Inflammatory bowel disease and thromboembolism

Table 1 Incidence, risk and clinical features of venous thromboembolism in inflammatory bowel disease patients

Venous thromboembolism and IBD
Prevalence: 1.3%-7% - postmortem about 40%
Risk overall: about 2-3-fold
Features
Deep vein thrombosis (legs) and pulmonary embolism
Younger age
Spontaneously
Recur - 30% (risk about 2.5-fold)
Significant morbidity and mortality
Risk factors
Active disease (ambulatory and hospitalized patients)
Complicated disease
Corticosteroid use
Extensive colonic involvement (UC and CD)
Recent hospitalization
Surgery
Pregnancy
Previous history of VTE
Family history of VTE

IBD: Inflammatory bowel disease; VTE: Venous thromboembolism; UC: Ulcerative colitis; CD: Crohn’s disease.

Table 2 Incidence, risk and clinical features of arterial thromboembolism in inflammatory bowel disease patients

Arterial thromboembolism and IBD
Common sites and risk
Cerebrovascular events about 1.2-fold
Ischemic heart disease about 1.2-fold
Mesenteric ischemia about 3.5-fold
Features
Younger age
Female
Post-surgically >> spontaneously
Active disease (ambulatory and hospitalized patients)
Significant morbidity and mortality

IBD: Inflammatory bowel disease.

Table 3 Acquired and hereditary thrombotic risk factors in inflammatory bowel disease patients

Factors	Mechanism
Acquired
Inflammation	Hypercoagulation, vascular endothelial injury
Immobilization	Stasis
Indwelling IV catheters	Vascular injury
Dehydration	Stasis
Steroid use	Hypercoagulation
Oral contraceptives	Hypercoagulation
Surgery	Stasis, hypercoagulation, vascular injury
Pregnancy	Stasis, hypercoagulation
Cancer	Hypercoagulation
Infections	Hypercoagulation
Age	Hypercoagulation
Smoking	Hypercoagulation
Hereditary
Proteins C and S deficiencies	Hypercoagulation
Antithrombin deficiency	Hypercoagulation
Factor V Leiden	Hypercoagulation
Hyperhomocysteinemia-MTHFR gene mutation	Hypercoagulation
Prothrombin gene mutation G20210A	Hypercoagulation
Dysfibrinogenemia	Hypercoagulation

Table 4 Prothrombotic abnormalities of hemostasis and coagulation in inflammatory bowel disease patients

Category	Abnormality
Coagulation factors	↑ V, VIII, vWf, and fibrinogen
Products of thrombin generation	↑ F1 + 2, TAT
Products of fibrin formation	↑ fibrinopeptide A, D-Dimers
Vascular endothelium activation	↑ vWf, thrombomodulin
Acquired deficiencies and dysfunction of natural anticoagulants	↓ protein C, protein S, and AT
Defects in fibrinolytic system	↓ t-PA
	↑ PAI-1
Platelets	↑ number, activation and aggregation

vWf: von Willebrand; F1 + 2: Prothrombin fragment 1 + 2; TAT: Thrombin- antithrombin complex; t-PA: Tissue plasminogen activator; PAI-1: Plasminogen-activator inhibitor type-1.

Table 5 Management of thromboembolic complications in inflammatory bowel disease patients

Primary prevention of thromboembolic complications
Ambulatory patients	Hospitalized patients
General measures	General measures
Physician awareness	Disease activity amelioration
Patient education	Early mobilization
Active disease treatment and remission maintenance	Judicious use of catheters
Recognition, elimination or modification of risk factors	Dehydration or nutritional deficiencies restoration
Steroid use	Medication modification
Smoking	Peri-operatively or in severely ill non-surgical patients
Oral contraceptives	Prophylactic anticoagulation (UH or LMHW)
Cardiovascular risk factors and other co-morbidities	Plus mechanical measures when increased thrombosis risk or mechanical measures only, when anticoagulation contraindicated with high bleeding risk
Long-distance flights
Post-hospitalization period
Compressive stockings?
Treatment of a thromboembolic event
Amelioration of disease activity
Hematology consultation and thrombophilia screening
Therapeutic anticoagulation - UH or LMWH
Thrombolysis - interventional radiology/surgical consultation
Secondary prevention of thromboembolic complications
After a first TE episode
Active disease - spontaneous event
Short term anticoagulation? - 3 to 6 mo
Plus anticoagulation during subsequent flares?
Inactive disease - spontaneous event
Long term anticoagulation?
Recurrent TE or inherited thrombophilia
Hematology consultation
Long term anticoagulation

UH: Unfractionated heparin; LMHW: Low molecular weight heparin.