Etiopathogenesis, Prevention, and Treatment of Thromboembolism in Inflammatory Bowel Disease

The prevalence and risk factors of pulmonary embolism in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

BACKGROUND

An increased prevalence of PE has been found in patients with acute exacerbation of chronic obstructive pulmonary disease(AECOPD). Early identification of risk factors for the development of PE in patients with AECOPD and intervention is important. Therefore, we comprehensively pool and analyze the prevalence and risk factors of PE among patients experiencing AECOPD, aiming to provide valuable insights for clinical-based diagnostic determination and prevention of PE in the AECOPD patient population.

METHODS

A systematic literature search was conducted for studies reporting the incidence and risk factors for PE in patients with AECOPD. Study quality was assessed using the modified Newcastle-Ottawa Quality Assessment Scale. The degree of heterogeneity was assessed by the I2 statistic. The publication bias (studies ≥ 10) was evaluated using Egger's test.

RESULTS

Among the 1421 studies initially retrieved, 22 articles were ultimately selected and incorporated into the analysis. Based on the meta-analysis and the review's updated findings, the prevalence of PE in AECOPD is 17.82% (95% CI 12.72%-23.57%, P<0.001). The following factors were identified as risk factors for PE among patients with AECOPD: age(weighted mean difference [WMD] 2.0119, 95% CI 0.7126-3.3133, I2 = 51.8%, P = 0.02), males(odds ratio [OR] 0.9528, 95% CI 0.6869-1.3216, I2 = 65.0%, P<0.001), obesity(OR 1.3086, 95% CI 0.1895-9.0385, I2 = 74.5%, P = 0.02), malignant disease(OR 1.5902, 95%CI 0.9689-2.6097, I2 = 54.7%, P = 0.03), hypertension(OR 1.0663, 95%CI 0.7920-1.4355, I2 = 57.7%, P = 0.009), immobilization ≥ 3d(OR 3.9158, 95% CI 1.0925-14.0354, I2 = 91.6%, P<0.001), edema of lower limb(OR 2.1558, 95% CI 1.3365-3.4773, I2 = 75.4%, P<0.001), pulmonary hypertension(OR 1.3146, 95%CI 0.7481-2.3100, I2 = 70.1%, P = 0.04), cough(OR 0.7084, 95%CI 0.1304-3.8497, I2 = 88.8%, P<0.001), purulent sputum(OR 0.7570, 95%CI 0.4005-1.4309, I2 = 61.9%, P = 0.049), and D-dimer(WMD 0.8619, 95%CI 0.0449-1.6789, I2 = 91.4%, P<0.001), C-reactive protein(CRP)(WMD 0.8852, 95%CI -4.0639-5.8344, I2 = 76.4%, P = 0.005) or fibrinogen(WMD 0.8663, 95%CI -0.2572-1.9898, I2 = 92.2%, P<0.001) levels. Clinical risk factors(including S1Q3 pattern on electrocardiograph(ECG), hospital stay and home oxygen therapy) showed no significant association with the occurrence of PE (P>0.05).

CONCLUSIONS

This updated meta-analysis and systematic review revealed that the prevalence of pulmonary embolism in the AECOPD was 17.82%. This figure may vary depending on how the diagnostic procedure is carried out. Age, males, obesity, malignant disease, hypertension, immobilization ≥ 3d, edema of lower limb, pulmonary hypertension, cough, purulent sputum, and D-dimer, CRP or fibrinogen level may serve as potential risk factors for PE among patients with AECOPD.

[Prevention of venous thromboembolic complications in patients with ulcerative colitis]

BACKGROUND

The incidence of venous thromboembolic complications (VTEC) in patients with inflammatory bowel diseases is approximately 3 times higher than in the general population and leads to a 2-fold increase in the risk of mortality. The risk of VTEC is the highest during the patient's hospital stay.

AIM

To compare the overall VTEC risk in inpatients with ulcerative colitis (UC) with and without VTEC primary prevention.

MATERIALS AND METHODS

In 2020, anticoagulant therapy was used for patients with UC in the case of acute venous thrombosis, and in 2022, primary thromboprophylaxis in patients with UC with moderate and high VTEC risk was based on the data obtained from the previous analysis of VTEC risk factors in inpatients with inflammatory bowel diseases. VTEC prophylaxis in UC patients was performed with a low molecular weight heparin (LMWH) - calcium nadroparin - at a dose of 0.3 mL (2850 IU anti-Xa) per day subcutaneously throughout the stay in the round-the-clock hospital.

