clinical difficulties and challenges associated with diagnosis and treatment of CVST, as well as presents the current state of knowledge about this complication among patients with IBDs. Physicians taking care of IBD patients should be aware of this alarming hemostatic abnormality.

The risk of venous thromboembolism in women with inflammatory bowel disease during pregnancy and the postpartum period: A systematic review and meta-analysis

Pregnancy and inflammatory bowel disease (IBD) are independent risk factors for venous thromboembolism (VTE). Nevertheless, the optimal VTE prevention strategy for women with IBD in pregnancy and postpartum period has not been established yet. We assessed VTE risks during pregnancy and the postpartum period in women with IBD through systematic review and meta-analysis.Systematic searches were conducted in MEDLINE (Ovid), Embase (Ovid), CENTRAL (Ovid), and Web of Science (Tomson Reuters) from the database inception till May 2017 to identify relevant studies reporting the risk of VTE during pregnancy and/or the postpartum period in women with IBD. Random effect meta-analyses were performed to compare VTE-related outcomes between women with IBD and without IBD. Our protocol was registered: CRD 42017060199 in the PROSPERO International prospective register of systematic reviews.In the analysis of 5 studies reviewed, IBD population (n = 17,636) had a significantly increased risk of VTE during pregnancy (pooled risk ratio (RR) 2.13, 95% confidence interval (CI) 1.66-2.73) and postpartum (RR 2.61, 95% CI 1.84-3.69), comparing to the non-IBD population (n = 11,251,778). According to the location of VTE, the risk of deep vein thrombosis increased significantly by RR of 2.74 (95% CI 1.73-4.36) during pregnancy, whilst risk increase of pulmonary embolism was not statistically significant. In the subgroup analysis, the degree of VTE risk was higher in both periods in the UC group than in the CD group, as compared to that in the non-IBD population (UC group, during pregnancy: RR 2.24, 95% CI 1.6-3.11; postpartum period: RR 2.85, 95% CI 1.79-4.52).Significantly increased risks of VTE during pregnancy were found in the women with IBD, according to the periods and type of IBD, which might support a detailed strategy regarding administration of prophylactic anticoagulants to women with IBD.

Contribution of the TNF-α (Tumor Necrosis Factor-α)-TNF-Rp55 (Tumor Necrosis Factor Receptor p55) Axis in the Resolution of Venous Thrombus

Objective- Deep vein thrombosis results from a combination of risk factors including genetic conditions, obesity, drugs, pregnancy, aging, and malignancy. We examined pathophysiological roles of the TNF-α (tumor necrosis factor-α)-TNF-Rp55 (tumor necrosis factor receptor p55) axis in thrombus resolution using Tnfrp55^-/- (TNF-Rp55-deficient) mice. Approach and Results- On ligating the inferior vena cava of wild-type (WT) mice, venous thrombi formed and grew progressively until 5 days but shrunk to <50% of the thrombus weight at day 14. Concomitantly, inferior vena cava ligation enhanced intrathrombotic gene expression of Tnfa and Tnfrp55, and intrathrombotic macrophages expressed both TNF-α and TNF-Rp55 proteins. In Tnfrp55^-/- mice treated with the same manner, thrombus formed at a similar rate for 5 days, but shrinking was delayed compared with WT mice. Moreover, the blood flow recovery in thrombosed inferior vena cava was suspended in Tnfrp55^-/- mice compared with WT mice. Intrathrombotic Plau (urokinase-type plasminogen activator), Mmp2 (matrix metalloproteinase 2), and Mmp9 (matrix metalloproteinase 9) mRNA expression was significantly reduced in Tnfrp55^-/- mice, compared with WT ones. Supportingly, the administration of anti-TNF-α antibody or TNF-α inhibitor (etanercept) delayed the thrombus resolution in WT mice. Furthermore, TNF-α treatment enhanced gene expression of Plau, Mmp2, and Mmp9 in WT macrophages but not Tnfrp55^-/- macrophages. These effects were significantly suppressed by ERK (extracellular signal regulated kinase) and NF-κB (nuclear factor-kappa B) inhibitors. Therefore, the lack of TNF-Rp55 has detrimental roles in the thrombus resolution by suppressing PLAU, MMP-2, and MMP-9 expression. In contrast, TNF-α administration accelerated thrombus resolution in WT but not Tnfrp55^-/- mice. Conclusions- The TNF-α-TNF-Rp55 axis may have essential roles in the resolution of venous thrombus in mice.

