A 31 years old female with known case IBD - CD with stricturing disease involving small bowel was admitted with abdominal pain with abdominal distention since 5 days. She was receiving 100mg azathioprime daily since 1 year. X ray abdomen was not showing air under diaphragm while USG showed moderate ascites with thombosed hepatic veins.
Triple phase CT showed thrombosed hepatic veins with narrowing of intrahepatic IVC - suggestive of BCS. Her ascites decreased with salt restriction and diuretics, she was also treated with LMWH followed by oral anti coagulation.
IBD patients have an increased risk (2 to 3 times) of venous thromboembolism (VTE) which is a significant cause of morbidity and mortality.
55 % of Gastroenterologists
are unaware of VTE guidelines in IBD and 65% gastroenterologists may not use
VTE prophylaxis in hospitalized patients with acute severe colitis.
Major sites for VTE – deep vein thrombosis, pulmonary
thromboembolism, portal and mesenteric veins
Etiology:
Multifactorial – hereditary and acquired
Dehydration, indwelling
catheters, prolonged immobilization, hyperhomocysteinaemia, surgical
interventions and active disease
Non pharmacological
prophylaxis:
Maintain hydration
Correct vitamin deficiencies –
Vitamin B12, B6 and Folic acid (to reduce homocysteine levels)
Graduated compression stockings
or pneumatic devices
Early
mobilization
Pharmacological
prophylaxis:
Recommended (ECCO, BSG, ACG)
in hospitalized patients with active disease either LMWH or unfractionated heparin
(UH).
NO RCTS, BASED ON OBSERVATIONAL STUDIES
Treatment:
Treatment of VTE in IBD is same
as those without IBD
If no hemodynamically significant bleeding or indications
of thrombolysis >> LMWH is ideal which should be switched to an oral
anticoagulant (Duration – not well established)
33 % risk of second
episode of VTE within 5 years
The benefits of long
term anti-coagulation in reducing recurrent VTE outweigh risk of bleeding, particularly
in those who developed VTE in absence of active disease or other transient provoking
factors.
IVC filter is
indicated in cases of floating thrombi in deep veins and recurrent PE despite
anticoagulation and in cases with high risk of bleeding.
VTE is life- threatening extra
intestinal manifestation of IBD: Suspects, prevent and treat