Massive Pulmonary Embolism Associated with Hemorrhagic Colitis: what is the Link?

Authors

  • Sahar Mouram Faculty of Medicine and Pharmacy, Rabat.
  • Hicham Sabor Faculty of Medicine and Pharmacy, Rabat.
  • Imane Mouram Faculty of Pharmacy, Seville.

DOI:

https://doi.org/10.3823/1836

Keywords:

hemorrhagic colitis, pulmonary embolism, thrombolysis.

Abstract

Title: Deep vein thrombosis in the lower limbs and pulmonary embolism are the most common thromboembolic phenomena in patients with inflammatory bowel disease. The inflammatory and thrombotic processes are connected, creating a vicious circle. Inflammation is at least implicated in maintaining the inflammatory process in ulcerative colitis and Crohn's disease. Many factors have been investigated as determinants of the pro-thrombotic tendency such as acquired risk factors or genetic and immune abnormalities, but a unique cause has not been found. Background: We felt that this case was of interest due to the rarity of the condition and the therapeutic challenge given the high risk of bleeding and the management of anti-inflammatory and immunological treatment.  Case presentation We describe the rare case of a patient with ulcerative colitis who suffered a massive pulmonary embolism that caused shock. Despite the therapeutic challenge and the high risk of hemorrhagic complications given the underlying disease, thrombolytic treatment was administered with a good result. Conclusion: Autoimmune disorders in general should be regarded not only as inflammatory disorders, but also as hyper-coagulable disorders. This clinical observation can put the item on the necessity of establishing recommendations for prevention of embolic events in patients with hemorrhagic colitis. 

Author Biographies

Sahar Mouram, Faculty of Medicine and Pharmacy, Rabat.

Cardiology Department, Military Hospital.

Hicham Sabor, Faculty of Medicine and Pharmacy, Rabat.

Cardiology Department, Military Hospital.

Imane Mouram, Faculty of Pharmacy, Seville.

Biology Department,

References

- White R. The Epidemiology of venous thromboembolism. Circulation 2003; 107 (23 suppl 1): I4–I8.

- Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353: 1386–89.

- Goldhaber SZ, Elliott CG. Acute pulmonary embolism: part I: epidemiology, pathophysiology, and diagnosis. Circulation 2003; 108: 2726–29.

- Pogliani EM, Bozzan A, Radaelli F. Thrombolytic therapy for venous thrombosis in patients with gastrointestinal diseases. Pharmatherapeutica. 1982; 3: 268-273.

- Elikowski W, Malec M, Lawandowska M. Massive pulmonary embolism in a patient with ulcerative colitis and hyperhomocysteinaemia-a case report. Kardio Pol. 2006; 64: 405-409.

- Novotny DA, Rubin RJ, Slezak FA, et al. Arterial thromboembolic complications of inflammatory bowel disease: report of three cases. Dis Colon Rectum. 1992; 35: 193-196.

- Solem CA, Loftus EV, Tremaine WJ, et al. Venous thromboembolism in inflammatory bowel disease. Am J Gastroenterol. 2004; 99: 97-101.

- Chamouard P, Grunebaum L, Wiesel ML, Frey PL, Wittersheim C, Sapin R, et al. Prothrombin fragment 1 + 2 and thrombin-antithrombin III complex as markers of activation of blood coagulation in inflammatory bowel diseases. Eur J Gastroenterol Hepatol. 1995; 7:1183–8.

- Lake AM, Stauffer JQ, Stuart MJ. Hemostatic alterations in inflammatory bowel disease: response to therapy. Am J Dig Dis. 1978; 23:897–902.

- Chiarantini E, Valanzano R, Liotta AA, Cellai AP, Fedi S, Ilari I, et al. Hemostatic abnormalities in inflammatory bowel disease. Thromb Res. 1996;82:137–46.

- Smith CJ, Haire WD, Kaufman SS, Mack DR. Determination of prothrombin activation fragments in young patients with inflammatory bowel disease. Am J Gastroenterol. 1996; 91:1221–5.

- Van Bodegraven AA. Haemostasis in inflammatory bowel diseases: Clinical relevance. Scand J Gastroenterol. 2003; 239(suppl):51–62.

- Magro F, Soares JB, Fernandes D. Venous thrombosis and prothrombotic factors in inflammatory bowel disease. World J Gastroenterol. 2014;20(17):4857–72.

