1. SMV Thrombosis in IBD Patients
Thamer A. Bin traiki
Demonstrator GS
pgy-1
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2. 2-Smv thrombosis presentation
Content
1- Case presentation
2-Smv thrombosis presentation
3-literature review of
IBD &thrombosis
IBD & SMV thrombosis

3. Case Presentation Prednisolone 30 mg PO OD Imuran 75 mg PO OD
26 y/o male from eastern region Dx to have UC since 3 years.
Admitted 9 times with acute exacerbation of his illness & labeled as steroid dependant .
He was on:
Prednisolone 30 mg PO OD
Imuran 75 mg PO OD
Pentasa 800 mg PO QID
Pentasa 1 g Supp. BD

4. Cont….
Admitted now for Elective Laparoscopic proctocolectomy with Ileostomy

5. Cont…. Upon admission Imuran & Pentasa were held.
The pt. started on soft diet.
Heparinization with LMWH
2 days later
His operation day
During the operation Pneuomatic compressing device & TED stoking were applied .

6. Cont….
Post operatively Antithrombotic measures of LMWH , TED stoking & Pneumatic device were cont…. .
And to start the pt. on clear fluid diet when fully awake as tolerated .

7. Cont…. D 1 post op Fluid diet was tolerated. V/S : stable afebrile .
Abd. Soft & lax .
Stoma looks good .
Stoma output in 1st day was 200 cc .

8. Cont…. D 2 Soft diet started  BUT was not tolerated
Vomited once & abd. pain
V/S stable, afebrile .
Abd : soft , lax with +ve bowel sound .
Stoma output : nil .

9. Abdominal pain disproportional to his abdominal examination,
Cont….
Abdominal pain disproportional to his abdominal examination,
despite of proper analgesia
(PCA morphine )
All of his labs were within normal

10. Cont….
5th day CT abdomen requested : Filling defect occupying the SMV at the proximity with the PV most likely to be a thrombus SMV thrombosis

15. Cont…. Hematology team was consulted
Therapeutic dose of LMWH started (1mg/kg SQ bid).
Pain subsided
On/Off attacks of vomiting .
TPN started
Stoma continued to look healthy & functioning well with variable amount of output .

16. Cont…. D 11 the stoma was mildly congested & edematous .
D 12 stoma bag was filled with gas only even though he was not complaining of pain & his abdomen was soft .
D 13 stoma was draining well
D 15 F/U CT was requested :

17. CT Result Thrombus disappeared . Ascitis present .
Mucosal enhancement of the distal ileum without pneumatosis intestinale .

18. Cont…. D 17 a severe attack of severe generalized abdominal pain
Stoma output was nill not even gas
Folly's cath. was inserted & large amount came out of the stoma ( > 1 L ) .
The cath kept in place .

19. Cont….
D 18
The stoma was continue to function in the presence of the catheter .
Retrograde enema was requested .

20. Cont…. The result showed Strictured area @ 7 cm proximal to the stoma
? Kinck
? Ischemic changes

23. Cont….
Then the patient was taken to the theater For Minilaparotomy For refashioning of his stoma with Resection of strictured part .

25. Post op the patient was doing fine
Tolerating oral feeding .
V/S stable afebrile
Stoma was functioning very well.

26. D 42 the patient was discharged home in good condition .
Cont….
D 42 the patient was discharged home in good condition .

27. Superior Mesenteric Vein Thrombosis

28. SMV Thrombosis
SMV thrombosis causes 5%-10% of acute mesenteric ischemia .
Cause intestinal ischemia .
The mortality of SMV thrombosis is around 25% .

29. Symptoms
Abdominal pain in 85% usually severe and disproportionate to physical findings .
Anorexia in 50%.
GI bleeding in 45%.
Nausea and vomiting in 45%

30. Signs
Physical signs depend on the severity and stage of intestinal injury.
Peritoneal signs are late manifestations that indicate bowel infarction.

31. Diagnosis Usually made by CT or Angiography . CT : Diagnostic in ~ 80%
Demonstrates thrombus in the mesenteric vein as a central area of low density surrounded by an enhanced peripheral vascular rim.
Angiography :
Less sensitive in detecting superior mesenteric venopathy than arteriopathy .

33. Treatment Full course of anticoagulation with heparin
Prolonged anticoagulation with coumadin
post acute heparinization (6months - longer if thrombophilic condition present)
Surgery to resect nonviable bowel if peritoneal signs present.
Thrombolytic therapy success in small number of patients though still considered experimental

34. Literature Review
IBD & thrombosis

35. The incidence rising to 39–41% in postmortem studies.
Thromboembolic (TE) events in (IBD) patients were first described in 1936.
Arch. Intern. Med.1936; 58: 17–31.
Miehsler, W. et al
Large cohort study
Showed  overall incidence of TE events is ~6.5% in both Crohn’s disease and ulcerative colitis patients.
Gut 53: 542–548
The incidence rising to 39–41% in postmortem studies.
Gastroenterology 1968;54:(suppl):819–22

36. Bernstein et al 2001 Population-based study
IBD patients have ~ 3 folds risk of DVT and PE. than general population”
J Clin Gastroenterol 2005;39:27–31

37. Cont….
In IBD, systemic TE events occur mainly in the venous circulation Gut 2004;53: 542–548
NOVACEK et al. reported
Two cases Aortic mural thrombi in IBD patients
Inflamm. Bowel Dis : 430–435. .

