St. Joseph Medical Center Paterson, NJ, United States
Sherif Roman, MD1, Nader Mekheal, MD2, Isabel Mora, BS, MD3, Erinie Mekheal, MD1, Neslyne Augustin, MD3, Gabriel Melki, MD4, Yana Cavanagh, MD5, Monisha Singhal, MD4 1St. Joseph Medical Center, Paterson, NJ; 2St. Joseph University Medical Center, Wayne, NJ; 3St. Joseph's Regional Medical Center, Paterson, NJ; 4St. Joseph's University Medical Center, Paterson, NJ; 5St. Joseph's Hospital and Medical Center, Paterson, NJ
Introduction: Crohn's disease (CD) is a chronic inflammatory condition that can affect any part of the GI tract. Patients with CD have an increased risk of vascular complications, both venous and arterial. Arterial thromboembolism is a rare complication of CD which can lead to significant morbidity and mortality. We present a case of CD complicated with DVT and recurrent extensive arterial occlusion.
Case Description/Methods: A 59-year-old male with a history of CD and RLE DVT presented with worsening right foot ulcers and LLQ abdominal pain of 1-week duration. All vitals were normal, and physical exam was positive for LLQ abdominal tenderness, and the right foot exam revealed diminished pulses with necrotic ulcers. Labs revealed anemia, leukocytosis, thrombocytosis and elevated inflammatory markers.
Bilateral LE venous and arterial duplexes revealed right posterior tibial, peroneal and dorsalis pedis arteries stenosis. For the concern of bleeding may be a cause of patient’s anemia, EGD was done and revealed non-bleeding gastric and duodenal ulcers, while colonoscopy showed ileitis and colitis secondary to CD with skip ulcerations and erythema (Figure). The patient had balloon angioplasty and laser atherectomy of multiple lower extremity arteries with restoration of his peripheral pulses and was eventually discharged.
Two weeks later, the patient presented with right foot pain and bloody diarrhea. CT angiography revealed significant occlusion of right lower extremity vessels (Figure). He underwent another angioplasty and mechanical thrombectomy with amputation of three toes. The patient was initiated on steroids for acute exacerbation of CD. Again, he improved and was discharged with outpatient follow-up.
Discussion: Arterial thrombosis is a rare yet serious complication of CD. The exact mechanism of this process is not well understood. Chronic inflammation in the intestinal tract and systemic circulation leads to vascular endothelial dysfunction associated with a hypercoagulable state and development of atherosclerosis. Patients with active disease are at increased risk of thromboembolic complications and significant morbidity. Corticosteroids are effective as a short-term therapy for acute flares of CD. Anticoagulation therapy and duration present a significant safety concern as many of these patients may have ongoing rectal bleeding. This case highlights the importance of considering thromboembolic events in patients with CD presenting with lower extremity pain.
Figure: Ascending colon (A), terminal ileum (B) showing mucosal inflammatory changes secondary to Crohn's disease, with ileitis and colitis characterized by skip ulcerations and erythema. (C) CT angiography revealed significant occlusion of right lower extremity vessels.
Disclosures: Sherif Roman indicated no relevant financial relationships. Nader Mekheal indicated no relevant financial relationships. Isabel Mora indicated no relevant financial relationships. Erinie Mekheal indicated no relevant financial relationships. Neslyne Augustin indicated no relevant financial relationships. Gabriel Melki indicated no relevant financial relationships. Yana Cavanagh indicated no relevant financial relationships. Monisha Singhal indicated no relevant financial relationships.
Sherif Roman, MD1, Nader Mekheal, MD2, Isabel Mora, BS, MD3, Erinie Mekheal, MD1, Neslyne Augustin, MD3, Gabriel Melki, MD4, Yana Cavanagh, MD5, Monisha Singhal, MD4. P1674 - Crohn's Flare Can Be a Vascular Nightmare: A Case of Crohn’s Disease Complicated With Recurrent Vascular Occlusion, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.