A different therapeutic approach in patients with severe ulcerative colitis: hyperbaric oxygen treatment. (Letters to the Editor).

To the Editor: Hyperbaric oxygen treatment (HBOT) has been used in patients with some diseases of the gastrointestinal system, such as radiation enterocolitis, CD, and experimental colitis; however, the experience with HBOT in patients with ulcerative colitis (UC) is limited. (1,2) We present a case of clinical remission after HBOT in a patient with UC who did not respond to treatment with 5-amino salicylic acid, methylprednisolone, and azathioprine.

A 52-year-old woman with relapsing UC was admitted because of a 3-month history of bloody diarrhea with mucus, abdominal pain, fatigue, and loss of appetite. She had diarrhea (16-18 bowel movements/d), tenesmus, and macroscopic bleeding. Her first laboratory workup revealed anemia and thrombopenia. Albumin was 2.9 g/dl, serum iron was 26 [micro]g/dl, and ferritin was 5 ng/ml. A colonoscopic examination revealed left-sided UC with Grade IV endoscopic activity (Truelove scale). (3) The histopathologic findings supported the clinical and endoscopic findings. The stool cultures, stool microscopy, and tests for Clostridium difficile were negative. Oral mesalamine 4 g/d and methyl prednisolone 40 mg/d were started. The patient became asymptomatic within 2 weeks. Corticosteroids were gradually tapered and then stopped within 4 weeks.

A colonoscopy performed 4 months after the cessation of prednisolone was completely normal. The mesalamine dose was decreased gradually to 1.5 mg/d thereafter. Within 4 weeks, the patient's symptoms recurred with the same degree of severity as the first attack. The mesalamine dose was increased to 4 mg/d. Methylprednisolone 40 mg/d was reinitiated. There was no response to this treatment at 3 weeks. Azathioprine 50 mg tid was added while the steroids were tapered. At the end of the 31st week, the patient's symptoms were the same, with almost no response.

At this stage, HBOT with 100% oxygen at 2.0 atm absolute for 120 min/d was initiated. HBOT was administered in a double-lock multiplace chamber for 35 days. In the second week of HBOT, the patient's diarrhea and rectal bleeding decreased and her abdominal pain was remarkably improved. Twenty days after the initiation of HBOT, the patient was asymptomatic, and she was discharged to home to continue HBOT on an outpatient basis. Mesalamine and azathioprine at the same dosages were continued during and after HBOT. Despite clinical remission, the patient's endoscopic activity in a colonoscopy performed after the cessation of HBOT was Grade II. More than 6 months after the cessation of HBOT, the patient was still in remission.

In recent years, there have been reports about heparin as a therapeutic option in patients with severe UC in accordance with suggestions that microthromboembolism may play a role in the etiopathogenesis of UC. (4,5) In light of the fact that the success of heparin has been attributed to its effects on colonic microcirculation, the application of HBOT in these patients seems reasonable. With this therapeutic concept in mind, HBOT was tried previously with successful results in a patient with toxic megacolon. (1) Clinical remission that lasted more than 2 months with the use of HBOT also was reported recently in a patient with severe UC refractory to medical treatment. (2) Although clinical remission was achieved in the patient, there was a relatively small decrease in the endoscopic severity of the disease. We also were able to induce clinical remission in our case, but the decrease in endoscopic activity was smaller. The difference in our case is that the clinical remission was longer than that in the previou sly reported case. The two cases reported previously and our case point out that HBOT can be effective in inducing remission in patients with severe UC.

Ahmet Kemal Gurbuz, MD

Department of Gastroenterology

Emin Elbuken, MD

Department of Sea and Underwater Medicine

Yusuf Yazgan, MD

Department of Gastroenterology

Senol Yildiz, MD

Department of Sea and Underwater Medicine

Gulhane Military Medical Academy

Haydarpasa Training Hospital

Istanbul, Turkey

References

(1.) Kuroki K, Masuda A, Uehara H, Kuroki A. A new treatment for toxic megacolon. Lancet 1998;352:782.

(2.) Buchman AL, Fife C, Torres C, Smith L, Aristizibal J. Hyperbaric oxygen therapy for severe ulcerative colitis. J Clin Gastroenterol 2001;33:337-339.

(3.) Truelove SC, Richards WCD. Biopsy studies in ulcerative colitis. Br Med J 1956;6:1315-1318.

(4.) Webberley MJ, Hart MT, Melikian V. Thromboembolism in inflammatory bowel disease: Role of platelets. Gut 1993;34:247-251.

(5.) Folwaczny C, Spannagl M, Wiebecke W, Jochum M, Heidwein W, Loeschke K. Heparin in the treatment of highly active inflammatory bowel disease. Gastroenterology 1996;110(4):A908 (abstract).