RESULTS

In 2020, venous thrombosis was diagnosed in 16 (1.8%) patients with UC, including venous thrombosis of the lower extremities in 3 (0.3%) patients, venous thrombosis of the upper extremities in 7 (0.8%), pulmonary embolism in 2 (0.2%), and combined thrombosis in 4 (0.5%). In 2022, venous thrombosis was diagnosed in 5 (0.5%) patients with UC, including venous thrombosis of the lower extremities in 1 (0.1%) patient, venous thrombosis of the upper extremities in 3 (0.3%), and pulmonary embolism in 1 (0.1%). Thus, primary prevention with an LMWH significantly reduces the risk of VTEC in hospitalized patients with UC (relative risk 0.285, 95% confidence interval 0.103-0.774; χ2=6.917; p=0.009).

CONCLUSION

Our results demonstrate that primary prevention with an LMWH significantly reduces the risk of VTEC in patients with UC hospitalized in a round-the-clock hospital.

Ocular endothelial dysfunction in pediatric inflammatory bowel disease

OBJECTIVES

To assess ocular microvasculature changes using optical coherence tomography angiography (OCTA) in pediatric patients with inflammatory bowel disease (IBD).

METHODS

Patients (aged 6-18 years) with IBD were recruited between September 2021 and May 2023. All eligible participants underwent comprehensive clinical assessment and laboratory investigation. Patients with functional gastrointestinal disorders served as the controls. This study assessed specific IBD phenotypes, disease duration, clinical and endoscopic activity indices, laboratory markers, and medication histories. OCTA was utilized to evaluate ocular microvasculature changes in both groups.

RESULTS

A total of 63 children (mean age 12.9 ± 3.3 years) were enrolled, comprising 38 in the IBD group (16 ulcerative colitis, 22 Crohn's disease, and 25 in the control group). Most patients in the IBD group were in remission or had mild-to-moderate disease activity at enrollment. Analysis of the OCTA results revealed significant differences in the choroidal luminal area and total choroidal area between the IBD and control groups.

CONCLUSIONS

The study identified distinct ocular microvasculature changes in pediatric IBD patients through OCTA, suggestive of potential systemic endothelial dysfunction. These findings underscore the utility of OCTA in evaluating microvascular alterations associated with pediatric IBD, offering insights into potential systemic complications linked to inflammation in IBD patients.

Contraceptive Recommendations for Women with Immune-Mediated Inflammatory Diseases: A Delphi Consensus

INTRODUCTION

Immune-mediated inflammatory diseases (IMID) are a group of disorders characterized by chronic inflammation caused by an altered immune regulation in targeted organs or systems. IMID itself could have an implied increased risk of venous thromboembolism (VTE) and this risk varies throughout the course of the disease as well as with some contraceptive methods and treatments. The aim of this study was to present some key considerations in relation to contraception in women with IMID.

METHODS

This was an exploratory study conducted in Spain following the online modified Delphi methodology with two rounds of participation. Four questionnaires were designed for each medical specialty: gastroenterology, rheumatology, dermatology, and gynecology. Each questionnaire was divided in three domains: general recommendations about IMID, specific recommendations, and contraceptive methods for patients with IMID. A 5-point Likert scale measured agreement with each statement, with an 80% agreement threshold. Following the first round, the percentage of each response was calculated for every item. Subsequently, a second round was conducted to reach a consensus on the items for which discrepancies were observed.

RESULTS

A total of 52 and 50 experts participated in the first and second round, respectively. Participants agreed on the existence of a higher risk of VTE in inflammatory bowel diseases, psoriasis, and rheumatoid arthritis diseases. Regarding recommendations for contraceptive methods in patients with IMID, experts considered the hormonal intrauterine device (IUD) as a first-line contraceptive (80.0%) and low doses of progesterone-only pills if the latter is not recommended (88.0%). Most of the interviewees concurred on the importance of the patients' contraceptive needs during the disease course (98.1%).

CONCLUSION

Raising awareness and promoting a multidisciplinary relationship among the physicians involved in the therapeutic decisions by considering all the risk factors when prescribing a contraceptive method is important to prevent VTE in women with IMID.

