A 30-year-old man is evaluated after being hospitalized for an acute flare of extensive ulcerative colitis. He reports six to eight bloody bowel movements daily with prominent urgency and lower abdominal cramping for the past 2 weeks. He has been taking prednisone daily for 1 week. His only other medication is mesalamine.
On physical examination, vital signs are normal. Abdominal examination reveals lower abdominal tenderness. The abdomen is not distended and bowel sounds are normal. Blood is seen on digital rectal examination.
Hemoglobin level is 10 g/dL (100 g/L). He remains hemodynamically stable.
Which of the following is the most appropriate venous thromboembolism prophylaxis for this patient?
B. Graduated compression stockings
D. Intermittent pneumatic compression
E. Low-dose warfarin
MKSAP Answer and Critique
The correct answer is C. Heparin. This content is available to MKSAP 18 subscribers as Question 46 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
Subcutaneous heparin is the most appropriate venous thromboembolism (VTE) prophylaxis for this patient. VTE is a common clinical problem and is associated with substantial morbidity and mortality among hospitalized patients. Most medical patients have one or more risk factors for VTE. More than a quarter of patients with undiagnosed and untreated pulmonary embolism (PE) will have a subsequent fatal PE, and between 5% and 10% of all in-hospital deaths are a direct result of PE. VTE is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD); patients with IBD have a three-fold risk for VTE compared to patients without IBD. VTE represents a significant cause of morbidity and mortality in patients with IBD, and risk for VTE is highest at the time of disease flare. Although the incidence of VTE increases with age, the highest relative risk for VTE in IBD is observed in patients younger than 40 years old. Patients with IBD who develop VTE have an increased mortality rate, and the most important risk factor for development of VTE is active IBD. For these reasons, prevention of VTE in patients with IBD is essential. All hospitalized patients with IBD should be given pharmacologic VTE prophylaxis with subcutaneous heparin. Systematic reviews of trials comparing prophylactic low-molecular-weight heparin with unfractionated heparin have not shown a statistically significant difference for mortality or major bleeding events, although there was a nonsignificant trend favoring low-molecular-weight heparin in the prevention of PE.
Mechanical VTE prophylaxis with graduated compression stockings or intermittent pneumatic compression devices is not recommended either with or in place of pharmacologic prophylaxis, although intermittent pneumatic compression has shown some efficacy in surgical patients and may be an option for nonsurgical patients with a contraindication to pharmacologic therapy, such as severe gastrointestinal bleeding. Compression stockings are no more effective than placebo in preventing VTE and are associated with harm in the form of increased incidence of skin breakdown.
Aspirin and low-dose warfarin have no role in VTE prophylaxis for hospitalized medical patients or patients with IBD.
- All hospitalized patients with inflammatory bowel disease should be given pharmacologic venous thromboembolism prophylaxis with subcutaneous heparin.