Venous Thromboembolism in Patients with Inflammatory Bowel Disease: The Role of Pharmacological Therapy and Surgery

Vascular complications in hospitalized patients with inflammatory bowel disease and acute gastroenteritis and colitis: A propensity score-matched study

OBJECTIVES

Atherosclerotic cardiovascular disease (ASCVD) and venous thromboembolism (VTE) are severe complications of inflammatory bowel disease (IBD). Risk factors for ASCVD and VTE in IBD are not entirely elucidated. This study investigated the incidence and risk factors for ASCVD and VTE in IBD compared to acute infective gastroenteritis and colitis (AGC).

METHODS

We reviewed the clinical records of inpatients with IBD and AGC over 6 years. Each group's propensity score-matched (PS) subpopulation consisted of 831 patients, ensuring a balanced comparison. Additionally, the effect of IBD on ASCVD and VTE was assessed.

RESULTS

The PS cohorts indicated a significantly higher number of ASCVD events in IBD than controls (10.1 % vs. 5.5 %, p = 0.001) and an increased prevalence of ischemic heart disease (IHD) (7.9 % vs. 3.6 %, p < 0.001). Conversely, the study groups demonstrated similar VTE incidence. IBD diagnosis, male sex, hypertension, diabetes, and the Charlson Index were independently associated with ASCVD. Age was significantly associated with VTE.

CONCLUSIONS

Inpatients with IBD demonstrated an increased risk of ASCVD and IHD. IBD was an independent risk factor for ASCVD, and chronic inflammation was a significant enhancer factor for ASCVD. Aggressive control of inflammation is an essential target to reduce ASCVD risk.

Finding the Balance: Venous Thromboembolism Prophylaxis during Hematochezia in Crohn's Disease

Introduction

Despite heightened risk of venous thromboembolism (VTE) in hospitalized patients with inflammatory bowel disease (IBD), pharmacologic prophylaxis remains underutilized, particularly in those presenting with hematochezia. Although placement of retrievable inferior vena cava filters (rIVCF) may be considered in those with contraindications to anticoagulation and VTE risk, current recommendations from clinical guidelines are incongruent, leading to wide variation in practice.

Case Presentation

This report highlights a case of rIVCF used in the management of recurrent VTEs in a patient hospitalized for persistent gastrointestinal bleeding.

Conclusion

Our case demonstrates the need for a lower threshold for initiating VTE prophylaxis in patients with active IBD, even when hematochezia is the presenting symptom. A small group of patients with recurrent VTE and clear contraindications to anticoagulation may require IVCFs, necessitating close follow-up and monitoring for filter complications.

Gut dysbiosis-related thrombosis in inflammatory bowel disease: Potential disease mechanisms and emerging therapeutic strategies

Patients with inflammatory bowel disease (IBD) have an increased risk of developing venous thromboembolic events, which have a considerable impact on morbidity and mortality. Chronic inflammation plays a crucial role in the pathogenesis of thrombotic events in patients with IBD. However, many unresolved questions remain, particularly regarding the mechanisms that determine the persistent inflammatory state independent of disease activity. This review explored the role of gut microbiota dysbiosis and intestinal barrier dysfunction, which are considered distinctive features of IBD, in determining pro-thrombotic tendencies. Gut-derived endotoxemia due to the translocation of bacterial lipopolysaccharides (LPS) from the intestine to the bloodstream and the bacterial metabolite trimethylamine-N-oxide (TMAO) are the most important molecules involved in gut dysbiosis-related thrombosis. The pathogenic prothrombotic pathways linked to LPS and TMAO have been discussed. Finally, we present emerging therapeutic approaches that can help reduce LPS-mediated endotoxemia and TMAO, such as restoring intestinal eubiosis, normalizing intestinal barrier function, and counterbalancing the effects of LPS and TMAO.

Venous thromboembolism risk stratification for patients undergoing surgery for IBD using a novel six factor scoring system using NSQIP-IBD registry

BACKGROUND

Patients undergoing colorectal surgery for inflammatory bowel disease (IBD) are recognized to have an increased risk of venous thromboembolism (VTE). The aim of this study was to determine the perioperative risk factors for VTE and to create a predictive scoring system for VTE in the IBD cohort.

METHODS

The NSQIP-IBD Collaboration Registry from 2017 to 2020 was used to identify patients. Demographics, operative and outcomes data of IBD patients undergoing surgeries for IBD were analysed. A logistic multivariate regression model was performed using all significant variables to develop a predictive scoring system of VTE.

RESULTS

Five-thousand and three patients (51.9% male, mean age: 42.7, 42.7% ulcerative colitis) were included in the study. 125 (2.49%) developed VTE. On multivariate analysis ASA grade, ulcerative colitis, sepsis, serum sodium <139 mmol/L, an open abdomen and preoperative inter hospital transfer were associated with greater risk of VTE. Using these 6 significant factors, a risk model was constructed. The risk of VTE with one risk factor was 0.7% and 1.8% with two risk factors. The risk of VTE increased to 3.6% and 4.5% with three and four risk factors respectively. With five and six risk factors, the risk of VTE increased exponentially to 10.9% and 25% respectively.

CONCLUSION

This study shows that there are cumulative risk factors which increase the risk of VTE after surgery for IBD. The risk increases exponentially with more than five risk factors, and extended chemoprophylaxis may not be enough in reducing this risk.

Clinical Characteristics, Risk Factors, and Outcomes of Acute Pulmonary Embolism in Asian Population

BACKGROUND

Acute pulmonary embolism (APE) is a common condition with increasing worldwide incidence. However, the clinical characteristics, risk factors, and clinical outcomes of APE in the Asian population especially in the Thai population are still limited. Therefore, the objective of this study was to identify the clinical characteristics, risk factors, and clinical outcomes of APE in the Asian population.