The Use of JAK/STAT Inhibitors in Chronic Inflammatory Disorders

The Janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway plays a critical role in orchestrating immune and inflammatory responses, and it is essential for a wide range of cellular processes, including differentiation, cell growth, and apoptosis. Over the years, this pathway has been heavily investigated due to its key role in the pathogeneses of several chronic inflammatory conditions, e.g., psoriasis, atopic dermatitis (AD), and inflammatory bowel diseases (IBDs). Nevertheless, the impact of this pathway on the pathogenesis of inflammatory conditions remains unclear. This review describes the role of the JAK/STAT signaling pathway in the pathogenesis of inflammatory diseases such as psoriasis (Pso), psoriatic arthritis (PsA), AD, and IBD with a focus on ulcerative colitis (UC) and briefly resumes the use of JAK inhibitors in their clinical management.

Perioperative Management of Ulcerative Colitis: A Systematic Review

BACKGROUND

Patients with ulcerative colitis may require colectomy for severe disease unresponsive or refractory to pharmacological therapy. Managing ulcerative colitis is complicated because there are many factors at play, including patient optimization and treatment, as the guidance varies on the ideal perioperative use of corticosteroids, immunomodulators, biologics, and small molecule agents.

OBJECTIVE

A systematic literature review was performed to describe the current status of perioperative management of ulcerative colitis.

DATA SOURCES

PubMed and Cochrane databases were used.

STUDY SELECTION

Studies published between January 2000 and January 2022, in any language, were included. Articles regarding pediatric or endoscopic management were excluded.

INTERVENTIONS

Perioperative management of ulcerative colitis was included.

MAIN OUTCOME MEASURES

Successful management, including reducing surgical complication rates, was measured.

RESULTS

A total of 121 studies were included in this review, including 23 meta-analyses or systematic reviews, 25 reviews, and 51 cohort studies.

LIMITATIONS

Qualitative review including all study types. The varied nature of study types precludes quantitative comparison.

CONCLUSION

Indications for colectomy in ulcerative colitis include severe disease unresponsive to medical treatment and colitis-associated neoplasia. Urgent colectomy has a higher mortality rate than elective colectomy. Corticosteroids are associated with postsurgical infectious complications and should be stopped or weaned before surgery. Biologics are not associated with adverse postoperative effects and do not necessarily need to be stopped preoperatively. Additionally, the clinician must assess individuals' comorbidities, nutrition status, and risk of venous thromboembolism. Nutritional imbalance should be corrected, ideally at the preoperative period. Postoperatively, corticosteroids can be tapered on the basis of the length of preoperative corticosteroid use.

Gastrointestinal System: COVID-19 and Potential Mechanisms Associated with Coagulopathy

SARS-CoV-2 is a novel coronavirus that expanded worldwide, generating a pandemic of acute respiratory syndrome called "coronavirus disease 2019" (COVID-19), which resulted in a global health crisis. The spectrum of COVID-19 manifestations ranges from none or mild symptoms to severe respiratory failure associated with systemic manifestations, mostly gastrointestinal symptoms. Hypercoagulability is an important feature of COVID-19 disease, which can potentially influence patients' prognosis. Therefore, gastroenterologists should focus on subjects with concomitant hypercoagulable gastrointestinal disorders as they may display a higher risk of thrombotic complications during SARS-CoV-2 infection. The aim of this review is to summarize the available evidence regarding the interplay of the prothrombotic pathogenetic mechanisms of both COVID-19 and hypercoagulable digestive diseases and the possible clinical implications. We summarized the potential interplay of prothrombotic mechanisms of both COVID-19 and hypercoagulable digestive diseases in the graphical abstract.

Celiac Disease and Thrombotic Events: Systematic Review of Published Cases

Extraintestinal manifestations of celiac disease (CD) should be considered, even in patients without typical intestinal symptoms. The aim of our study is to examine the literature regarding the occurrence of thrombotic events in CD, and to synthesize the data from case reports and case series. A systematic review of the literature was conducted by searching the Pub-Med/MEDLINE database, from the date of database inception to January 2022, to identify published cases and case series on this topic, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 55 cases were included in the study. The majority of patients were previously healthy individuals, with no comorbidities. In less than one-third of the cases (30.91%), the diagnosis of CD was established before the onset of thrombosis, while in the remaining cases (34.54%), thrombosis preceded the diagnosis or was diagnosed concomitantly with CD. The most common sites for thrombosis occurrence were hepatic veins (30.91%), while thrombosis of cerebral blood vessels, deep venous thrombosis of lower extremities, and pulmonary thromboembolism were less frequent. Thrombosis was most commonly isolated to one site only (78.18%). In 69.09% of cases (n = 38), some form of anticoagulation, along with a gluten-free diet, was initiated.