Gastrointestinal Tract Vasculopathy: Clinicopathology and Description of a Possible "New Entity" With Protean Features

Noninfectious gastrointestinal (GI) vasculopathic disorders are rare and are often overlooked in histopathologic examination or when forming differential diagnoses due to their rarity. However, involvement of the GI tract may lead to serious complications, including ischemia and perforation. Since awareness of the types of vasculopathy that may involve the GI tract is central to arriving at a correct diagnosis, we reviewed our institutional experience with GI tract vasculopathy in order to enhance diagnostic accuracy of these rare lesions. We report the clinical and histologic features of 16 cases (excluding 16 cases of immunoglobulin A vasculitis) diagnosed over a 20-year period. Of the 16 patients, 14 presented with symptoms related to the GI vasculopathy (including 2 presenting with a mass on endoscopic examination). The remaining 2 patients presented with incarcerated hernia and invasive adenocarcinoma. The vasculopathy was not associated with systemic disease and appeared limited to the GI tract in 8 patients. Eight had associated systemic disease, but only 6 had a prior diagnosis. The underlying diagnoses in these 6 patients included systemic lupus erythematosus (1), dermatomyositis (2), rheumatoid arthritis (1), eosinophilic granulomatosis with polyangiitis (1), and Crohn disease (1). One patient with granulomatous polyangiitis and 1 patient with systemic lupus erythematosus initially presented with GI symptoms. The 8 cases of isolated GI tract vasculopathy consisted of enterocolic lymphocytic phlebitis (4), idiopathic myointimal hyperplasia of the sigmoid colon (1), idiopathic myointimal hyperplasia of the ileum (1), granulomatous vasculitis (1), and polyarteritis nodosa-like arteritis (1). Isolated GI tract vasculopathy is rare, but appears to be almost as common as that associated with systemic disease. The chief primary vasculopathies are enterocolic lymphocytic colitis and idiopathic myointimal hyperplasia. Although the latter occurs predominantly in the left colon, rare examples occur in the small bowel and likely represent a complex, more protean disorder.

Papaverine adjuvant therapy for microcirculatory disturbance in severe ulcerative colitis complicated with CMV infection: a case report

Ulcerative colitis has hypercoagulable state and high risk of thrombosis; so mucosal disturbance of microcirculation may be mediate and amplify the inflammation of ulcerative colitis. A 56-year-old female patient was admitted in hospital for discontinuously mucous bloody stool for more than 1 year. Ulcerative colitis was determined after colonoscopy and pathologic examination. Mesalazine was effective during the year, but her symptoms recurred three times due to her bad compliance. One month before admission, the patient had severe recurrence after mesalazine withdrawal. At this time, the result of quantitative fluorescence PCR of colonic histic CMV-DNA was 1.6 × 10⁴ copies/mL positive, CMV colitis was accompanied. After 4 weeks of ganciclovir and 6 weeks of mesalazine usage and nutrition support, the symptoms of diarrhea and abdominal cramp did not improve; stool frequency was more than twenty times a day. Probe-based confocal laser endomicroscopy revealed local microcirculation disturbance. Papaverine 90-mg slow drip for at least 10 h a day was added. The symptoms dramatically disappeared after 3 days of papaverine treatment. The patient had yellow mushy stool 2–3 times a day. Pathological findings showed diffuse submucosal hemorrhage and transparent thrombosis in capillaries. Treatment of microcirculatory disturbance in severe UC is a promising adjuvant therapy. Confocal laser endomicroscopy may be an effective method for microcirculation judgment.

