View Abstract

A7025 - Pulmonary Embolism and Diverticular Bleeding: A Missed Diagnosis and Clinical Dilemma
Author Block: A. Chowdhury1, F. Berenyi2, B. Fernandes3; 1St Vincent’s Hospital, Sydney, Australia, 2Royal Melbourne Hospital, Melbourne, Australia, 3Royal Prince Alfred Hospital, Sydney, Australia.
Introduction: The synchronous presentation of a patient with PE and active gastrointestinal (GI) bleeding is uncommon and presents a therapeutic dilemma. Both conditions are potentially life-threatening and require opposing management strategies. We report the rare case of bilateral pulmonary embolism in a patient with active diverticular bleeding.
Case Report: A sixty-nine year old female was admitted for active per rectal bleeding secondary to confirmed diverticular disease extending throughout the colon. She was noted to have ongoing sinus tachycardia up to 120 bpm, which was originally attributed to intravascular depletion secondary to haemorrhage. She denied any chest pain, dyspnoea, cough, wheeze, haemoptysis or calf pain or swelling, with no past or family history of thromboembolism. She was otherwise haemodynamically stable with no postural hypotension, remained afebrile with no clinical features suggestive of oxygenation problems or right ventricular strain. After a positive D-dimer, a CT Pulmonary Angiogram revealed an acute PE in the bilateral basal segmental and right middle lobe segment branches. In the context of her ongoing bleeding, she was not commenced on any anticoagulation and was instead planned for a total colectomy and formation end ileostomy. An Inferior Vena Cava (IVC) filter was inserted in the interim whilst awaiting her operation. Post-operatively she was commenced on a therapeutic dose of subcutaneous Enoxaparin. She was later changed to Apixaban following an IVC filter removal.
Discussion: Anticoagulation is integral to the treatment of thromboembolism globally, however other options include thrombolysis and catheter based or surgical embolectomy. In patients with massive pulmonary emboli, thrombolysis is the first line management, particularly when cardiac arrest is imminent. Low Molecular Weight Heparin is recommended as the first line anticoagulation for non-massive pulmonary emboli. Unfractionated heparin is only considered as a first dose bolus, when reversal may be required or in massive PE. In intermediate and high probability patients, heparin may be administered prior to confirming diagnosis. Oral anticoagulation can be commenced following radiological confirmation, aiming for an international normalised ratio (INR) between 2-3. An Inferior Vena Cava (IVC) filter is recommended patients to prevent the establishment of pulmonary emboli from deep vein thrombi, particularly where anticoagulation has been unsuccessful or when anticoagulation is contraindicated. There is a dearth of case reports in the literature that discuss actively haemorrhaging patients with thromboembolism. Further prospective studies will be beneficial to ascertain the best management pathway for this treatment dilemma.