METHODS

A cross-sectional study was conducted on patients diagnosed with APE at Chiang Mai University Hospital, Thailand during 2011-2020.

RESULTS

During the study period, 696 patients confirmed the diagnosis of APE with a mean age of 57.7 ± 15.7 years and 41.1% males. APE was suspected in 468 of 696 patients (67.2%), while 228 patients (32.8%) had incidental PE. Active malignancy during treatment was found in 388 (55.7%). Dyspnea, cough, and chest pain were the most common presenting symptoms. Respiratory failure was found in 129 patients (18.6%). The thirty-day all-cause mortality rate was 19.1%. PE-related mortality was 5.6%. Most PE-related mortality was high-risk PE.

CONCLUSION

APE was not uncommon in the Asian population. Active cancer, especially lung cancer was the most common risk factors. High-risk and intermediate-high-risk PE were associated with high mortality. Risk stratification and prompt management are warranted to improve outcomes.

Venous thromboembolism in chronic gastrointestinal disorders

INTRODUCTION

Chronic gastrointestinal disorders (including autoimmune gastritis, celiac disease, inflammatory bowel disease, and diverticular disease) are highly prevalent disorders, that may be associated with unpredictable, life-threatening complications, such as thromboembolic events. Venous thromboembolism (VTE) is one of the major causes of morbidity and mortality worldwide. Several conditions, including cancer, major trauma, surgery, prolonged immobilization, are well-established risk factors for VTE. Over the past decade, chronic inflammation has also been identified as an independent risk factor for VTE due to the prothrombotic effects of inflammatory cytokines and oxidative stress on the coagulation cascade. Other several mechanisms were shown to be associated with a higher incidence of VTE in patients with gastrointestinal disorders.

AREAS COVERED

We critically discuss the latest insights into the mechanisms responsible for thromboembolic manifestations in chronic gastrointestinal disorders, also focusing on the recognition of risk factors and treatment.

EXPERT OPINION

The occurrence of thrombotic complications is underestimated in patients with chronic gastrointestinal disorders. Identifying potential risk factors and concomitant predisposing conditions and to prevent VTE and guide treatment require a multidisciplinary approach, and this is critically important for clinicians, in order to provide the best care for such patients.

Occurrence of Thromboembolism in Paediatric Patients With Inflammatory Bowel Disease: Data From the CEDATA-GPGE Registry

OBJECTIVE

Among patients with inflammatory bowel disease (IBD), the risk of thromboembolism (TE) is increased, representing a relevant cause of morbidity and mortality. In contrast to other extraintestinal IBD manifestations, TE receives much less attention because of its low incidence, estimated at merely 0.4-0.9% in hospitalised children with IBD.

METHODS

Cases with TE, as documented in the German-Austrian Paediatric IBD registry gesellschaft für pädiatrische gastroenterologie und ernährung - large paediatric patient registry (CEDATA-GPGE), were analyzed retrospectively. For all patients with signs of TE, a questionnaire was filled in by the treating paediatric gastroenterologist.

RESULTS

Over 10 years, 4,153 paediatric patients with IBD (0-18 years) were registered in the registry, and 12 of them identified with TE. Eight patients were diagnosed with ulcerative colitis (UC), three with Crohn's disease (CD), and one with IBD-unclassified. The median age at IBD diagnosis was 10 years and at the manifestation of TE 13 years, respectively, with a median latency to TE of 2 years. Prevalence of TE was 0.3%, with a significantly higher risk for patients with UC than CD (OR 5.9, CI 1.56-22.33, p = 0.008). More girls than boys were affected (f:m = 7:5) without reaching significance. Approximately 90% of patients experienced TE during active disease, with relevant cerebral and limb involvement in 6/12 patients. Various risk factors, e.g., hospitalisation, coagulopathy, or anaemia were identified. TE management included intensive care and surgery. Among the 12 patients, 11 recovered fully, in which one patient has focal epilepsy as a sequela.

CONCLUSION

Paediatric patients with IBD have a substantially increased risk for TE. Risk factors, such as those identified should be considered when managing paediatric IBD and preventive measures for those hospitalised taken routinely. Initiating pharmacological thromboprophylaxis is challenging for the lack of published trials on efficacy and safety in paediatric IBD but should be considered carefully in each case.

Inflammatory bowel diseases and the risk of adverse health outcomes: Umbrella review of meta-analyses of observational studies

BACKGROUND AND AIM

Accumulating evidence indicates a plausible association between inflammatory bowel diseases and the risk of adverse health outcomes. However, the conclusions are inconsistent. We aimed to perform an umbrella review of meta-analyses to appraise and grade the evidence of the association between inflammatory bowel diseases and the risk of adverse health outcomes.

METHODS

Meta-analyses of observational studies that examined the associations between inflammatory bowel disease and the risk of adverse health outcomes in PubMed, EMBASE, and Web of Science were screened.

RESULTS

This umbrella review identified 25 meta-analyses, which yielded 123 effect estimates for 60 unique putative health outcomes. Patients with inflammatory bowel diseases had a higher risk of adverse health outcomes, including multiple cancers, cardiovascular disease, adverse pregnancy outcomes, adverse oral outcomes, and other adverse events. Moreover, inflammatory bowel diseases caused greater harm to health based on the presented evidence. However, none of the evidence was classified as "high" quality, only 15% was classified as "moderate," and 65% of outcomes were rated as "very low."

CONCLUSION

Patients with inflammatory bowel diseases had a higher risk of adverse health outcomes and further studies should be conducted to draw firmer conclusions.