Evaluation of Risk for Thromboembolic Events in Pediatric Inflammatory Bowel Disease

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.

Venous Thromboembolism Among Patients With Inflammatory Bowel Diseases is Not Related to Increased Thrombophilia: A Case-Control Study

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.

Frequency and risk factors for thromboembolic complications in patients with inflammatory bowel diseases

Background. Inflammatory bowel diseases (IBD) are characterized by chronic immune inflammation of the mucous membrane and/or the thickness of the intestinal wall, and are also accompanied by disorders of the blood clotting system and the development of a hypercoagulation state. Aim. To identify the frequency of thromboembolic complications (TEC) in IBD patients and to determine the influence of acquired and inherited hypercoagulation factors that contribute to the development of TEС. Materials and methods. The clinical status of 1,238 IBD patients who were treated in 2019 was evaluated. Of these, 748 patients with ulcerative colitis (UC) and 490 patients with Crohn's disease (CD). Among UC patients, there were 369 (49.3%) men and 379 (50.7%) women. In 10.1% of patients with UC, there were clinically significant feasibility studies. There were 227 (46.3%) men and 263 (53.7%) women among patients with CD; 7.3% of patients with CD had clinically significant feasibility studies. Results. In general 112 (9.0%) of 1,238 IBD patients had clinically significant feasibility studies. Among patients with UC (n=748), 76 (10.2%) showed clinically significant feasibility studies. Among patients with CD (n=490), 36 (7.3%) had a feasibility study. Of 112 IBD patients with clinically significant TEC, 45 (40.2%) had genetic polymorphisms that increase affinity for fibrinogen, increase platelet aggregation, and contribute to a decrease in the activity of folate cycle enzymes, including methylenetetrahydrofolate reductase, which may be manifested by a moderate increase in homocysteine levels. Of the 45 IBD patients with clinically significant TEC due to inherited factors, 30 (66.6%) patients had UC, 15 (33.7%) patients had CD (hazard ratio 1.038, 95% confidence interval 0.7461.444; 2=0.049; p=0.83921); 67 (59.8%) patients with IBD who had clinically significant TEC did not have genetic polymorphisms leading to hypercoagulation. Conclusion. Based on the analysis, we can conclude that such risk factors for the development of TEC as the status of a smoker, long bed rest, taking hormonal contraceptives, varicose veins of the lower extremities, high activity of the disease, glucocorticoids therapy, the extent of intestinal damage in patients with IBD, genetic factors, should be taken into account by gastroenterologists in the treatment of patients with UC and CD. The hereditary factor of hypercoagulation equally affects the development of TEC, both in patients with UC and CD.

Real-World Insurance Claims Analysis of Venous Thromboembolism in Japanese Patients with Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD), which encompasses both ulcerative colitis (UC) and Crohn's disease (CD), is a risk factor for venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE).

AIM

To investigate the incidence of, and risk factors for, VTE in patients with IBD in Japan.

METHODS

This was a retrospective, non-interventional study in patients with IBD from the Japan Medical Data Center claims database. Incidence rates (IRs; unique patients with events per 100 patient-years) were calculated for VTE, DVT, and PE among the IBD, UC, and CD cohorts. Odds ratios of potential risk factors were calculated by univariate and multivariate analyses in a nested case-control design.

RESULTS

Overall, 16 273 patients with IBD were included: 13 585 with UC and 3443 with CD. VTE events occurred in 1.3%, 1.2%, and 1.9% of patients with IBD, UC, and CD, respectively. In patients with IBD, UC, and CD, IRs of VTE were 0.45, 0.40, and 0.64, respectively, IRs of DVT were 0.42, 0.38, and 0.61, respectively, and IRs of PE were 0.07, 0.07, and 0.11, respectively. In patients with IBD, treatment history (immunomodulators), cardiovascular risk (hypertension, high-density lipoprotein or diabetes mellitus, and history of coronary artery disease or heart failure), malignancy, and undergoing major surgery were identified as potential risk factors for VTE in the multivariate analysis, with similar risk factors reported for patients with UC and CD.

CONCLUSIONS

This large study provides insight into the incidence and risk factors for VTE in patients with IBD from Japan.