38. DVT and PE are the most common types of TE. HOWEVER
Thrombosis are also reported in unusual sites such:
Cerebral V.
Innominate V.
Retinal V.
Hepatic V.
Mesenteric veins.
Ann. N.Y. Acad. Sci ;1051: 166–173.

39. Cont….
TE was also shown to occur at a younger age in IBD patients .
Scand J Gastroenterol 2000;35:619-23
Papa et al , 2005
demonstrated  IBD patients have a greater intima-media thickness of the carotid arteries
a marker of early atherosclerosis.
Aliment Pharmacol Ther 2005;22:839–46.

40. Why Do IBD Patient Develop Thrombosis?
1 – Inflammatory Reaction
Activation of coagulation acts as a constituent of the inflammatory response by directly mediating cytokine responses and some proinflammatory cytokines, such as IL-6, activate coagulation .
Hypofibrinolysis, a prothrombotic condition, is a typical feature of inflammation .
Am J Gastroenterol 2007;102:174–186
2- Related to the Disease itself
TE is a specific feature of IBD .
Gut 2004;53:542-8

41. Cont… Abnormalities of coagulation ↑ Fibrinogen ↑ Factors V, VIII, IX
↑ Fragment 1 + 2, fibrinopeptide A&B
TAT (thrombin antithrombin complex)
↓ Factor XIII/subunit A factor XIII
↓ Protein C, protein S, antithrombin III
↓ TFPI (tissue factor pathway inhibitor)
Abnormalities of platelets
↑ Number, activation, aggregation
Abnormalities of fibrinolysis
↓ tPA (tissue-type plasminogen activator)
↑ PAI (plasminogen activator inhibitor),
TAFI (thrombin-activatable fibrinolyis inhibitor)
↑ D-dimer, FDP (fibrin degradation products),
FgDP (fibrinogen degradation products)
Endothelial abnormalities
↑ Circulating thrombomodulin, ECPR,and von Willebrand factor
↓ Tissue thrombomodulin and EPCR

42. Cont…. Nutritional abnormalities ↑ Homocysteinemia, lipoprotein A
↓ Vitamin B6
Immunological abnormalities
Antibodies:
Antiphospholipid
antiprotein S
antiendothelial cells
anti-tPA

43. Does The Disease Activity Have a Role ?
% Active
# Active
Total # Pts
Author/Year 68 47 69
Talbot, 1996 75 39 52
Jackson, 1997 66 10 15
Guedon, 2001 55 6 11
Minjhout, 2004

44. Cont…. From these data : One third of IBD patient can develop TE
During disease quiescence .

45. Literature Review
IBD & SMV Thrombosis

46. Retrospective review of 545 patients with IBD 6 with MVT; 3 CD; 3 UC
All post surgery,
3 within 60 days of abdominal colectomy,
2 post OLT
1 post terminal ileal resection
Conclusion: MVT is an important clinical consideration in IBD patients, specifically during the perioperative setting .
Hatoum, O J clin Gastro 39, 2005;

47. 83pt. consecutive with total colectomy for IBD (1999-2001)
New post-op abdominal pain
Abdominal CT 4 MVT/2 PVT
Interval 6-90 days, Median 10 days.
“Direct surgical trauma to the middle colic veins, with resulting thrombosis and clot propagation into the SMV and portal vein is likely to be the precipitating factor in a borderline intrinsically hypercoagulable environment ”
Fischera ,A Dis Colon Rectum 46,2003;

48. Incidence of MV thrombosis in IBD
Visceral/PVT
Total TE
Study Type
Author/Year
16% vs. 3-6%
39% vs. 14.5%
100 consecutive autopsies in IBD vs. Control
Graef, 1966
8 patients
2 PVT
1.3%
Review of 7199 patients ( )
Talbot, 1986
6(1.1%) 2 PVT
Not reported
Review of 545 patients
Hautoum, 2005

49. Does Surgery Protect ? Solem et al. 2004 .
Retrospective study of IBD pt. with TE events over 9 yrs
59 UC & 39 CD
16 of UC pt. underwent proctocolectomy 2 (13% )of them develop recurrent thromboembolic event .
Conclusion: Proctocolectomy is not protective of recurrent TE events
Am J Gastroenterol Jan;99(1):97-101

50. Conclusion
Clinical features of thrombosis in inflammatory bowel disease
Overall incidence of thrombosis %
Risk ratio for TE event –3.6
Median time to occurrence of first TE event ~5 years
Two-year mortality following a TE event –25%
Evidence for bowel disease activity at
the time of TE event CD: 60–89%
UC: 45–60%
Prevalence of DVT or PE –87%
Ann. N.Y. Acad. Sci. 2005;1051: 166–173.

51. Thrombosis post op in IBD patient is
Take Home Message
Thrombosis post op in IBD patient is
a Known Complication
With these data shall we
Give therapeutic doses of anticoagulant peri-operatively ?
And if yes for how long ?

52. Thank You