Ulcerative colitis (UC), a member of the family of inflammatory bowel disease (IBD), occurs worldwide. It has an incidence which in recent years has been rising in areas such as Southern Europe and Asia, while remaining relatively constant in Northern Europe and North America

A Repiso

C Dejaco

CA Solem

CN Bernstein

D Ertem

FJ Zijlstra

GT Ho

IA Naess

JA Bargen

LM Jackson

Mark J Phelan

Michael J Regan

MJ Webberly

Mortimer B O'Connor

Neil O'Donovan

RW Talbot

W Miehsler

English

PubMed

Crossref

Inflammatory bowel disease, such as Ulcerative colitis, is a risk factor for recurrent thromboembolic events: a case report

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BioMed CentralCases Journal
ssOpen AcceCase Report
Inflammatory bowel disease, such as Ulcerative colitis, is a risk 
factor for recurrent thromboembolic events: a case report
Mortimer B O'Connor*1, Neil O'Donovan2, Mark J Phelan3,4 and 
Michael J Regan3,4
Address: 1Department of Medicine, South Infirmary - Victoria University Hospital, Old Blackrock Road, Cork, Ireland, 2Department of Radiology, 
South Infirmary - Victoria University Hospital, Old Blackrock Road, Cork, Ireland, 3Arthritis and Osteoporosis Centre, Department of 
Rheumatology, South Infirmary - Victoria University Hospital, Old Blackrock Road, Cork, Ireland and 4The School of Medicine, University College 
Cork, Cork, Ireland
Email: Mortimer B O'Connor* - mortimeroconnor@gmail.com; Neil O'Donovan - odonovan.neil@sivuh.ie; 
Mark J Phelan - mjiphelan@gmail.com; Michael J Regan - regan.michael@sivuh.ie
* Corresponding author    
Abstract
Ulcerative colitis (UC), a member of the family of inflammatory bowel disease (IBD), occurs
worldwide. It has an incidence which in recent years has been rising in areas such as Southern
Europe and Asia, while remaining relatively constant in Northern Europe and North America.
Complications associated with UC include toxic dilatation, perforation, carcinoma and massive
haemorrhage. Extra-intestinal complications also occur and these include Thromboemboli (TE).
Thromboembolic disease has a greater incidence and recurrence rate among patients with IBD
than the general population.
Introduction
Ulcerative colitis (UC), a member of the family of inflam-
matory bowel disease (IBD), occurs worldwide. In the
United Kingdom, the incidence of UC is approximately
10/100,000 with a point prevalence of 200/250,000 [1].
Presentation can occur at any age; however the typical age
is in the third to fourth decade. Men and women tend to
be equally affected. The incidence rates for UC have
remained relatively constant in many regions such as
Northern Europe and North America; however areas
where there was previously a low incidence, such as
Southern Europe and Asia, are showing an increase [1].
Patients with UC can suffer typically from diarrhoea, rec-
tal bleeding and colicky abdominal pain. Symptoms most
frequently present insidiously but may also present
acutely, mimicking an infective aetiology. Its diagnosis is
principally based on clinical, endoscopic and histological
examinations [2].
Increasing data provide evidence of a complex interplay
between components of the innate immune system and
environmental factors, notably the microflora of the intes-
tinal mucosa, in the healthy gut. Unusually smoking
appears to be a protective in both development and exac-
erbations [3].
Complications associated with UC include toxic dilata-
tion, perforation, carcinoma and massive haemorrhage.
These are more common than in Crohn's disease. Extra-
intestinal complications also occur and these include
Published: 29 October 2009
Cases Journal 2009, 2:173 doi:10.1186/1757-1626-2-173
Received: 16 May 2008
Accepted: 29 October 2009
This article is available from: http://www.casesjournal.com/content/2/1/173
© 2009 O'Connor et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Cases Journal 2009, 2:173 http://www.casesjournal.com/content/2/1/173Thromboemboli (TE). The association between TE and
IBD was first described by Bargen and Barker in 1936 [4].
Here we present the case of a patient with UC who has had
recurrent TE.
Case Report
A 61 year old gentleman presented to our Accident and
Emergency department, via General Practitioner referral,
complaining of a left below knee swelling, pain and
superficial thrombophlebitis. The superficial throm-
bophlebitis had been present for seven days while the
swelling and pain was of one day duration. The throm-
bophlebitis was unsuccessfully treated with amoxicillin
250 mg PO TDS daily along with diclofenac sodium 75
mg PO BD for pain relief.
In the week prior to this presentation he suffered an exac-
erbation of UC.
His past history included: Ulcerative colitis (diagnosed
Aug 2005), pulmonary embolism (Oct 2005), Ischaemic
heart disease, myocardial infarction with stenting to the
long anterior descending artery (2003), hypercholestero-
lemia, hypertension and asthma. Medications on admis-
sion included: co-amoxiclav 625 mg PO BD × 4/7,
olsalazine sodium 250 mg PO TDS, aspirin 75 mg PO
OD, bumetanide 2 mg PO OD, rosuvastain 10 mg PO
OD, bisoprolol fumarate 5 mg PO OD, amlodipine 10 mg
PO OD, ramipril 10 mg PO OD, pantoprazole 40 mg PO
OD, ergocalciferol one tablet POBD, salbutamol 100 mcg
2 puffs INH QDS and beclometasone dipropionate 250
mg two puffs INH BD. He had no known drug allergies.
The pulmonary emboli experienced in 2005 were diag-
nosed one week following an exacerbation on UC. At that
presentation the C Reactive protein (CRP) was 102 mg/l,
Erythrocyte sedimentation rate (ESR) 119 mm/h and D-
