Venous thromboembolism in hospitalized inflammatory bowel disease patients: the magnitude of the problem is staggering

Superior Mesenteric Vein Thrombosis in a Pediatric Patient: Case Report and Review of the Literature

ABSTRACT

Patients with inflammatory bowel disease are at increased risk of thromboembolism. There are various sites for thromboembolism including the cerebral, limbs, abdominal vessels, retina, and lungs. Here, we report a case of a 17-year-old patient with a history of Crohn disease presenting with abdominal pain. Upon further evaluation, the patient was found to have mesenteric vein thrombosis, which was discovered on computed tomographic scan. Potential causes, contributing factors, diagnosis, and treatment are discussed here.

Trends and Outcomes of Hip Fracture Hospitalization Among Medicare Beneficiaries with Inflammatory Bowel Disease, 2000-2017

BACKGROUND

Patients with inflammatory bowel disease (IBD) have a higher risk of hip fracture, but lower likelihood of having arthroplasties than non-IBD patients in Nationwide Inpatient Sample. Little is known about hip fracture-associated hospitalization outcomes.

AIMS

We assessed the trends in hip fracture hospitalization rates from 2000 to 2017 and estimated 30-day readmission, 30-day mortality, and length of stay in 2016 and 2017.

METHODS

We estimated trends of age-adjusted hospitalization rates using a piecewise linear regression. Medicare beneficiaries aged ≥ 66 years with Crohn's disease (CD, n = 2014) or ulcerative colitis (UC, n = 2971) hospitalized for hip fracture were identified. We performed propensity score matching to create 1:3 matched samples on age, race/ethnicity, sex, and chronic conditions and compared hospitalization outcomes between matched samples.

RESULTS

In 2017, the age-adjusted hospitalization rates (per 100) were 1.15 [95% CI = (1.07-1.24)] for CD, 0.86 [95% CI = (0.82-0.89)] for UC, and 0.59 [95% CI = (0.59-0.59)] for no IBD. The hospitalization rates for CD and UC decreased from 2000 to 2012 and then increased from 2012 to 2017. Compared to matched cohorts, CD patients had longer hospital stays (5.55 days vs. 5.30 days, p = 0.01); UC patients were more likely to have 30-day readmissions (17.27% vs. 13.71%, p < 0.001), longer hospital stays (5.59 days vs. 5.40 days, p = 0.02), and less likely to have 30-day mortality (3.77% vs. 5.15%, p = 0.003).

CONCLUSIONS

Prevention of hip fracture is important for older adults with IBD, especially CD. Strategies that improve quality of inpatient care for IBD patients hospitalized for hip fracture should be considered.

Case Report: Inflammatory Bowel Disease and Thrombosis

Patients with inflammatory bowel disease (IBD) have a greater risk for developing venous thromboembolism (VTE). Patients admitted to the hospital with IBD flares often require insertion of long-term venous access devices, such as peripherally inserted central catheters (PICCs), to provide access for medications, blood draws, fluid management, and nutrition. PICCs have been associated with an increased risk for upper extremity deep vein thrombosis. In this case study analysis, 2 patients with IBD and PICCs who developed VTE are examined. The case report includes a thorough discussion of medical history, symptomology, PICC insertion, and events leading to VTE development. A review of acquired risk factors for IBD patients and a comparison of risk factors that predisposed each to VTE are explored. These cases highlight the need for nurses and physicians to heighten surveillance and engage in proactive strategies to prevent VTE in this population of patients.

Coagulation state in patients with Crohn's disease: the effect of infliximab therapy

BACKGROUND

Growing evidence has shown that coagulation processes play an important role in disease pathogenesis and/or disease progression in patients with inflammatory bowel disease. However, no study has ever focused on the possible influence of infliximab (IFX) therapy on the coagulation status in patients with Crohn's disease (CD).

OBJECTIVE

To investigate the difference in the coagulation biomarkers between the CD patients and the control participants, and evaluate the impact of IFX usage on the coagulation status of CD patients.