Inflammatory bowel disease and the risk of cardiovascular diseases

Inflammatory bowel disease (IBD) includes both ulcerative colitis and Crohn's disease, which are well recognised as chronic systemic and immune-mediated conditions that frequently involve extraintestinal manifestations. Although comorbidities have long been the subject of research in other chronic inflammatory diseases, this concept is also emerging in IBD. Many pathologies have been linked to IBD, including cardiovascular disease, which is the main cause of death in developed countries. IBD patients are at increased risk of conditions such as early atherosclerosis and myocardial infarction or venous thrombosis and pulmonary thromboembolism. The aim of this review is to make an approximation of the physiopathology of the different manifestations of cardiovascular disease in patients with IBD and how to prevent them.

Unexplained fever in a young man with Crohn's disease: a case report and review of literature

A 23-year-old man with a known history of Crohn's disease (CD), who underwent an ileocaecal resection for localized disease activity three months ago, suffered from persistent fever with chills since 10 days. Despite the empirical antibiotic therapy that was started, his fever remained. A computed tomography (CT) angiography of the thorax and abdomen revealed a thrombosis of the iliacal veins bilateral and a pulmonary embolism (PE) in the right lower lobe with adjacent infiltrate. Venous thromboembolism (VTE) can be a life-threatening extraintestinal manifestation of inflammatory bowel disease (IBD). The risk that IBD patients develop a VTE is three times higher in comparison with healthy controls. They have a higher risk of recurrence and a higher mortality ratio. The pathogenesis of VTE in IBD is complex and until now not fully understood. More awareness should be raised, given the fact that it can be prevented by appropriate thromboprophylaxis.

Venous thromboembolism in patients with inflammatory bowel disease: review of literature and practical algorithms

Inflammatory bowel disease (IBD) is associated with several extra-intestinal complications, including venous thromboembolism (VTE). In patients with IBD, VTE occurs at younger age and is associated with higher recurrence and mortality rates as compared to patients without IBD. The risk appears to be higher during active disease and hospitalization. In this review we target the importance of prophylaxis and aim to describe strategies for treatment of VTE in patients with IBD. More awareness is needed, given the fact that VTE is often preventable with appropriate pharmacological prophylaxis. Algorithms are provided on which patients should be given prophylaxis and on treatment duration of VTE in patients with inflammatory bowel disease.

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.

A postdischarge venous thromboembolism risk calculator for inflammatory bowel disease surgery

BACKGROUND

Guidelines recommend extended chemoprophylaxis for venous thromboembolism in high-risk patients having operations for inflammatory bowel disease. Quantifying patients' risk of venous thromboembolism, however, remains challenging. We sought (1) to identify factors associated with postdischarge venous thromboembolism in patients undergoing colorectal resection for inflammatory bowel disease and (2) to develop a postdischarge venous thromboembolism risk calculator to guide prescribing of extended chemoprophylaxis.

METHODS

Patients who underwent an operation for inflammatory bowel disease from 2012 to 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program for colectomy and proctectomy procedure targeted modules. Postdischarge venous thromboembolism included pulmonary embolism or deep vein thrombosis diagnosed after discharge from the index hospitalization. Multivariable logistic regression estimated the association of patient/operative factors with postdischarge venous thromboembolism. A postdischarge venous thromboembolism risk calculator was subsequently constructed.

RESULTS

Of 18,990 patients, 199 (1.1%) developed a postdischarge venous thromboembolism within the first 30 postoperative days. Preoperative factors associated with postdischarge venous thromboembolism included body mass index (1.9% with body mass index ≥35 vs 0.8% with body mass index 18.5-24.9; odds ratio 2.34 [95% confidence interval 1.49-3.67]), steroid use (1.3% vs 0.7%; odds ratio 1.91 [95% confidence interval 1.37-2.66]), and ulcerative colitis (1.5% vs 0.8% with Crohn's disease; odds ratio 1.76 [95% confidence interval 1.32-2.34]). Minimally invasive surgery was associated with postdischarge venous thromboembolism (1.2% vs 0.9% with open; odds ratio 1.42 [95% confidence interval 1.05-1.92]), as was anastomotic leak (2.8% vs 1.0%; odds ratio 2.24 [95% confidence interval 1.31-3.83]) and ileus (2.1% vs 0.9%; odds ratio 2.60 [95% confidence interval 1.91-3.54]). The predicted probability of postdischarge venous thromboembolism ranged from 0.2% to 14.3% based on individual risk factors.

CONCLUSION

Preoperative, intraoperative, and postoperative factors are associated with postdischarge venous thromboembolism after an operation for inflammatory bowel disease. A postdischarge venous thromboembolism risk calculator was developed which can be used to tailor extended venous thromboembolism chemoprophylaxis by individual risk.

