Spontaneous venous thrombosis in inflammatory bowel disease: relevance of factor V Leiden and the prothrombin gene mutation

Incidence and risk factors for venous thrombosis among patients with inflammatory bowel disease in China: a multicenter retrospective study

Background/Aims

Risk of venous thrombosis is increased in patients with inflammatory bowel disease (IBD); data on Asian IBD patients is limited and status quo of thrombosis screening and prophylaxis are unknown. Therefore, we aimed to investigate the incidence, screening, prophylaxis, and risk factors for venous thrombosis among Asian IBD patients.

Methods

Medical files of patients with Crohn’s disease (CD) and ulcerative colitis (UC) from 17 hospitals across China between 2011 and 2016 were reviewed for venous thrombosis, use of screening and prophylaxis. A case-control study was performed among hospitalized patients with venous thrombosis and their age-, sex-matched IBD controls hospitalized around the same period; disease characteristics and known provoking factors of venous thrombosis were recorded. Risk factors were analyzed in both univariate and logistic regression analyses.

Results

A total of 8,459 IBD patients were followed for 12,373 person-year. Forty-six patients (0.54%) had venous thrombosis, yielding an incidence of 37.18 per 10,000 person-year. Incidence increased with age, especially among CD. Less than 20% of patients received screening tests and 35 patients (0.41%) received prophylaxis. Severe disease flare was an independent risk factor for venous thrombosis (odds ratio [95% confidence interval]: CD, 9.342 [1.813– 48.137]; UC, 5.198 [1.268–21.305]); past use of steroids and extensive involvement were 2 additional risk factors in CD and UC, respectively.

Conclusions

Incidence of venous thrombosis in China was 37.18 per 10,000 person-year (0.54%). Use of screening and prophylaxis were rare. Severe disease flare was an independent risk factor for thrombosis among hospitalized patients.

Contraceptive use among women with inflammatory bowel disease: A systematic review

BACKGROUND

There are theoretical concerns that use of hormonal contraceptives by women with inflammatory bowel disease (IBD) might increase disease relapse and risk of other adverse health outcomes, including thrombosis. In addition, there are concerns that IBD-related malabsorption might decrease the effectiveness of orally ingested contraceptives. The objective of this systematic review was to evaluate the evidence on the safety and effectiveness of contraceptive use among women with IBD.

STUDY DESIGN

We searched the PubMed database for peer-reviewed articles relevant to contraceptive use and IBD that were published in any language from inception of the database through February 2009. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence.

RESULTS

From 207 articles, we identified 10 studies that met our inclusion criteria. Evidence from five cohort studies (Level II-2, fair to good) suggests no increased risk of IBD relapse with use of oral contraceptives. Evidence from two pharmacokinetic studies (not graded) suggests that women with mild ulcerative colitis and those with an ileostomy following a proctocolectomy with small ileal resections have plasma concentrations of steroid hormones after oral ingestion of higher doses of combined oral contraceptives that are similar to the plasma concentrations among healthy volunteers. No studies were found that examined the risk of thrombosis among women with IBD who used hormonal contraceptives.

CONCLUSIONS

Limited evidence suggests there is no increased risk of disease relapse among women with IBD who use oral contraceptives, and there seem to be no differences in the absorption of higher-dose combined oral contraceptives between women with mild ulcerative colitis and small ileal resections and healthy women.

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.

Inflammation and coagulation in inflammatory bowel disease: The clot thickens

Inflammation and coagulation play crucial roles in the pathogenesis of multiple chronic inflammatory disorders. Growing evidence highlights a tight mutual network in which inflammation, coagulation, and fibrinolysis play closely related roles. Crohn's disease (CD) and ulcerative colitis (UC), the two major forms of inflammatory bowel disease (IBD), are chronic inflammatory conditions, characterized by a hypercoagulable state and prothrombotic conditions, and accompanied by abnormalities in coagulation. From a pathophysiological point of view, cells and molecules classically implicated in the physiological process of coagulation have now been shown to behave abnormally in IBD and possibly to also play an active role in disease pathogenesis and/or disease progression. This paper reviews studies performed on the coagulation profile and risk factors for thrombosis in IBD. In particular, an overview is provided of the epidemiology, clinical features, and etiology of thromboembolic complications in IBD. Furthermore, we review hemostatic abnormalities in IBD, as well as the cell types involved in such processes. Finally, we highlight the coagulation system as a dynamic participant in the multifaceted process of chronic intestinal inflammation. Overall, an overview is provided that the coagulation system represents an important, though previously underestimated, component of IBD pathogenesis, and may be a possible target for therapeutic intervention.

Thrombosis in inflammatory bowel diseases: role of inherited thrombophilia

BACKGROUND

Inflammatory bowel diseases (IBD) are characterized by an increased risk for venous and arterial thrombosis. Although the pathogenetic mechanisms of this predisposition are unclear, a possible role of inherited risk factors for thrombosis in determining this predisposition has been suggested.

AIM

To evaluate the role of factor V Leiden (G1691A) and G20210A prothrombin gene mutations in determining the occurrence of thrombosis in IBD patients.

PATIENTS AND METHODS

Forty-seven IBD patients (30 ulcerative colitis and 17 Crohn's disease) with a positive history for thrombosis (9 at arterial sites and 38 at venous sites) were enrolled in the study. For each patient, two non-IBD subjects matched for sex and age, type, and site of thrombosis were used as controls. Peripheral blood DNA specimens were amplified by PCR using appropriate primers and analyzed by restriction analysis on agarose gel electrophoresis. Statistical analysis was performed by means of Fisher's exact test.

RESULTS

The total number of subjects with one or both mutations was significantly lower in IBD patients with thrombosis than in control subjects (12.8%vs 29.8%, respectively; p= 0.035, OR = 0.34, 95% CI 0.13-0.90). The total frequency of the mutated alleles was also significantly lower in IBD than in controls (7.4%vs 16.5%, respectively; p= 0.041, OR = 0.40, 95% CI 0.17-0.96). Prothrombotic mutations were particularly unfrequent in IBD patients with active disease at the time of thrombosis compared with patients with quiescent disease (8.0%vs 36.4%, respectively; p= 0.057, OR = 0.15, 95% CI 0.02-1.01).

CONCLUSIONS

The major inherited risk factors for thrombosis are significantly less frequent in thrombotic IBD patients than in thrombotic non-IBD subjects, suggesting that acquired risk factors play the most relevant role in determining thromboembolic events observed in IBD patients, particularly during active phases of the disease.

Venous thrombosis in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) have a threefold increased risk of venous thrombosis, a major cause of morbidity and mortality. Although the exact mechanism explaining the initiation of thrombosis remains unclear, it is likely to be a multifactorial process. Reported abnormalities include activation of markers of the coagulation cascade, disturbed fibrinolysis and the activation of platelets. The contribution of thrombophilic disorders such as factor V Leiden, prothrombin gene mutations and hyperhomocysteinaemia are discussed, but their role in thrombosis associated with IBD has remained unclear. Recent research has examined elevated CD40, P-selectin levels and tissue factor-bearing microvesicles in venous thrombosis, and the relevance of these observations to IBD is reviewed.