The Risk of Upper Gastrointestinal Bleeding and Coagulopathy in IBD Patients with Cirrhosis

doi:10.21203/rs.3.rs-4266765/v1

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The Risk of Upper Gastrointestinal Bleeding and Coagulopathy in IBD Patients with Cirrhosis

https://doi.org/10.21203/rs.3.rs-4266765/v1

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Introduction: In cirrhotic patients, systemic inflammation disrupts the delicate balance of hemostatic variables, akin to what occurs in inflammatory bowel disease (IBD), potentially resulting in a shift towards either a procoagulant or anticoagulant state. Current guidelines advocating for anticoagulation use in hospitalized IBD patients lack strong evidence, and there is a notable absence of guidelines tailored specifically for those with underlying cirrhosis. This study seeks to explore how underlying cirrhosis impacts the risk of coagulopathy and gastrointestinal bleeding in IBD patients, aiming to provide insights for making well-informed decisions regarding anticoagulation therapy.

Patients and Methods: Utilizing the National Inpatient Sample database, we identified hospitalizations with a primary or secondary diagnosis of IBD and cirrhosis based on ICD-10 codes from 2016 to 2020. This retrospective cohort study excluded pregnant women, patients requiring chronic anticoagulation, and those with malignancies to mitigate confounding. A meticulous 1:1 matching for significant comorbidities between cohorts was performed. Primary outcome studied is incidence of upper GI bleed, secondary outcomes include mortality, venous thromboembolism, length of stay.

Results: Of the total IBD patients, 5,375 had cirrhosis. Following 1:1 matching, both the cirrhotic and non-cirrhotic groups comprised 4,195 patients. In the matched cohorts, IBD patients with cirrhosis exhibited an increased risk of upper gastrointestinal bleeding (RR-3.60, p < 0.0001) and mortality (RR-2.78, p < 0.002), while there was no significant difference in venous thromboembolism (VTE) events (RR-1.70, p-0.446). Length of stay did not significantly differ between the groups.

Conclusion: This study uncovers a markedly elevated incidence of upper gastrointestinal bleeding among IBD patients with cirrhosis. Our results underscore the importance of diligent monitoring and close follow-up for individuals with both conditions. The efficacy of anticoagulation in preventing thromboembolic events remains uncertain in these patients, given the heightened propensity for bleeding observed in our study among those with IBD and cirrhosis. Future randomized clinical trials are warranted to investigate the effect of anticoagulation in this population, taking into account the varying severity of underlying cirrhosis.

Cirrhosis

coagulopathy

Inflammatory bowel disease

venous thromboembolism

upper gastrointestinal bleeding

Inflammatory bowel disease (IBD) represents a persistent inflammatory condition affecting the gastrointestinal tract, manifesting as Crohn's disease or ulcerative colitis. This condition arises in genetically predisposed individuals due to an amplified immune reaction to typically benign triggers like food and gut microbiota [1]. Being a pro-inflammatory condition, IBD increases the susceptibility to both arterial and venous thrombosis through analogous prothrombotic mechanisms. These mechanisms involve the activation of coagulation, partially mediated by the compromised intestinal barrier and the release of bacterial components [2]. In comparison to the general population, individuals with IBD face a threefold higher risk of venous thromboembolism (VTE) [3]. Previous studies have revealed that the presence of cirrhosis independently adversely affects outcomes in hospitalized IBD patients, manifesting as heightened in-hospital mortality and increased admission costs. Coagulopathy in cirrhosis is intricate due to the liver's role in clotting factor production [4]. Cirrhotic patients may transition to a procoagulant state in the presence of systemic inflammation, resulting in a higher risk of VTE compared to those without liver disease. There is paucity of data on VTE or hemorrhagic events in IBD patients with underlying cirrhosis [4,5]. The current guidelines regarding anticoagulation in IBD patients are based on international consensus statements (2021) and Canadian association of gastroenterology (2014) with weak levels of evidence which indicates a need for further studies [6,7]. They broadly suggest that thromboprophylaxis should be administered to IBD patients during hospitalization for “any cause”. This report also suggests that thromboprophylaxis does not elevate the risk of gastrointestinal bleeding in IBD patients with active disease (evidence level 2+) [7]. While these statements are supported by limited data, there is a notable absence of studies examining outcomes in IBD patients with underlying cirrhosis. Understanding the risk of VTE or gastrointestinal bleeding in these complex cases is crucial to improve outcomes and prevent harm. The cirrhotics with IBD may require closer monitoring including screening esophagogastroduodenoscopies (EGDs) to prevent adverse events from anticoagulation and hemodynamic fluctuations. Our study aims to address this gap in knowledge and contribute to a higher level of evidence, offering insights to refine consensus statements and guide management in patients with both cirrhosis and IBD.