Bidirectional gut-brain-microbiota axis as a potential link between inflammatory bowel disease and ischemic stroke

Emerging evidence suggests that gut-brain-microbiota axis (GBMAx) may play a pivotal role linking gastrointestinal and neuronal disease. In this review, we summarize the latest advances in studies of GBMAx in inflammatory bowel disease (IBD) and ischemic stroke. A more thorough understanding of the GBMAx could advance our knowledge about the pathophysiology of IBD and ischemic stroke and help to identify novel therapeutic targets via modulation of the GBMAx.

Coagulopathies and inflammatory diseases: '…glimpse of a Snark'

Coagulopathies and inflammatory diseases, ostensibly, have distinct underlying molecular bases. Notwithstanding, both are host defense mechanisms to physical injury. In invertebrates, clotting can function directly in anti-pathogen defense. Molecules of the vertebrate clotting cascade have also been directly linked to the regulation of inflammation. We posit that thrombophilia may provide resistance against pathogens in vertebrates. The selective pressure of improved anti-pathogen defense may have retained mutations associated with a thrombophilic state in the human population and directly contributed to enhanced inflammation. Indeed, in some inflammatory diseases, at least a subset of patients can be identified as hypercoagulable. Therefore, anticoagulants such as warfarin or apixaban may have a therapeutic role in some inflammatory diseases.

Incidence and Risk Factor Analysis of Thromboembolic Events in East Asian Patients With Inflammatory Bowel Disease, a Multinational Collaborative Study

BACKGROUND

Inflammatory bowel disease (IBD) increases the risk of venous thromboembolism (VTE) events. However, the incidence and necessity of prophylaxis for VTE in Asian IBD patients is unknown. We examined the incidence of VTE in East Asian IBD patients and analyze the possible risk factors.

METHODS

We conducted a multinational retrospective study of 2562 hospitalized IBD patients from 2010 to 2015. Moreover, a nationwide cohort study from 2001 to 2013 from the Taiwan National Health Insurance Research Database (NHIRD) was conducted to analyze the incidence rate of VTE in IBD and non-IBD patients.

RESULTS

In the hospitalized cohort, 24 IBD patients [17 ulcerative colitis (UC) and 7 Crohn's disease (CD)] received a VTE diagnosis (0.9%). These patients had a higher proportion of extensive UC (P = 0.04), penetrating-type CD (P < 0.01), and bowel operation history (P = 0.01). VTE was associated with low hemoglobin (P < 0.01), low platelet (P < 0.01), and low albumin (P < 0.01) levels. For the nation-wide cohort study, 3178 IBD patients and 31,780 age- and sex-matched non-IBD patients were analyzed. The average incidence rate was 1.15 per 1000 person-years in the IBD cohort and 0.51 in the non-IBD cohort. The relative risk was 2.27 (95% CI, 1.99-2.60).

CONCLUSIONS

East Asian IBD patients carry a 2-fold increased risk of VTE than the general population. The incidence of VTE in the East Asian IBD patients is still lower than that in Western countries. Therefore, close monitoring rather than routine prophylaxis of VTE in East Asian IBD patients is recommended.

Elevated serum antiphospholipid antibodies in adults with celiac disease

BACKGROUND AND AIMS

An increased incidence of thrombosis is suggested in celiac disease. We explored serum levels of antiphospholipid antibodies in untreated and treated adult celiac disease patients.

METHODS

A cohort of 179 biopsy-proven celiac disease patients (89 untreated, 90 on long-term gluten-free diet) and 91 non-celiac controls underwent clinical examination, assessment of celiac serology and enzyme immunoassay testing for anticardiolipin IgG and IgM, prothrombin IgG, and phosphatidylserine-prothrombin IgG and IgM.

