Case Report

A 40-year-old man presented to the Emergency Department with complaint of pain and swelling in right lower limb below the knee since 1 week. He had been treated with antibiotic and painkiller for this. The patient gave a history of bloody diarrhea with 6-7 loose stools/day and lower abdominal pain since 3 months. He also reported similar episode of diarrhea about 2 years back. He stated that he had lost about 3 kg of weight since the last 6 months. The patient is a nonsmoker and nonalcoholic. There was no history of recent fever, nausea, vomiting, chest pain, any respiratory complaint, arthralgia or any drug intake. There was no family history of any malignancy.

On examination, the vitals were stable with mild tachycardia 108 beats/ min. Abdominal xamination was unremarkable. Lungs were clear on auscultation. He had pitting pedal edema and the right calf muscle was tender on palpation on the medial aspect and popliteal fossa. Lab tests showed total leukocyte count (TLC) 10,000/mm3, hemoglobin (Hb) 8.1 g/dL, hematocrit 28%, prothrombin time (PT) 12.5 sec, INR 1, activated partial thromboplastin time (aPTT) 28 sec, erythrocyte sedimentation rate (ESR) 45 mm/h, C-reactive protein (CRP) 7.5 mg/L. D-dimer levels were raised to 4,750 ng/mL. Color Doppler ultrasound of the lower extremities was done, which showed thrombosis of the right popliteal vein.

The patient was hospitalized in ICU and treatment with enoxaparin (low molecular weight heparin) was started. A unit of blood was transfused. When the patient’s general condition improved, he was further investigated for the cause of diarrhea. Stool samples were negative for ova and parasites. Three sequential stool cultures were negative for any infective pathology. A colonoscopy was done, which showed edematous and erythematous mucosa from the rectum to the cecum suggestive of ulcerative colitis (UC) with pancolonic involvement. Superficial ulcerations were also present throughout. Biopsy confirmed the diagnosis of UC. Raised perinuclear antineutrophilic cytoplasmic antibody (pANCA) titers further supported the diagnosis of UC. The patient was started on oral mesalamine and mesalamine enema at bedtime. When the optimal therapeutic INR range (between 2 and 3) was reached, the patient was put on warfarin. He was discharged on warfarin along with oral mesalamine.

Diagnosis

Ulcerative colitis (pancolitis) with thromboembolic disease.

Discussion

Thromboembolism is a well-recognized complication of inflammatory bowel disease (IBD) to the extent that it is considered an extraintestinal manifestation of IBD. Patients with UC and Crohn’s disease (CD) have a threefold risk of developing thromboembolism when compared with the general population.1 Not only do patients who have pancolitis experience a more aggressive disease course, but these patients are also more likely to suffer from extraintestinal complications of the disease.2

Venous thromboembolism (VTE) is a lifethreatening complication of IBD with mortality rate ranging from 8 to 25%. In contrast to other chronic inflammatory conditions such as rheumatoid arthritis or celiac disease, IBD has been shown to be an independent risk factor for thromboembolism.3

The extent of the disease (pancolonic inflammation in UC) was also shown to correlate positively with the risk of developing thromboembolism.1 In a study that defined IBD as active if the patient had any pertinent gastrointestinal symptoms within the 3-month period prior to thrombotic episodes or endoscopic or radiographic evidence of active disease, 76% of patients with UC had pancolonic involvement and 79% of UC patients had active disease.3,4

In patients with UC, thromboembolic events manifest as deep venous thrombosis or pulmonary embolism. Renal artery thrombosis, cerebrovascular accidents, coronary artery thrombosis and venous thrombosis of mesenteric, portal and hepatic vessels all have been reported.5

Patients with these complications should be treated with anticoagulants, just as in other patient populations. Although, there may be concerns of an increased risk of gastrointestinal bleeding with anticoagulation, it generally is safe and rarely is complicated by colonic bleeding.5 Patients with IBD should be investigated for the presence of hypercoagulable states including factor V Leiden mutation and hyperhomocysteinemia. This complication should be borne in mind, and physicians caring for these patients must be aware of this as early diagnosis is important because in some of these patients thromboembolism may be silent to start with and manifest as pulmonary embolism, which can be fatal.1

References

1. Issa H, Al-Momen S, Bseios B, et al. Thromboembolism in inflammatory bowel diseases: a report from Saudi Arabia. Clin Exp Gastroenterol 2011;4:1-7.
2. Cuffari C, Present DH, Bayless TM, et al. Optimizing therapy in patients with pancolitis. Inflamm Bowel Dis 2005;11(10):937-46.
3. Choi SK, Kasturi L, Tavakoly A, et al. Ulcerative colitis diagnosed in a patient with venous thromboembolism. Hospital Physician 2008;44(8):32-6.
4. Solem CA, Loftus EV, Tremaine WJ, et al. Venous thromboembolism in inflammatory bowel disease. Am J Gastroenterol 2004;99(1):97-101.
5. Osterman MT, Lichtenstein GR. Chapter 112. Ulcerative colitis. In: Feldman: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 9th edition, Elsevier: Saunders 2011:p.1975-2012.