CASE REPORT TWO CASES OF PERICARDITIS ASSOCIATED WITH INFLAMMATORY BOWEL DISEASE

limits. She was treated with indomethacin and mesalamin and a dramatic improvement was seen in patient’s condi-tion. The causes of cardiac involvement in IBD remain un-clear, but the pericarditis must be recognized as a potential extraintestinal manifestation of IBD. That may be diagnosed before, concomitantly or after the diagnosis of the specific type of inflammatory bowel disease. Between 25% and 36% of patients with either type of IBD will have at least one extraintestinal manifestation. It is seen more frequent-ly in men and in those with ulcerative colitis. This complication is not related to the activity of the bowel disease (1,2,3,4,5,6,8,9,11). The heart involvement responds well to either nonsteroidal anti-inflammatory drugs or to cortico-steroids. Although majority of these cases were interpreted as true extraintestinal manifestations of IBD; a few patients Summary: Extraintestinal manifestations are common complications of inflammatory bowel disease (IBD) whereas the as-sociation of cardiac disease with IBD is rarely reported. Cardiac manifestations may be diagnosed before, concomitantly or after the diagnosis of the specific type of inflammatory bowel disease. Pericarditis and myocarditis are potentially serious complications. This extraintestinal manifestation developed in one patient concomitantly with onset of intestinal disease. One patient had ulcerative colitis (UC), while other had Crohn’s disease (CD). Indomethacin was effective in one and the other patient required prednisone in addition. Chest symptoms in patients with inflammatory bowel disease should be evaluated to exclude myopericardial disease.

appearance of the pericardial effusion. She is currently on a maintenance therapy of mesalamine.

Case 2.
A 31 year-old-woman with seven-year history of ulcerative colitis (UC) was admitted to clinic with chest pain, palpitation and bloody diarrhea. Echocardiography confirmed the presence of a moderate pericardial effusion. Collagen-vascular screenings of antinuclear antibody, rheumatoid factor, and complement levels were within normal limits. Viral serology showed no evidence of recent infection. The chest x-ray and electrocardiogram were within normal limits. She was treated with indomethacin and mesalamin and a dramatic improvement was seen in patient's condition.

Discussion
The causes of cardiac involvement in IBD remain unclear, but the pericarditis must be recognized as a potential extraintestinal manifestation of IBD. That may be diagnosed before, concomitantly or after the diagnosis of the specific type of inflammatory bowel disease. Between 25% and 36% of patients with either type of IBD will have at least one extraintestinal manifestation. It is seen more frequently in men and in those with ulcerative colitis. This complication is not related to the activity of the bowel disease (1,2,3,4,5,6,8,9,11). The heart involvement responds well to either nonsteroidal anti-inflammatory drugs or to corticosteroids. Although majority of these cases were interpreted as true extraintestinal manifestations of IBD; a few patients 43

Bilge Tunc 1 , Levent Filik 2 , Aysel Ulker 1 , Erkan Parlak 1
Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey: Gastroenterology Clinic 1 ; Baskent University, Faculty of Medicine, Ankara, Turkey: Department of Gastroenterology 2 Summary: Extraintestinal manifestations are common complications of inflammatory bowel disease (IBD) whereas the association of cardiac disease with IBD is rarely reported. Cardiac manifestations may be diagnosed before, concomitantly or after the diagnosis of the specific type of inflammatory bowel disease. Pericarditis and myocarditis are potentially serious complications. This extraintestinal manifestation developed in one patient concomitantly with onset of intestinal disease. One patient had ulcerative colitis (UC), while other had Crohn's disease (CD). Indomethacin was effective in one and the other patient required prednisone in addition. Chest symptoms in patients with inflammatory bowel disease should be evaluated to exclude myopericardial disease.

Key words: Pericarditis; Ulcerative colitis; Crohn's disease
were considered to develop cardiac complications as a side effect of treatment (sulfasalazine, mesalamine, and azathioprine). Pericarditis usually starts together with a relapse of the bowel symptoms, or may be the initial manifestation of IBD. Most cases of pericarditis are associated with colonic involvement in both common types of IBD, nevertheless the incidence of pericarditis is slightly higher in UC (2,3,4,6,8,9,11). In the specific setting of the two cases reported, pericarditis was considered as an extraintestinal manifestation of IBD. Because both had not used mesalamine, sulfasalasine or other medication soon before diagosis of pericarditis. Accordingly, treatment with 5-aminosalicylic acid (5-ASA) was never stopped and pericarditis has not relapsed during follow-up. Clinical presentations range from asymptomatic pericardial effusions to cardiac tamponade. In the literature, there is a reported case of constrictive pericarditis related to IBD or its treatment (9). Although that patient may have had IBD-associated constrictive pericarditis, her mesalamine use raises the possibility of a druginduced constrictive pericarditis. Additionally, in drug induced pericarditis omission of the 5-ASA therapy was sufficient in a few cases. Pericarditis and myocarditis are rare, but potentially serious complications because there was a few fatal cases (with myocarditis). Both sulfasalazine and the aminosalicylates have been known to cause this complication. Pericarditis as a side effect induced by sulfasalazine or 5-aminosalicylic acid, drugs used in the therapy of these diseases, was first described 15 years ago. Kupferschmidt H et al. reported that pericarditis was not associated with high activity of bowel disease in all cases (7). In the literature, there is also a reported case of acute pericarditis caused by azathioprine. It is believed that pericarditis is yet another potential manifestation of hypersensitivity to this drug (12). Infliximab, a chimeric antibody targeting tumour necrosis factor is believed to cause cardiac adverse effects but it is still controversial (13). The decision whether pericarditis is a symptom of the underlying disease or a side effect of the drug used for the treatment of the disease is not always easy. Conversely occult inflammatory bowel disease should be excluded when investigating any patient with pericarditis of obscure origin. In conclusion, during the follow-up of patients with IBD, care must be taken concerning extraintestinal cardiac manifestation.