Hyperbaric Oxygen Therapy (HBOT) - a new treatment for toxic megacolon (Case Report)
The Lancet: Sept 5, 1998
Case Study: A 41-year-old man came to our hospital with bloody diarrhoea in December, 1997. A diagnosis of ulcerative colitis was made because of his fever (38-39C), abdominal pain, diarrhoea more than ten times a day,
C-reactive protein (CRP) of 10.7 mg/dL, and colonoscopic findings.
Intravenous prednisolone (60 mg/day) and broad-spectrum antibiotics did not relieve his abdominal pain, and he was given intravenous pentazocine. 9 days after admission, his temperature was 39.6C, he had a tachycardia of 120/min, anaemia (haemoglobin 8.4 g/dL), abdominal distension, decreased consciousness, and dilatation of the transverse colon (figure, A). CRP was 17.5 mg/dL, aspartate aminotransferase 77 IU/L, alanine aminotransferase 277 IU/L, y-glutamyltranspeptidase 841 IU/L, and total protein 5.2 g/dL. Toxic megacolon was diagnosed.1
Although surgical treatment was considered, we tried hyperbaric oxygen (2 atm [203 kPa] for 60 min once a day) to reduce the volume of gas in the colon. His temperature decreased to 36-37C after day 2 of treatment and abdominal pain was relieved after day 3. Abdominal distension was improved after the seventh treatment and CRP decreased to 0.7 mg/dL after day 12. An abdominal radiograph showed marked reduction of gas in the transverse colon (figure, B). After the first treatment, interleukin 6, which was 13.2 pg/mL before the treatment, came down to 7.2 pg/mL. Intravenous prednisolone was changed to oral prednisolone (30 mg/day) after day 15 of hyperbaric treatment.
Colonoscopy was done to see whether the colonic mucosa was improved by hyperbaric oxygen. The next day, he had high fever, abdominal pain, abdominal distension, increased CRP, and dilatation of the transverse colon suggesting the recurrence of toxic megacolon. Hyperbaric oxygen was given immediately and continued daily. His temperature fell. Abdominal pain and distension were relieved, and CRP was improved after 12 days of treatment. He was discharged 89 days after admission, and when last seen in July 1998, he was well.
The frequency of toxic megacolon complicating ulcerative colitis is reported to be 1.6-8.0%.2 79% of patients undergo surgery with a mortality rate of 16%.3 Surgical texts recommend colectomy after 48-72 h if there is persistent colonic distension.4 In our case, hyperbaric oxygen given within 48 h resulted in marked improvement without any side-effects.
Mechanisms of action of hyperbaric oxygen may be compression of intestinal gas with reduction of colonic dilatation and as a consequence improvement of circulation to the mucosa.5 Hyperbaric oxygen may also improve the diffusion gradient for nitrogen and thereby decrease the diameter of the colon.
Our observations suggest that hyperbaric oxygen is promising as a non-surgical treatment for toxic megacolon.
References
- Jalan KN, Circus W, Cord WI, et al. An experience with ulcerative colitis: toxic dilatation in 55 cases. Gastroenterology 1969; 57: 68-82.
- Purrman J, Strohmeyer G. Pathogenesis and management of ulcerative colitis. Hepatogastroenterology 1989; 36: 209-12.
- Greenstein AJ, Sachar DB, Gibos A, et al. Outcome of toxic dilatation in ulcerative and Crohn's colitis. J Clin Gastroenterol 1985; 7: 137-43.
- Sheth SG, LaMont JT. Toxic megacolon. Lancet 1998; 351: 509-13.
- Kweicinski MG. Therapeutic value of hyperbaric oxygen in lower extremity ulcerations. J Foot Surg 1987; 26: 394-96.
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