We conducted a retrospective review of the Nationwide Inpatient Sample (NIS) database spanning from 2016 to 2020. The NIS is a comprehensive inpatient hospital database derived from hospitals' billing data, covering approximately 97% of the United States (US) population. It comprises a 20% stratified sample of participating hospitals across 48 states and includes patient and hospital-level discharge information. Each discharge is coded with one primary and multiple secondary diagnoses using the International Classification of Diseases, 9th and 10th Revision, Clinical Modification (ICD-10-CM) coding system. The NIS is part of the Healthcare Cost and Utilization Project under the Agency for Healthcare Research and Quality.

We included patients with a primary diagnosis of inflammatory bowel disease (IBD) without active flare and examined baseline characteristics and outcomes in patients with and without underlying cirrhosis. Employing 1:1 matching, each patient with IBD and cirrhosis was matched against a patient with IBD without cirrhosis based on age, sex, ethnicity, and comorbidities, including coronary artery disease (CAD), diabetes mellitus (DM), hypertension (HTN), and chronic kidney disease (CKD). We excluded patients requiring chronic anticoagulation, such as those with a history of deep vein thrombosis (DVT) or pulmonary embolism (PE), mechanical heart valve, atrial fibrillation, and those predisposed to a procoagulant state like malignancy or pregnancy. The primary outcome studied was the incidence of upper GI bleed, with secondary outcomes including venous thromboembolism (VTE), mortality, and hospital length of stay. Statistical analyses were performed using linear and logistic regression models for continuous and categorical variables, respectively, to obtain standard errors, p-values, and 95% confidence intervals for each predictor variable.

Baseline Characteristics and Comorbidities:

We identified a total of 277,280 hospitalized patients with IBD between 2016 and 2020, among whom 5,375 had both IBD and cirrhosis. Patients with concurrent IBD and cirrhosis were older, with a mean age of 58 compared to 51 in those with IBD alone. After 1:1 matching, both groups were similar in gender, race, age, and comorbidities, including CAD, CKD, hypertension, and diabetes. In the unmatched cohorts, patients with IBD alone had a higher proportion of females (59% vs. 52%) and a racial distribution of Whites (75.9%), Blacks (11.6%), Hispanics (5.7%), Asian (1.1%), Native American (0.3%), and other (2.1%), similar to patients with IBD and cirrhosis. Baseline comorbidities were more prevalent in patients with cirrhosis, including type 2 DM (30.1% vs. 13.1%, p < 0.05), hypertension (35.6% vs. 27.5%, p < 0.05), CKD (22.8% vs. 12.4%, p < 0.05), and CAD (14% vs. 12%, p = 0.089). In the matched sample, racial distribution consisted of Whites (85.5%), Blacks (5.3%), Hispanics (6.4%), Asian (0.7%), Native American (0.3%), and other (1.5%), with similar comorbidity rates in each group (Table 1).

In-Hospital Outcomes:

Mortality: In both matched cohorts, inpatient mortality was higher in patients with IBD and cirrhosis compared to those without cirrhosis. The mortality rates were 3.2% vs. 0.7% (RR = 2.78, p < 0.05) (Table 2), (Fig. 1).