dimer 2044 ng/ml. All other blood tests, which included
a Factor V Leiden screen, were normal. Computed Tomog-
raphy Pulmonary Angiogram demonstrated multiple
emboli in both lungs.
On examination at his most recent presentation, he had a
hot, swollen and tender left below knee swelling which
was painful to touch on the medial aspect and in the pop-
liteal fossa. The remainder of his examination was nor-
mal.
Investigations showed a raised D-dimer level of 4880 ng/
ml, ESR 47 mm/h, CRP 7.1 mg/l. All other blood results
being normal. A venogram confirmed the presence of a
Deep Vein Thrombosis (DVT).
After a period of four days he was discharged on warfarin
sodium, the dosage as per International normalized ratio
(INR), along with all his medications at admission. The
target INR was between 2 and 3. Follow up in out-patients
clinic for INR level monitoring was arranged.
A venogram of the lower limb showing a filling defect associ-ated with a deep vein th o bo is (red arrow)Figure 2
A venogram of the lower limb showing a filling defect 
associated with a deep vein thrombosis (red arrow).
A Computed Tomography Pulmonary Angiogram showing the filling d fect associated with a pulmo ary embolism (red arrow)Figure 1
A Computed Tomography Pulmonary Angiogram 
showing the filling defect associated with a pulmo-
nary embolism (red arrow).Page 2 of 4
(page number not for citation purposes)
Cases Journal 2009, 2:173 http://www.casesjournal.com/content/2/1/173Discussion
Patients with IBD are at an increased risk of thromboem-
bolic complications by approximately three-fold [5], and
both venous and arterial systems can be involved [6].
Studies using different approaches have revealed conflict-
ing data on the prevalence of TE in IBD, varying between
1.2% and 6.7% in clinical studies and rising to 39% in
postmortem studies [7]. In UC the incidence rate of DVT
has been recorded as 30.0/10,000 person-years and for
Pulmonary Emboli the value is 19.8/10,000. These values
give an incident rate ratio to the general population of 2.8
(95% CI, 2.1 - 3.7) for DVT and 3.6 (95% CI, 2.5 - 5.2) for
PE in patients with UC [8].
Despite the risk of thromboembolic disease (TED) in UC
being recognised in adults, for over seventy years [4], and
also in children [9], the exact pathogenetic mechanisms
are unclear. Fluctuations in the levels of fibrinogen [10],
factor II, V, and VIII [10], and fibrinopeptide A [10] have
all been linked with active IBD. Active IBD has been
recorded concurrently in up to 89% of cases [11]. Throm-
bosis, vasculitis, and tissue infarction have been proposed
as contributing factors in UC and its exacerbations [10].
Furthermore, patients with haemophilia and Von Wille-
brand's disease have been shown to have a lower risk of
IBD [11].
With an over all TE prevalence reported in the region of
3% [12], identification and prevention of such events is
highly desirable as they are an important cause of morbid-
ity and mortality in IBD patients. Among those with IBD
who have a TE the mortality rate is up to 22% at a 1.8 year
follow up [13]. The risk of death for UC patients is highest
in the first months after a TE and then returns toward the
rate for the general population [14]. This is compounded
by the literature stating that the risk of recurrence of a TE
is in the region of 13% [11]. Also of note 11% of TE in
patients with IBD occur in unusual sites such as inominate
veins, intracardiac sites and cerebral sites [11].
The published literature also states that 60% of TEs in UC
occur in those under 50 years of age, which is younger
than the general population [11] and females are more
likely to suffer from TE events than males [14].
For those IBD patients with a TED history the long-term
treatments are: 1. Anticoagulation alone, 2. Anticoagula-
tion with an IVC filter and 3. IVC filter alone. However
before a TE can be treated it must first be identified and
imaging plays a major role in this process. In patients with
UC, imaging for PE involves two modalities: Computed
Tomography Pulmonary Angiogram and ventilation per-
fusion scanning. Regards imaging for DVT in patients with
UC, venography and Doppler ultrasound are the predom-
inant modalities. Figures 1, 2 &3 show radiological imag-
ing on this patient.
Conclusion
TED has a greater incidence among patients with IBD than
the general population.
There is a 13% recurrence risk of a TE in the IBD popula-
tion, while 11% experience their TE in an unusual site
such as an intracardiac site.
A period of exacerbation of IBD is the time of greatest risk
for a TE in a patient with an IBD such as UC.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
MOC interviewed and managed the patient care, reviewed
the radiology and prepared the manuscript. NOD
reviewed the radiology. MJP prepared the manuscript.
A venogram of the lower limb showing a filling defect associ-ated with a deep vein th o bo is (red arrow)Figure 3
A venogram of the lower limb showing a filling defect 
associated with a deep vein thrombosis (red arrow).Page 3 of 4
(page number not for citation purposes)
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MJR interviewed and managed the patient care, and pre-
pared the manuscript.
Acknowledgements
Many thanks to the patient who attended our services for allowing us to 
share (written consent) his experiences in the medical literature.
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Inflammatory bowel disease, such as Ulcerative colitis, is a risk factor for recurrent thromboembolic events: a case report

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