A 49-year-old male with acute superior mesenteric artery occlusion during active ulcerative colitis: report of a case

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.

Heart failure and anti tumor necrosis factor-alpha in systemic chronic inflammatory diseases

Tumor necrosis factor alpha (TNF-alpha) antagonists have emerged as an effective therapy for patients with diseases as Crohn's disease, rheumatoid arthritis, and other chronic systemic inflammatory diseases. In the last years, there has been a growing interest in the role that inflammatory cytokines, which sustain the pathogenesis of these diseases, plays in regulating cardiac structure and function, particularly in the progression of chronic heart failure. In fact there is an increase of anti-TNF alpha levels in advanced heart failure but the treatment with anti-TNF alpha has been shown to worsen the prognosis of heart failure in randomized controlled trials. Patients with rheumatoid arthritis have an increased risk for cardiovascular disease and anti-TNF alpha therapy seems to be beneficial on the risk of cardiovascular disease. In Crohn's disease the increased risk of cardiovascular disease is controversial and therefore it is impossible to demonstrate an effect in reduction of the risk; however, heart failure in patients treated with anti-TNF alpha, despite in a small proportion, has been observed. On the basis of this observation, anti-TNF alpha therapy is contraindicated in patients with Crohn's disease and III-IV New York Heart Association heart failure class.

Successful treatment of extensive splanchnic arterial and portal vein thrombosis associated with ulcerative colitis

Venous and arterial thromboembolism is a significant cause of morbidity and mortality in patients with ulcerative colitis (UC). Arterial thrombosis of the splanchnic region is a rare event with a very high mortality rate. Furthermore, it represents a challenging complication since it tends to be overlooked and misinterpreted as a clinical exacerbation of UC. We present the case of a 62-year-old female with pancolonic UC complicated by an extensive arterial thrombosis involving the aorta, the celiac trunk, the hepatic, gastric and splenic arteries and the superior mesenteric artery. A thrombosis of the splenic vein extending into the proximal portal vein was also present. The patient was successfully treated by a combined interventional-radiological and surgical treatment. We discuss the rationale behind our management of this case and review the literature on splanchnic arterial thrombosis associated with UC.

Risk of arterial thrombotic events in inflammatory bowel disease

OBJECTIVES

Patients with inflammatory bowel disease (IBD) have an increased risk of venous thrombotic events. The risk of arterial thrombotic events in IBD, however, has been less well characterized. We explored whether Crohn's disease (CD) and ulcerative colitis (UC) are associated with a higher risk for thrombotic events involving the mesenteric, cardiac, or cerebral arteries.

METHODS

Using the Thomson Reuters MarketScan Research claims database, we conducted a retrospective cohort study of IBD patients observed for the occurrence of pre-defined thrombotic events. For comparison, four non-IBD controls were age-, sex-, and index date-matched to each IBD case. The outcomes of interest were acute mesenteric ischemia, transient ischemic attack, cerebrovascular occlusion, atherosclerosis, peripheral vascular disease, and myocardial infarction. We performed a multivariate analysis adjusting for potential confounders for thrombotic events, including hypertension, diabetes, hyperlipidemia, and, in women, the use of contraceptives. We calculated the adjusted hazard ratios (HRs) for each event by comparing IBD patients with controls and used the log-rank test to determine statistical significance.

RESULTS

The study included 17,487 IBD patients and 69,948 controls. Overall, IBD patients had a markedly increased risk of acute mesenteric ischemia (HR=11.2, P<0.001). IBD patients as a whole did not have an increased risk of other arterial thrombotic events, including myocardial infarction and transient ischemic attack, when compared with controls. However, women with IBD who were over the age of 40 years had a higher risk of myocardial infarction (HR=1.6, P=0.003). In addition, women with IBD below the age of 40 years who showed a significantly higher risk for stroke (HR=2.1, P=0.04). For all events, the risks in CD and UC were similar.

CONCLUSIONS

Patients with IBD have a markedly increased risk of acute mesenteric ischemia. Subgroup analysis reveals that women over the age of 40 years with IBD are at increased risk of myocardial infarction, whereas those below the age of 40 years exhibit a two-fold higher risk for stroke. In contrast, men with IBD did not share these same risks for arterial thrombotic events.

Intra-abdominal venous and arterial thromboembolism in inflammatory bowel disease

Venous and arterial thromboembolism constitutes a significant cause of morbidity and mortality in patients with inflammatory bowel disease. The most common thrombotic manifestations are lower extremity deep vein thromboses with or without pulmonary embolism. Occasionally, thromboembolic events occur in the main abdominal vessels, such as the portal and superior mesenteric veins, vena cava and hepatic vein, aorta, splanchnic and iliac arteries, or in the limb arteries. The decision-making process for the treatment of these uncommon thromboembolic complications in inflammatory bowel disease may be very challenging for several reasons: 1) no standardized therapies are available; 2) the decision of starting anticoagulant therapy implies the potential risk of intestinal bleeding; 3) thromboembolic events may recur and be life-threatening if inadequately treated. The literature was searched by using MEDLINE, Embase, and the Cochrane library database. Studies published between 1970 and 2007 were reviewed. We discuss the medical and surgical therapeutic options that should be considered to optimize the outcome and reduce the risk of complications in abdominal thromboembolisms associated with inflammatory bowel disease.