Upper GI Bleeding: The risk of upper GI bleed, including variceal and nonvariceal bleed, was significantly higher in patients with IBD and cirrhosis compared to those without cirrhosis. The risk was 7.8% vs. 1.3% (RR = 3.6, p < 0.05) (Table 2), (Fig. 2).

Venous Thromboembolism (VTE): The risk of VTE events in both matched and unmatched cohorts was noted to be discordant; however, neither showed statistical significance. The risk of VTE was slightly elevated in the IBD with cirrhosis group (also not statistically significant) (1.9% vs. 1.4%, RR = 1.7, p = 0.44) (Table 2), (Fig. 3).

Hospital Length of Stay: The total length of stay was higher in the unmatched cohort among patients with IBD and cirrhosis compared to those without cirrhosis (6.07 days vs. 5.28, p < 0.05); however, after matching, this difference was no longer statistically significant (5.92 days vs. 5.26, p = 0.116) (Table 2), (Fig. 4).

Table 1

Baseline characteristics
	BEFORE MATCHING				AFTER MATCHING
	IBD without cirrhosis ((N = 271,905)	IBD with cirrhosis (N = 5,375)	P-value		IBD without cirrhosis (N = 4,195)	IBD with cirrhosis (N = 4,195)	P-value
Demographics				Demographics
Age (mean, std. dev.)	51.95, 46.11	58.12, 30.64	< .0001	Age group			1.00
				19–32	205(4.8%)	205
				33–46	680(16.2%)	680
				47–59	1,425(33.9%)	1,425
				60–72	1,490(35.5%)	1,490
				over 73	395(9.4%)	395
Sex- M/F (%)	160,940 (59.1%)	2,800(52%)	< .0001	Sex- M/F (%)	2,165(51.6%)	2,165	1.00
Ethnicity			< .0001	Ethnicity			1.00
White (%)	206,530 (75.9%)	4,510(83.9%)		White (%)	3,590(85.5%)	3,590
Black	31,735(11.6%)	375(6.9%)		Black	225(5.3%)	225
Hispanic	15,640(5.7%)	310(5.7%)		Hispanic	270(6.4%)	270
Asian PI	3,260(1.1%)	55(1.02%)		Asian PI	30(0.7%)	30
Native American	860(0.3%)	35(0.6%)		Native American	15(0.3%)	15
Other	5,805(2.1%)	115(2.1%)		Other	66(1.5%)	66
Diagnoses(%)				Diagnoses(%)
CAD	32,545(11.9%)	755(14%)	0.0895	CAD	425(10.1%)	425	1.00
DM2	35,810(13.17%)	1,620(30.1%)	< .0001	DM2	1,220(29.1%)	1,220	1.00
HTN	75,000(27.5%)	1,915(35.6%)	< .0001	HTN	1,480(35.2%)	1,480	1.00
CKD	33,875 (12.4%)	1,230(22.8%)	< .0001	CKD	870(20.7%)	870	1.00

Table 1: Baseline Characteristics Before and After Matching: This table presents the baseline characteristics of patients with Inflammatory Bowel Disease (IBD) both before and after matching, with and without cirrhosis. The data are weighted to provide a representative sample. Demographics: Age (mean and standard deviation) and age group distribution, Sex distribution (% male and female), Ethnicity distribution (% White, Black, Hispanic, Asian Pacific Islander, Native American, Other) and Prevalence of comorbidities such as Coronary Artery Disease (CAD), Type 2 Diabetes Mellitus (DM2), Hypertension (HTN), and Chronic Kidney Disease (CKD). Abbreviations: IBD - Inflammatory Bowel Disease; CAD - Coronary Artery Disease; DM2 - Type 2 Diabetes Mellitus; HTN - Hypertension; CKD - Chronic Kidney Disease; std. dev. - standard deviation; PI - Pacific Islander. P-values indicate statistical significance levels, with values < 0.05 considered statistically significant."