Pharmacology and safety of tofacitinib in ulcerative colitis

The use of Janus kinase (JAK) inhibitors is a new approach in the therapy of inflammatory diseases with immune base. Tofacitinib is one of these inhibitors targeting JAK1 and JAK3, and its efficacy has been demonstrated in the treatment of moderate to severe ulcerative colitis (UC). It is a small synthetic molecule administered orally, with a fast bioavailability and elimination rate, predictable pharmacokinetics and lack of immunogenicity, which are convenient characteristics for both efficacy and safety. This article reviews the pharmacological characteristics of tofacitinib and its safety profile.

The risk of cardiovascular complications in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic, relapsing disease of unknown etiology involving gastrointestinal tract. IBD comprises two main entities: ulcerative colitis and Crohn's disease. Several studies showed increased risk of cardiovascular complications in chronic inflammatory disorders, especially during IBD relapses. Endothelium plays a role in physiologic regulation of vascular tone, cell adhesion, migration and resistance to thrombosis. Also, its dysfunction is associated with increased risk of atherosclerosis development. There are several potential links between chronic IBD-related inflammatory processes and the risk of cardiovascular disease, but insight into pathogenetic pathways remains unclear. We present the current concepts and review of adult and pediatric studies on the risk of CVD in IBD.

Inflammatory Bowel Disease and Thrombosis: A National Inpatient Sample Study

Introduction  Thrombosis is more common in inflammatory bowel disease (IBD) patients than the general population, but disease-specific correlates of thrombosis remain unclear.

Methods  We performed a retrospective analysis of discharge data from the National Inpatient Sample between 2009 and 2014, using International Disease Classification codes to identify IBD and non-IBD patients with or without thrombosis. We used NIS-provided discharge-level weights to reflect prevalence estimates. Categoric variables were analyzed by Rao-Scott Chi-square test, continuous variables by weighted simple linear regression, and covariates associated with thrombosis by weighted multivariable logistic regression.

Results  Thrombosis prevalence in IBD was significantly greater than in non-IBD, 7.52 versus 4.54%, p  < 0.0001. IBD patients with thrombosis were older and more likely to be Caucasian than IBD without thrombosis, each p  < 0.001. Thrombosis occurred most commonly in the mesenteric vein. Thrombotic risk factors in IBD include surgery, ports, malignancy, dehydration, malnutrition, and steroids at 53.7, 13.2, 13.1, 12.4, 8.9, and 8.2%, respectively. Those with thrombosis had greater severity of illness, 1.42 versus 0.96; length of stay, 7.7 versus 5.5 days; and mortality, 3.8 versus 1.5%; all p  < 0.0001. Adjusting for age and comorbidity, odds ratios for predictors of thrombosis included ports, steroids, malnutrition, and malignancy at 1.73, 1.61, 1.34, and 1.13, respectively, while Asian race, 0.61, was protective, each p  < 0.001.

Conclusion  Thrombosis prevalence is 1.7-fold greater in IBD than non-IBD patients. Adjusting for age and comorbidity, the odds ratio for thrombosis in IBD was 73% higher with ports, 61% higher with steroids, 34% with malnutrition, and 13% with malignancy. Whether long-term anticoagulation would benefit the latter is unknown.

Cerebral sinovenous thrombosis in a child with ulcerative colitis: A case report

RATIONALE

Cerebral sinovenous thrombosis (CVT) associated with inflammatory bowel disease (IBD) is infrequent, but clinically nonnegligible due to its high disability and fatality rates.

PATIENT CONCERNS

A 12-year-old child with newly developed ulcerative colitis (UC) suffered from a sudden left-sided hemiparesis and numbness.

DIAGNOSES

Cerebral sinovenous thrombosis due to ulcerative colitis was diagnosed in this girl.

INTERVENTIONS

The patient was treated with blood transfusion and anticoagulation therapy. Digital subtraction angiography (DSA) and urokinase thrombolysis were implemented followed.

OUTCOMES

The patient achieved a complete recovery of limb functions and did not present any other stroke recurrences at follow-up a year later.

LESSONS

CVT in UC is a serious condition and can occur in the children and adolescents. Rapidly diagnosis of this complication of IBD and apply anticoagulant therapy early can contribute to avoiding a potentially fatal outcome.