PATIENTS AND METHODS

A retrospective study that included a case-control study and a self-control study was designed. The medical records of CD patients and control participants were evaluated according to the inclusion and exclusion criteria. The results of laboratory tests including blood routine, coagulation, D-dimer, C-reactive protein, and erythrocyte sedimentation rate were retrieved to assess the coagulation state.

RESULTS

In the case-control study, almost all the parameters showed a statistically significant difference between the CD patients and the control participants, except for activated partial thromboplastin time and thrombin time (the P value ranged from 0.000 to 0.002). Most of the values of the parameters reverted to normal over time during IFX therapy in the self-control study. Moreover, the fibrinogen concentration decreased obviously after IFX infusion (P=0.000) and the D-dimer concentration also decreased obviously by about half of the start value after IFX usage (P=0.018).

CONCLUSION

IFX therapy could ameliorate the hypercoagulable state in patients with CD.

Surgical management of Crohn's disease

Although medical management can control symptoms in a recurring incurable disease, such as Crohn's disease, surgical management is reserved for disease complications or those problems refractory to medical management. In this article, we cover general principles for the surgical management of Crohn's disease, ranging from skin tags, abscesses, fistulae, and stenoses to small bowel and extraintestinal disease.

Thromboembolism in pediatric inflammatory bowel disease: systematic review

BACKGROUND

Several studies suggest an increased risk of venous and arterial thromboembolism (TE) in adults with inflammatory bowel disease (IBD) compared to the general population. We performed a systematic review of studies on incidence and characteristic of TE in children with IBD.

METHODS

We searched Medline, LILACS, EMBASE, POPLINE, CINHAL, and reference lists of identified articles, without language restrictions, in August 2010.

RESULTS

Population studies suggest that there is an increased risk of TE in children with IBD compared to controls. TE occurred in children with IBD in all age ranges, mostly (82.8%) during active disease, and more frequently in children with ulcerative colitis (odds ratio [OR] 3.7, 95% confidence interval [CI] 1.8-7.6). At least one specific risk factor for TE was recognized in 50% of cases; two risk factors were present in 24%. Out of 92 published cases of TE in children with IBD, 54.3% occurred in cerebral site, 26% in the limbs, 13% in the abdominal vessels, and the remaining in the retina and lungs. After a first episode of TE, an early recurrence was observed in 11.4% of children, a late recurrence in 10%. A number of different therapeutic schemes were used. Overall mortality was 5.7% and was mostly associated with cerebral TE.

CONCLUSIONS

Population studies are needed to clarify the risk of TE in children with IBD, the relative weight of other risk factors, the characteristics of the events, and to define guidelines of therapy and prophylaxis.

Venous thromboembolism during active disease and remission in inflammatory bowel disease: a cohort study

BACKGROUND

Patients with inflammatory bowel disease who develop deep vein thrombosis or pulmonary embolism often have active disease at the time of thromboembolism. We therefore aimed to quantify the risk of venous thromboembolism prospectively during different activity phases of inflammatory bowel disease.

METHODS

From the General Practice Research Database, we matched patients with prospectively recorded inflammatory bowel disease from November, 1987, until July, 2001 with up to five controls by age, sex, and general practice. A flare was defined as the period 120 days after a new corticosteroid prescription. We used Cox regression analysis with time-varying covariates to accommodate changes in the state of inflammatory bowel disease, and whether patients were at high risk of venous thromboembolism after hospitalisation.

FINDINGS

13 756 patients with inflammatory bowel disease and 71 672 matched controls were included in the analysis, and of these 139 patients and 165 controls developed venous thromboembolism. Overall, patients with inflammatory bowel disease had a higher risk of venous thromboembolism than did controls (hazard ratio 3.4, 95% CI 2.7-4.3; p<0.0001; absolute risk 2.6 per 1000 per person-years). At the time of a flare, however, this increase in risk was much more prominent (8.4, 5.5-12.8; p<0.0001; 9.0 per 1000 person-years). This relative risk at the time of a flare was higher during non-hospitalised periods (15.8, 9.8-25.5; p<0.0001; 6.4 per 1000 person-years) than during hospitalised periods (3.2, 1.7-6.3; p=0.0006; 37.5 per 1000 person-years).