Table 2

Outcomes (data are weighted)
MATCHED DATA
	IBD without cirrhosis (%)	IBD with cirrhosis	Relative risk with CI	P- value
VTE (Acute PE/DVT)	60 (1.4%)	80 (1.9%)	1.70 (0.760–1.80)	0.446
GI bleed	55 (1.3%)	330 (7.8%)	3.60 (2.08–6.27)	< .0001
Mortality	30 (0.7%)	135 (3.2%)	2.78 (1.35–5.75)	0.002
Hospital LOS (mean, std. dev.)	5.26, 23.98	5.92, 12.970	n/a	0.1163

Table 2: This table illustrates the outcomes associated with Inflammatory Bowel Disease (IBD) with and without cirrhosis with data presented as percentages. The data are weighted to ensure representativeness. The following outcomes are included: 1. VTE (Venous Thromboembolism), encompassing Acute Pulmonary Embolism (PE) and Deep Vein Thrombosis (DVT) 2. GI bleed (Gastrointestinal bleed) 3. Mortality rate 4. Hospital LOS (Length of Stay), represented by mean and standard deviation.For each outcome, the RR (Relative Risk) with confidence intervals (CI) and corresponding p-values are provided, indicating statistical significance levels.

Inflammatory bowel disease (IBD) has been associated with an elevated risk of thrombosis, attributed to an upsurge in tissue factor, plasminogen activator inhibitor-1, and platelet count, along with a reduction in tissue plasminogen activator levels [8]. Additionally, mesenteric vein thrombosis and portal vein thrombosis have demonstrated higher prevalence in individuals with IBD compared to those without IBD [9]. This evidence underscores the imperative need for anticoagulant administration in IBD patients to mitigate the recurrence of thrombosis. Studies indicate that the timely initiation of thromboprophylaxis within 24 hours of admission reduces the likelihood of venous thromboembolism (VTE) by half [10]. Recognizing this, international consensus guidelines recommend administering thromboprophylaxis to hospitalized IBD patients for "any cause" [7]. However, the safety and benefits of thromboprophylaxis in IBD patients with cirrhosis remain uncertain, as systemic inflammation in cirrhosis, while promoting a procoagulant state, is also associated with an elevated risk of upper gastrointestinal (GI) bleeding [11]. Hence, the rationale for thromboprophylaxis in admitted IBD patients with cirrhosis warrants further investigation.

In our study, the incidence of upper GI bleeding is significantly elevated in patients with both cirrhosis and IBD compared to those with IBD alone. In cirrhosis, the risk of upper GI hemorrhage from non-variceal causes, predominantly ulcers, contributes to 30–40% of cases, with varices accounting for the remainder [5].

In liver disease alone, upper GI bleeding is influenced by various interacting factors commonly encountered in decompensated cirrhosis. These factors encompass portal hypertension, endothelial dysfunction characterized by the hyperdynamic state, release of endogenous heparinoids especially during infection, renal failure leading to volume overload, vascular congestion, uremic platelet dysfunction, alterations in pro- and anticoagulant factors associated with cirrhosis, dysfibrinogenemia, changes in phospholipid metabolism, and thrombocytopenia [12]. The increased risk of upper GI bleeding in cirrhosis is not only due to higher portal hypertension causing variceal bleeding but also because cirrhotic patients are prone to non-variceal bleeding from ulcers due to coagulation disorders and thrombocytopenia. Despite similar frequencies of gastroduodenal ulcers compared to non-cirrhotic individuals, cirrhotic patients exhibit a higher presence of "high-risk" bleeding characteristics at the ulcer base (53% vs. 44%), necessitating more frequent endoscopic intervention (100% vs. 74%) [13]. Some studies also suggest that while patients with liver disease may encounter bleeding complications, a significant portion of these bleeds are not associated with hemostatic failure. Rather, they arise due to portal hypertension or mechanical vessel injury, which could occur due to accidental vessel puncture during invasive procedures [14].

Although IBD patients may occasionally report symptoms of upper GI hemorrhage, data indicate that there is no significant association between IBD and upper GI hemorrhage [15]. Consequently, cirrhosis emerges as a primary contributing factor to the heightened incidence of upper GI hemorrhage in IBD patients with cirrhosis in our study.

