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academies
Archives of General Internal Medicine | Volume 2
&
April 04-05, 2018 | Miami, USA
International Conference on
Internal Medicine & Practice and Primary Care
International Meeting on
Breast Pathology & Cancer Diagnosis
Ulcerative colitis leading to repeated portal vein thrombosis despite anticoagulation
Yasmine Elamir
and
William Grist
RWJ Barnabas Health, USA
P
atient is a 33-year-old Puerto Rican female with past
medical history significant for pulmonary embolism,
portal vein thrombosis on Coumadin, untreated ulcerative
colitis, peptic ulcer disease, who presented with one
episode of syncope and dark red stools with duration of
one day. On review of systems, the patient also complained
of nausea, dizziness, and non-radiating “squeezing” upper
abdominal pain. Patient had fatigue and when she arose
from bed the day of admission, she found herself lying
on the floor with residual pain on the back of her head
and left side of her body. Patient was unsure how she fell
or how long she lost consciousness. Patient had one prior
episode of severe bleeding in the past four-five years ago
after banding procedure. Patient denies pain or straining
with bowel movements, NSAID use, fevers, chills, weight
loss, and pruritus, use of supplements or herbal remedies,
recent travel, sick contacts, history of right upper quadrant
abdominal pain, emesis or rashes. Vitals on admission were
pulse 89, respiratory rate 20, and blood pressure: 109/59,
PO2 99%. Physical exam was notable for minor orthostatic
hypotension and a soft non-distended abdomen with mild
tenderness to deep palpation in the epigastric area with
no rigidity, guarding, or masses. Patient was admitted to
the ICU when systolic blood pressure dropped to the 70’s
with tachycardia in the 100-110s. Hemoglobin was found
to be 5.3, prothrombin of 25.5, international normalized
ratio of 2.39, and partial thomboplastin time of 26.4.
Patient was then given three liters normal saline and six
units total of packed red blood cells with improvement of
symptoms. Patient was started on Protonix drip. Endoscopy
was performed which showed grade II esophageal varices,
gastritis and gastric erosion with no active bleeding. Patient
was then started on an octreotide drip. Patient’s ulcerative
colitis was diagnosed twelve years ago, but patient admits
to non-compliance after many attempted trials of therapy
without alleviation of symptoms. Patient continued to
have persistent symptoms including intermittent diarrhea,
cramping abdominal pain. Patient also had a negative
coagulopathic work up including Factor V Leiden deficiency,
prothrombin gene mutation, and Protein C and S deficiency.
Last colonoscopy was in August 2016, which showed diffuse
inflammation and polyps. Cirrhosis workup was obtained
to search for cause of increased portal venous pressure
and therefor varices. Magnetic resonance imaging of the
abdomen findings unexpectedly revealed thrombosis of
the portal vein with cavernous transformation. Patient
was then restarted on Coumadin which had been stopped
due to bleeding and was patient was bridged with heparin
until patient achieved therapeutic internationalized ratio
levels. After discussing at length with patient’s hematologist
and gastroenterologist the conclusion was reached that
her suspected herpcoagulability was due to uncontrolled
ulcerative colitis. This case illustrates the importance of
always considering portal vein thrombosis as part of initial
differential in someone with even minimal abdominal pain
who is hyercoagulable. Most notably it helps signify the
importance of treating uncontrolled inflammatory bowel
disease as it can cause hypercoagulability.
e:
yelamir16@gmail.com