A Case Report of a Patient with Recurrent Pouchitis and Large Pulmonary Emboli

Purpose: We report a case of a 33-year-old woman with a history of ulcerative colitis diagnosed 10 years prior to presentation status post total abdominal colectomy with ileal pouch anal anastomosis (IPAA) 6 years prior to presentation. The patient suffered recurrent severe antibiotic resistant pouchitis shortly after her surgery. Two years ago, a pouchoscopy demonstrated continued pouchitis with more extensive inflammation above the pouch. The patient was started on Azathioprine and responded to a course of steroids and antibiotics. After her endoscopic evaluation, the developed an idiopathic left upper extremity deep vein thrombosis at her IV site and completed 6 months of warfarin therapy. One month prior to presentation, the patient had another episode of severe pouchitis and was treated with antibiotics and a steroid taper. During her taper, the patient presented with dyspnea on exertion. Chest CT scan revealed large bilateral pulmonary emboli (PE) with severe right heart strain, enlargement of the right atrium and main pulmonary artery consistent with pulmonary hypertension. She was treated with enoxaparin and warfarin and discharged home. Our patient appeared to have developed thromboemboli in the setting of two episodes of pouchitis. Hospitalized inflammatory bowel disease (IBD) patients are known to be at increased risk for thromboembolism. The most frequent complication in ulcerative colitis patients after ileal pouch anal anastomosis (IPAA) is pouchitis, a nonspecific inflammation of the ileal pouch reservoir, having a cumulative prevalence of 50%. It is unknown if this inflammatory state increases hypercoagulability. While portal vein thrombi (PVT) have recently been linked to IPAA and patients found with PVT had a higher incidence of postoperative pouchitis, an association with PE has not been described. Hospitalized patients with IBD and pouchitis, such as our patient, must be considered at high risk for thromboembolism and receive appropriate prophylaxis or be considered for long-term anticoagulation regardless of history of thromboembolism.