Our investigation further reveals elevated mortality rates in patients with both cirrhosis and IBD compared to those with IBD alone. There is minimal data found on the impact of cirrhosis on the mortality of patients with IBD. However, when studied separately, the all-cause mortality for patients with IBD alone was 1.16 whereas the all-cause mortality rate was found to be six times higher in patients with compensated cirrhosis and about 10 times higher in those with decompensated cirrhosis in another study [16],[13]. The relative risk is higher in the matched sample, with a hazard ratio of approximately 3.0 in the matched controls, emphasizing the impact of cirrhosis on the mortality of IBD patients. In a recent study of notable indicators of mortality at the individual level, specific complications and accompanying conditions related to cirrhosis were. These included the clinical manifestation of bleeding, confirmed portal hypertension, hepatitis C infection, alcoholic liver disease, and the APR-DRG risk score, all of which demonstrated significance as predictors of mortality (all, P ≤ 0.005) [17]. As suggested by the existing literature and the results of our study, we propose that the mortality risk in IBD is exacerbated by the presence of cirrhosis of varying severity and accompanied by various complications.

Notably, the incidence of VTE does not differ significantly between the two groups in our study. In cirrhosis alone, several suggested mechanisms indicate the overcoming of the anticoagulant effect, resulting in hypercoagulability: Thrombocytopenia, stemming from splenic sequestration and decreased TPO, is offset by increased vWF. Additionally, liver-derived procoagulant factors decrease, while concomitantly diminished anticoagulant factors possibly contribute to a hypercoagulable state [18]. Meanwhile, thromboembolism in IBD appears multifactorial, largely due to coagulation activation and platelet aggregation during systemic inflammation [19]. We hypothesize that deficiencies in coagulation factors and platelets may counterbalance the additive procoagulant effect of cirrhosis in patients with IBD. Furthermore, studies indicate that as cirrhosis progresses, there is incremental resistance to the native anticoagulation system, contributing to a relative hypercoagulable state [20]. Hence, further research is necessary to elucidate the role of various stages of cirrhosis in coagulopathy among patients with IBD [20].

Regarding the length of hospital stay, our study reveals no statistically significant difference between matched cohorts of IBD and IBD with cirrhosis. While the mean duration of hospitalization in US adults with chronic liver disease is reported to be 6.3 days, the median length of stay is 4 days in patients with IBD [11, 21]. Our findings suggest that the presence of cirrhosis does not significantly prolong the length of hospital stay in patients with IBD.

Our study stands out as it explores novel territory, delving into the correlation between IBD and cirrhosis and its influence on patient outcomes, particularly regarding coagulopathy manifesting as GI bleeding. We aim to challenge the reliability of existing consensus guidelines regarding the use of anticoagulation in patients with IBD who also have underlying cirrhosis. By harnessing a comprehensive database like the NIS, we bolstered our study with a substantial sample size, thus augmenting its statistical power. Additionally, employing a 1:1 matching strategy enabled us to minimize bias in our observational study.

Despite the novel insights and strengths of our study, several limitations must be acknowledged. Firstly, the retrospective nature of the study and reliance on the National Inpatient Sample (NIS) hinder our ability to establish causation between risk factors and outcomes. Additionally, the inability to stratify outcomes based on the stages of cirrhosis is a notable limitation, as this factor could substantially impact results. These limitations underscore the need for further prospective studies with more detailed data collection methods to better elucidate the relationships

COI Statement:

The authors of this manuscript do not have any conflicts of interest to disclose

Author Contribution

Medha Rajamanuri- Literature search, manuscript writingSreeram pannala- Data illustrationAnirudh Danduboyina- assisted with discussion writingSophia Dar- Assisted with manuscript editingSteve Scaife- Data analysisHafiz Muhammad Sharjeel Arshad- Manuscript editing

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No competing interests reported.

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The Risk of Upper Gastrointestinal Bleeding and Coagulopathy in IBD Patients with Cirrhosis

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Baseline Characteristics and Comorbidities:

In-Hospital Outcomes:

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