Total gastrectomy for the treatment of Menetrier's disease persistent to medical therapy: A case report

BACKGROUND

Menetrier's disease is a rare hyperproliferative protein-losing gastropathy of the gastric foveolar epithelium. It is characterized by giant hypertrophic folds, excess mucus secretion, decreased acid secretion and hypoproteinemia due to selective loss of serum proteins across the gastric mucosa. The discovery of transforming growth factor-α overexpression opened the way of epidermal growth factor receptor blockade with cetuximab as first-line treatment modality for Menetrier's disease.

CASE REPORT- ETHODS

We present the case of a 46-year-old female patient with Menetrier's disease. The diagnosis was based on clinical, endoscopic and histological criteria. Two years before the diagnosis of the disease the patient had an episode of deep vein thrombosis and pulmonary embolism. Real time PCR revealed mutation of the gene responsible for coagulation factor II. The patient received anticoagulation therapy and after a period of 6 months a severe anemia due to a gastrointestinal bleeding was presented. The appropriate investigation revealed the presence of Menetrier's disease. The patient was referred to the surgical clinic with persistence of symptoms such as excessive weight loss, anemia and weakness, even after multiple medical treatment, including the monoclonal antibody against the EGFR receptor. A total gastrectomy was performed and the postoperative course was uneventful. One year follow up showed remarkable improvement of her health status.

CONCLUSION

A combination of clinical, laboratory, endoscopic and histopathologic findings is necessary for the diagnosis of this rare disease. Gastrectomy is the treatment of choice for those patients with intractable symptoms and signs refractory to medical therapy.

Drug-Loaded Microbubbles Combined with Ultrasound for Thrombolysis and Malignant Tumor Therapy

Cardiac-cerebral thrombosis and malignant tumor endanger the safety of human life seriously. Traditional chemotherapy drugs have side effects which restrict their applications. Drug-loaded microbubbles can be destroyed by ultrasound irradiation at the focus position and be used for thrombolysis and tumor therapy. Compared with traditional drug treatment, the drug-loaded microbubbles can be excited by ultrasound and release drugs to lesion sites, increasing the local drug concentration and the exposure dose to nonfocal regions, thus reducing the cytotoxicity and side effects of drugs. This article reviews the applications of drug-loaded microbubbles combined with ultrasound for thrombolysis and tumor therapy. We focus on highlighting the advantages of using this new technique for disease treatment and concluding with recommendations for future efforts on the applications of this technology.

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.

Assessment of the procoagulant potential and associated risk factors in pregnant patients with inflammatory bowel diseases

OBJECTIVE

Both inflammatory bowel diseases (IBDs) and pregnancy are established risk factors for thrombotic complications, thus IBD pregnant patients can be considered at even greater risk for thrombosis as compared to non IBD pregnant women. We aimed to evaluate the risk factors associated with this prothrombotic tendency among IBD women throughout gestation.

METHODS

Women with IBD attending a multidisciplinary clinic for the preconception,antenatal and postnatal treatment were prospectively recruited during 2017-2018. Prothrombotic tendency was assessed by thrombin generation, a global marker of the activation of the coagulation system, expressed as the endogenous thrombin potential (ETP).

RESULTS

Overall, 145 IBD women and 50 healthy control subjects were enrolled in this study. Body mass index (BMI) and gestational age were comparable between the groups. ETP level was significantly higher in women with IBD compared to control subjects in all time period (P < .0001). Among women with IBD, ETP level positively correlated with disease activity, as assessed by physician global assessment (P = .005), gestational age (P < .0001), extra-intestinal involvement (P = .04), C-reactive protein level (P < .0001), erythrocyte sedimentation rate (P < .0001), white blood cell count (P = .008), BMI (P = .02) and was inversely correlated with hemoglobin level (P < .0001). ETP level did not correlate with the occurrence of adverse pregnancy outcomes. In a multivariate analysis, active disease (β = 0.20, P = .009), gestational age (β = 0.45, P < .0001), extra-intestinal involvement (β = 0.17, P = .02) and BMI (β = 0.15, P = .05) retained independent predictors of high ETP levels.

CONCLUSION

As determined by thrombin generation, the procoagulant potential among IBD pregnant patients was independently associated with disease activity, BMI and extra-intestinal disease involvement.

