Korean J Gastroenterol.  2010 Oct;56(4):255-259. 10.4166/kjg.2010.56.4.255.

A Case of Inferior Vena Cava Thrombosis and Acute Pancreatitis in a Patient with Ulcerative Colitis

• Shin DH
• Lee KH
• Kim CH
• Kim KH
• Park SH
• Chang DK
• Lee JK
• Lee KT

• KMID: 1718362
• DOI: http://doi.org/10.4166/kjg.2010.56.4.255

Abstract

A 21-year-old man admitted complaining of sudden severe epigastric pain for 1 day. He had been diagnosed as ulcerative colitis (UC) and taking mesalazine for two months. UC was in nearly complete remission at admission. He never drank an alcohol, and serum amylase was 377 IU/L. CT scan showed inferior vena cava (IVC) thrombosis in addition to mild acute pancreatitis. To evaluate the cause of acute pancreatitis and IVC thrombosis, magnetic resonance cholangiopancreatogram (MRCP), endoscopic ultrasonogram (EUS), lower extremity Doppler ultrasonogram (US) and blood test of hypercoagulability including factor V, cardiolipin Ab, protein C, protein S1, antithrombin III, and anti phospholipids antibody were performed. There was no abnormality except mild acute pancreatitis and IVC thrombosis in all the tests. He was recommended to stop taking mesalazine and start having anticoagulation therapy. After all symptoms disappeared and amylase returned normal, rechallenge test with mesalazine was done. Flare-up of abdominal pain occurred and the elevation of serum amylase was observed. Ulcerative colitis came to complete remission with short-term steroid monotherapy. Acute pancreatitis and IVC thrombosis were completely resolved after 3-month anticoagulation therapy with no more mesalazine. We postulated that IVC thrombosis occurred due to hypercoagulable status of UC and intra-abdominal inflammation caused by mesalazine-induced pancreatitis.

Keyword

Ulcerative colitis; Inferior vena cava thrombosis; Acute necrotizing pancreatitis; Mesalazine

MeSH Terms

Acute Disease
Amylases/blood
Anti-Inflammatory Agents, Non-Steroidal/*adverse effects/therapeutic use
Anticoagulants/therapeutic use
Cholangiopancreatography, Magnetic Resonance
Colitis, Ulcerative/complications/*diagnosis/drug therapy
Endosonography
Humans
Male
Mesalamine/*adverse effects/therapeutic use
Pancreatitis/chemically induced/*diagnosis/ultrasonography
Tomography, X-Ray Computed
Ultrasonography, Doppler
*Vena Cava, Inferior/ultrasonography
Venous Thrombosis/complications/*diagnosis/drug therapy
Young Adult

Figure

• 

  Fig. 1. Diffuse hyperemic edema, erythema, superficial ulcers with whitish exudates were observed during an initial colonoscopy (A). After two months, nearly complete remission was observed during admission due to acute pancreatitis (B).

• 

  Fig. 2. Abdominal CT showed diffuse pancreatic swelling, peri-pancreatic infiltration with fluid collection and the fluid was ex-tended to the left anterior pararenal space. However, there was no other remarkable finding on the pancreatobiliary systems.

• 

  Fig. 3. EUS examination and CT scan showed partially occluding thrombus (white arrows) in the IVC.

• 

  Fig. 4. Severe abdominal pain and marked elevation of pancreatic enzyme was developed 1 day after a mesalazine was reade-ministered. His abdominal pain subsided and elevated pancreatic enzymes returned to normal after mesalazine was discontinued.

Reference

1. Miehsler W, Reinisch W, Valic E, et al. Is inflammatory bowel disease an independent and disease specific risk factor for thromboembolism? Gut. 2004; 53:542–548.

2. Solem CA, Loftus EV, Tremaine WJ, Sandborn WJ. Venous thromboembolism in inflammatory bowel disease. Am J Gastroenterol. 2004; 99:97–101.

3. Di Fabio F, Obrand D, Satin R, Gordon PH. Intraabdominal venous and arterial thromboembolism in inflammatory bowel disease. Dis Colon Rectum. 2009; 52:336–342.

4. Niemelä S, Lehtola J, Karttunen T, Lä hde S. Pancreatitis in patients with chronic inflammatory bowel disease. Hepatogastroenterology. 1989; 36:175–177.

5. Pitchumoni CS, Rubin A, Das K. Pancreatitis in inflammatory bowel diseases. J Clin Gastroenterol. 2010; 44:246–253.

6. Inoue H, Shiraki K, Okano H, et al. Acute pancreatitis in patients with ulcerative colitis. Dig Dis Sci. 2005; 50:1064–1067.

7. Lhee HY, Kim BI, Yoo TW, et al. Acute pancreatitis induced by 5-aminosalicylic acid in a patients with ulcerative colitis. Korean J Gastroenterol. 2002; 40:282–285.

8. Kim KH, Kim TN, Jang BI. A case of acute pancreatitis caused by 5-aminosalicylic acid suppositories in a patient with ulcerative colitis. Korean J Gastroenterol. 2007; 50:379–383.

9. Son CN, Lee HL, Joo YW, et al. A case of acute pancreatitis induced by multiple drugs in a patients with ulcerative colitis. Korean J Gastroenterol. 2008; 52:192–195.

10. Heikius B, Niemelä S, Lehtola J, Karttunen TJ. Elevated pancreatic enzymes in inflammatory bowel disease are associated with extensive disease. Am J Gastroenterol. 1999; 94:1062–1069.

11. Fiorentini MT, Fracchia M, Galatola G, Barlotta A, de la Pierre M. Acute pancreatitis during oral 5-aminosalicylic acid therapy. Dig Dis Sci. 1990; 35:1180–1182.

12. Balani AR, Grendell JH. Drug-induced pancreatitis: incidence, management and prevention. Drug Saf. 2008; 31:823–837.

13. Cohen RD. How should we treat severe acute steroid-re-fractory ulcerative colitis? Inflamm Bowel Dis. 2009; 15:150–151.

14. Arpaia G, Bavera PM, Caputo D, et al. Risk of deep venous thrombosis (DVT) in bedridden or wheelchair-bound multiple sclerosis patients: a prospective study. Thromb Res. 2010; 125:315–317.

15. Novacek G, Haumer M, Schima W, et al. Aortic mural thrombi in patients with inflammatory bowel disease: report of two cases and review of the literature. Inflamm Bowel Dis. 2004; 10:430–435.

16. Mutlu B, Ermeydan CM, Enç F, et al. Acute myocardial infarction in a young woman with severe ulcerative colitis. Int J Cardiol. 2002; 83:183–185.

17. Tabibian JH, Lada SJ, Tabibian N. Combined inferior vena cava & renal vein thromosis: Case and synopsis of thromboembolism in inflammatory bowel disease. Medscape J Med. 2008; 10:6.

18. Ma SK, Kim SW, Kim NH, Choi KC. Renal vein and inferior vena cava thrombosis associated with acute pancreatitis. Nephron. 2002; 92:475–477.

19. Jones AL, Ojar D, Redhead D, Proudfoot AT. Case report: Use of an IVC filter in the management of IVC thrombosis occurring as a complication of acute pancreatitis. Clin Radiol. 1998; 53:462–464.

20. Panés J, Esteve M, Cabré E, et al. Comparison of heparin and steroids in the treatment of moderate and severe ulcerative colitis. Gastroenterology. 2000; 119:903–908.