- Grainge J, West J, Card TR. Venous thromboembolism during active disease and remission in inflammatory bowel disease: a cohort study. Lancet. 2010; 375:657–63.

- Gris JC, Schved JF, Raffanel C, Dubois A, Aguilar-Martinez P, Arnaud A, et al.Impaired fibrinolytic capacity in patients with inflammatory bowel disease. Thromb Haemost. 1990; 63:472–5.

- Saibeni S, Bottasso B, Spina L, Bajetta M, Danese S, Gasbarrini A, et al. Assessment of thrombin-activatable fibrinolysis inhibitor (TAFI) plasma levels in inflammatory bowel diseases. Am J Gastroenterol. 2004; 99:1966–70.

- Xu J, Lupu F, Esmon CT. Inflammation, innate immunity and blood coagulation. Hamostaseologie 2010; 30: 5–9.

- Wang JY, Terdiman JP, Vittinghoff E, Minichiello T, Varma MG. Hospitalized ulcerative colitis patients have an elevated risk of thromboembolic events. World J Gastroenterol 2009; 15: 927–35.

- Grip O, Svensson PJ, Lindgren S. Infl ammatory bowel disease promotes venous thrombosis earlier in life. Scand J Gastroenterol 2000; 35: 619–23.

- Robert JH, Sachar DB, Aufses AH, Greenstein AJ. Management of severe hemorrhage in ulcerative colitis. Am J Surg. 1990; 159: 550-555.

- Haagsma CJ, Blom HJ, Van Riel PLCM, et al. Influence of sulphasalazine, methotrexate and the combination of both on plasma homocysteine concentrations in patients with rheumatoid arthritis. Ann Rheum Dis. 1999; 58: 79-84.

- Pogliani EM, Bozzan A, Radaelli F. Thrombolytic therapy for venous thrombosis in patients with gastrointestinal diseases. Pharmatherapeutica. 1982; 3: 268-273.

- Van Vanwoert JH, Thomson RC, Cangemi JR, Metzger PP, Blackshear JL, Fleming CR. Streptokinase therapy for extensive venous thrombosis in a patient with severe ulcerative colitis.Mayo Clinic Proc. 1990; 65: 1144-1149.

- Task Force on Pulmonary Embolism of the European Society of Cardiology. Guidelines on diagnosis, management of acute pulmonary embolism. Eur Heart J. 2000; 21: 1301- 1336.

- Kucher N, Luder CM, Dornhofer T, Windecker S, Meier B, Hess OM. Novel management strategy for patients with suspected pulmonary embolism. Eur Heart J. 2003; 24: 366-376.

- Kostadima E, Zakynthinos E. Pulmonary embolism: pathophysiology, diagnosis, treatment. Hellenic J Cardiol. 2007; 48: 94-107.

- Van Vanwoert JH, Thomson RC, Cangemi JR, Metzger PP, Blackshear JL, Fleming CR. Streptokinase therapy for extensive venous thrombosis in a patient with severe ulcerative colitis.Mayo Clinic Proc. 1990; 65: 1144-1149.

- Teefy AM, Martin JE, Kovacs MJ. Warfarin resistance due to sulfasalazine. Ann Pharmacother. 2001; 35: 506.

- Papa A, Danese A, Gasbarrini A, et al. Review article: potential therapeutic applications and mechanisms of action of heparin in inflammatory bowel disease. Aliment Pharmacol Ther.2000; 14: 1403-1409.

- Ang YS, Mahmud N, White B, et al. Randomized comparison of unfractionated heparin with corticosteroids in severe active inflammatory bowel disease. Aliment Pharmacol Ther. 2000; 14: 1015-102 .

- Panes J, Esteve M, Cabre E, et al. Comparison of heparin and steroids in the treatment of moderate and severe ulcerative colitis. Gastroenterology. 2000; 119: 903-908.

- Bloom S, Kiilerich S, Lassen MR, et al. Low molecular weight heparin (tinzaparin) vs placebo in the treatment of mild to moderately active ulcerative colitis. Aliment Pharmacol Ther. 2004; 19: 871-878.

- Carter MJ, Lobo AJ, Travis SP. Guidelines for the management of inflammatory bowel disease in adults. Gut. 2004; 53(Suppl 5): V1-V16.

Downloads

Published

2015-10-11

Issue

Section

Cardiology