RESULTS

The level of antiphospholipid antibodies was higher in celiac disease patients compared with controls: anticardiolipin IgG 4.9 (0.7-33.8) vs 2.2 (0.4-9.6) U/ml, antiprothrombin IgG 2.9 (0.3-87.8) vs 2.1 (0.5-187.0) U/ml, antiphosphatidylserine-prothrombin IgG 6.9 (0.0-54.1) vs 2.3 (0.5-15.1) U/ml; p < 0.05 for all. Anticardiolipin IgG, antiprothrombin IgG and antiphosphatidylserine-prothrombin IgG were higher in treated compared with untreated patients. The phenotype of celiac disease at presentation (gastrointestinal symptoms, malabsorption or anemia, and extraintestinal symptoms or screen-detected disease) had no effect on the level of serum antiphospholipid antibodies.

CONCLUSION

The serum level of antiphospholipid antibodies is increased in adults with celiac disease. The higher level of antibodies in treated patients suggests that the increase is not gluten-dependent. The prothrombotic role of antiphospholipid antibodies in celiac disease warrants further studies.

Anticoagulant therapy for venous thromboembolism in patients with inflammatory bowel disease

BACKGROUND

There is lack of evidence to guide the type, intensity, and the duration of anticoagulation following venous thromboembolism (VTE) in patients with inflammatory bowel disease (IBD).

PATIENTS AND METHODS

Registro Informatizado Enfermedad Trombo Embólica (RIETE) is an ongoing, multicenter, observational registry of consecutive patients with symptomatic, objectively confirmed, acute VTE. We used the RIETE database to compare the rate of VTE recurrences and major bleeding during the course of anticoagulation in noncancer patients with or without IBD.

RESULTS

As of October 2014, 41 927 patients without active cancer have been recruited in RIETE. Of these, 265 (0.63%) had IBD and 85 (32%) had the VTE during an acute flare. The duration of anticoagulation was similar in patients with VTE during an acute flare (8.3±8.8 months), in remission (9.4±11.5 months), or without IBD (10.0±12.8 months). The rate of VTE recurrences [7.25, 95% confidence interval (CI): 1.46-21.2; 8.84, 95% CI: 3.23-19.2; and 5.85, 95% CI: 5.46-6.26 per 100 patient-years, respectively] and major bleeding (7.25, 95% CI: 1.46-21.2; 2.95, 95% CI: 0.33-10.6; and 4.79, 95% CI: 4.44-5.15, respectively) were similar in all three subgroups. Propensity score matching analysis confirmed the absence of differences in the rate of VTE recurrences (rate ratio: 1.16, 95% CI: 0.54-2.47) or major bleeding (rate ratio: 0.84, 95% CI: 0.31-2.23) between patients with or without IBD.

CONCLUSION

Therapeutic anticoagulation for patients with IBD and VTE is as safe and effective as for those with VTE without IBD.

Risk of thrombosis and mortality in inflammatory bowel disease

Objectives

Patients with inflammatory bowel disease have a higher risk of thrombosis, which is associated with a higher morbidity and mortality. Most data about VTE are related to hospitalized patients with active disease, but several cases happen in the outpatient setting, and are not covered by current prophylaxis recommendation. As the knowledge of VTE in outpatients is still poor, the aim of this study is to evaluate the risk, clinical data and mortality of thrombosis in patients followed in our center, comparing our findings with the current prophylaxis recommendation.

Methods

The medical electronic chart of 1093 inflammatory bowel disease patients and their image exams were actively searched for words related to thrombosis, followed by charts reviewed to collect information about the event and data regarding clinical settings and thrombosis profile.

Results

Overall, 654 Crohn’s and 439 Colitis patients were included. Thrombosis prevalence was 5.1%,and mortality rate was higher in patients who had suffered thrombosis (10.71% vs. 1.45%, OR 8.0). Half of them developed thrombosis in the outpatient setting, 52% of these had disease activity, 17% had recent hospitalization, and 10% had previous thrombosis. In 27% of cases, diagnosis was done by routine image exams, with no clinical symptoms or previous history of thrombosis. None of them had used thromboprophylaxis. However, a great majority of patients who had thrombosis during hospitalization used heparin prophylaxis.