[Hepatobiliary Manifestation of Inflammatory Bowel Disease]

The hepatobiliary system is one of the most common sites of extraintestinal manifestation in patients with inflammatory bowel disease (IBD). The progression of IBD can lead to a primary hepatobiliary manifestation and can occur secondary to multiple drugs or accompanying viral infections. Primary sclerosing cholangitis is the representative hepatobiliary manifestation of IBD, particularly in ulcerative colitis. Although most agents used in the treatment of IBD are potentially hepatotoxic, the risk of serious hepatitis or liver failure is low. The prevalence of HBV and HCV in IBD is similar to the general population, but the clinical concern is HBV reactivation associated with immunosuppressive therapy. Patients undergoing cytotoxic chemotherapy or immunosuppressive therapy with a moderate to high risk of HBV reactivation require prophylactic antiviral therapy. On the other hand, HCV has little risk of reactivation. Patients with IBD are more likely to have nonalcoholic fatty liver disease than the general population and tend to occur at younger ages. IBD and cholelithiasis are closely related, especially in Crohn's disease.

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.

Lemierre Syndrome in Adolescent with Active Ulcerative Colitis

Inflammatory bowel disease (IBD) is a well-recognized risk factor for thrombotic events in adults but data on children are scarce. In the great majority of adult patients, thrombotic events are usually deep vein thrombosis and pulmonary embolism. Other sites such as jugular veins are extremely rare. We present a case of Lemierre syndrome in an adolescent girl with active ulcerative colitis and discuss possible risk factors. This is the first reported case of severe Lemierre syndrome with thrombus extension to cranial veins in a patient with ulcerative colitis. Early recognition of Lemierre syndrome in patients who present with rapidly worsening symptoms of neck pain, fever and signs of pharyngitis is imperative because it increases a chance of favorable prognosis. It is important for pediatricians treating IBD patients not to underestimate possible thrombotic events in children with IBD. Recognition of additional risk factors is crucial for prompt diagnosis and adequate treatment.

D-Dimer levels are correlated with disease activity in Crohn's patients

Various indices have been used to assess Crohn's disease (CD). However, the question of whether the Crohn's Disease Activity Index (CDAI) is associated with coagulation function has not been fully confirmed. In this study, we examined the association between CDAI and the coagulation and fibrinolysis parameters. In a retrospective and observational cohort study, the CDAI of 108 patients from two hospital centers was calculated, and its correlations with the prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), international normalization ratio (INR), fibrinogen (Fg) and plasma D-Dimer were investigated. Significant differences were found for PT, APTT, TT, INR, Fg and D-Dimer between the healthy controls and CD patients. However, no significant difference was found between the CDAI-High and CDAI-Low groups of CD patients. Moreover, the CDAI was positively correlated with the level of D-Dimer in CD patients of two hospitals, regardless of the detection method (hospital 1: r=0.3268, p= 0.0042; hospital 2: r=0.5553, p=0.0008). Among the blood coagulation and fibrinolysis parameters, the D-Dimer level was highly correlated with CDAI in CD patients. Thus, the level of D-Dimer expression may be a promising new marker for assessing CD disease activity.

Nutritional Strategies in the Management of Adult Patients with Inflammatory Bowel Disease: Dietary Considerations from Active Disease to Disease Remission

Inflammatory bowel disease (IBD) is a group of chronic, lifelong, and relapsing illnesses, such as ulcerative colitis and Crohn's disease, which involve the gastrointestinal tract. There is no cure for these diseases, but combined pharmacological and nutritional therapy can induce remission and maintain clinical remission. Malnutrition and nutritional deficiencies among IBD patients result in poor clinical outcomes such as growth failure, reduced response to pharmacotherapy, increased risk for sepsis, and mortality. The aim of this review is to highlight the consequences of malnutrition in the management of IBD and describe nutritional interventions to facilitate induction of remission as well as maintenance; we will also discuss alternative delivery methods to improve nutritional status preoperatively.

Examinations and procedures for licensure (competency assurance)

Patients with inflammatory bowel disease (IBD) are at higher risk of venous thromboembolism (VTE), though physicians may be unaware of this risk or hesitant to start pharmacologic VTE prophylaxis in the presence of active gastrointestinal bleeding. We report a case of a 38-year-old patient hospitalized with acute severe ulcerative colitis (UC) who was not placed on pharmacologic VTE prophylaxis and developed bilateral pulmonary embolism (PE). The patient's UC did not respond to medical therapy. Due to his PE, the patient’s total proctocolectomy was delayed six months. He also developed a large pelvic hematoma after colectomy requiring further surgical intervention. Hospitalized inflammatory bowel disease (IBD) patients require pharmacologic VTE prophylaxis unless they have life-threatening bleeding.