INTERPRETATION

Trials of primary prophylaxis of venous thromboembolism are warranted to find out whether this important complication can be prevented.

FUNDING

National Association for Colitis and Crohn's Disease.

IBD care in Europe: A comparative audit of the inpatient management of Crohn's disease and ulcerative colitis using the national UK IBD audit tool

BACKGROUND AND AIMS

The National UK IBD audit tool is an electronic database created to improve the quality and safety of care for IBD patients by auditing individual patient care, service resources and organisation against national standards. We used the National UK IBD audit tool to compare the organisation and process of IBD care between services in Oxford (UK) and Milan (Italy), as a pilot study to evaluate its application outside national boundaries.

METHODS

Clinical and demographic data of patients with CD and UC, consecutively admitted during a 2month period, were collected and compared between the centres, to each other and to the UK IBD standards obtained by previous audit analyses performed in Oxford in 2006.

RESULTS

20 and 26 patients with UC were admitted in Oxford and Milan, as well as 21 and 20 patients with CD, respectively. Most admissions in Milan were planned admissions for moderately active treatment-refractory disease. No patient died. Oxford had a higher surgery rate. Endoscopy for UC consisted mainly of colonoscopy in Milan (92%) and flexible sigmoidoscopy in Oxford (64%). In CD, Oxford data revealed a higher use of immununomodulators and CT scan, compared with higher use of bowel ultrasound in Milan. CRP was the preferred biomarker of disease activity. The following areas did not reach the standards set for the 2006 UK IBD Audit: the lack in Milan of IBD specialist nurses and few dietitian visits, as well as little attention to heparin prophylaxis and abdominal radiography in UC. Both sites paid little attention to stool cultures and revealed a high rate of active smokers in CD and little attention to bone protection in steroids users. Since the 2006 audit in Oxford, improvements include IBD specialist nurse visits, dietitian visits, number of active smokers, stool samples, prophylactic heparin, bone protection and nutritional assessment.

CONCLUSIONS

Consistent procedural differences between Oxford and Milan identified by audits of both UC and CD could be resolved by organisational change, with an improvement in the service. The UK IBD audit tool is an easy instrument to assess the processes and outcomes of care delivery in IBD and can be applied also outside UK.

The evolving epidemiology of inflammatory bowel disease

PURPOSE OF REVIEW

Epidemiologic studies in inflammatory bowel disease (IBD) include assessments of disease burden and evolving patterns of disease presentation. Although it is hoped that sound epidemiologic studies provide aetiological clues, traditional risk factor-based epidemiology has provided limited insights into either Crohn's disease or ulcerative colitis etiopathogenesis. In this update, we will summarize how the changing epidemiology of IBD associated with modernization can be reconciled with current concepts of disease mechanisms and will discuss studies of clinically significant comorbidity in IBD.

RECENT FINDINGS

The increased frequency of IBD, which has been consistently observed as society becomes developed or modernized, may be linked with changes in the gastrointestinal microbiota which, in turn, may affect the development of the immune system and influence the risk of inflammatory diseases. Although extra-intestinal disease associations have long been recognized to be linked to IBD, there is a disturbing increase in comorbidity with Clostridium difficile-associated disease, arterial and venous thromboembolism and abnormalities of cervical cytology. These have important implications in an era of increased use of immunomodulatory drugs.

SUMMARY

Advances in understanding the basic biology of IBD with rapidly emerging therapeutic strategies have prompted a shift in traditional epidemiologic approaches away from risk factor anthologies toward rapprochement with disease mechanisms and pursuit of changing patterns of comorbidity of clinical relevance.