Conclusion

Inflammatory bowel disease patients who develop thrombosis have an increased mortality risk. A significant proportion of the events happened in patients without a clear thromboprophylaxis recommendation or in those receiving heparin prophylaxis.

Steroid but not Biological Therapy Elevates the risk of Venous Thromboembolic Events in Inflammatory Bowel Disease: A Meta-Analysis

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.

Surgical options in the treatment of ulcerative colitis

Children and young adults with ulcerative colitis tend to present with more extensive colonic disease than an adult population. The need for surgical intervention in the pediatric population with ulcerative colitis occurs earlier after diagnosis and has a greater incidence than a comparably matched adult population with an estimated need for colectomy at 5 years following diagnosis of 14-20%. Perhaps, even more than the adult population, there is a desire to restore intestinal continuity for the pediatric patient to achieve as healthy and normal quality of life as possible. With surgery playing such a prominent role in the treatment of ulcerative colitis in this age group, an understanding of the surgical treatment options that are available is important. The surgeon's awareness of the complexities of the different operations associated with proctocolectomy and reestablishing intestinal continuity may help to avoid early complications and minimize the risk of less than ideal long-term outcomes.

Inflammatory bowel disease and thromboembolic events

Thromboembolism (TE) is an extraintestinal manifestation (EIM) of inflammatory bowel disease (IBD). According to previous pathological reports, the incidence of IBD complicated with TE is as high as 41%. However, this EIM is often overlooked. This review summarizes the results of the relevant clinical studies to date, analyzes the potential prothrombotic risk of IBD drug therapy, and discusses the current status on the treatment and prevention of TE, with an aim to provide a comprehensive reference for clinical work.

Serum platelet factor 4 is a reliable activity parameter in adult patients with inflammatory bowel disease: A pilot study

To investigate the diagnostic utility of serum platelet factor 4 (PF4) levels and to assess its accuracy in detecting inflammatory bowel disease activity.This study included 45 patients with ulcerative colitis (UC), 45 patients with Crohn disease (CD), and 30 control subjects at Jinling Hospital between May 2014 and July 2015. Laboratory tests measured white blood count, C-reactive protein, erythrocyte sedimentation rate, and platelet count. PF4 was examined by enzyme-linked immunosorbent assays. Patients were divided into 2 groups according to disease activity: active and inactive.Median PF4 values dramatically increased in UC and CD patients compared with the healthy group (UC: 26.64 [20.00-36.22] mg/mL vs 20.02 [14.63-26.83] mg/mL, P = 0.002; CD: 25.56 [18.57-36.36] mg/mL vs 20.02 [14.63-26.83] mg/mL, P = 0.014); however, the serum PF4 levels between UC and CD failed to show a significant difference (26.64 [20.00-36.22] mg/mL vs 25.56 [18.57-36.36] mg/mL, P = 0.521). Furthermore, serum PF4 levels were elevated in both UC and CD patients with active disease (UC: 20.19 [14.89-23.53] mg/mL vs 28.86 [22.57-37.29] mg/mL, P < 0.001; CD: 18.33 [16.72-25.77] mg/mL vs 34.38 [22.58-39.92] mg/mL, P < 0.001). Multivariate analysis revealed higher PF4 level as an independent predictor of disease activity in UC and CD patients (UC: odds ratio 30.375, P = 0.002; CD: odds ratio 54.167, P < 0.001). The cut-off level of PF4 for distinguishing active from inactive UC patients was 24.1 mg/mL. While in CD patients, the cut-off level of PF4 was 19.24 mg/mL.Serum PF4 levels could be a potential biomarker for monitoring the disease activity of inflammatory bowel disease.