War Stories: Miriam

Last revision: 02-27-24

By Eugene L. Heyden, RN

 

“Based on these initial encouraging results, off-label use of HBO [hyperbaric oxygen] might offer a solution to therapy-refractory patients, such as the cases presented here in which a proctectomy was already considered to be the next step.  ~ Lansdorp et al., 2020a

“What is hyperbaric oxygen (HBO)?”  “What does it do?”  “Is it a channel on cable TV?”  “How can it help me?”  Some of your questions are really good.  Let’s see . . .

“HBO consists of breathing 100% oxygen for 60–90 minutes under a higher than normal atmospheric pressure: usually 2.0–2.5 atmosphere absolute (ATA). This increases plasma and tissue oxygen levels, and decreases hypoxia. It has been shown to alter several signalling [sic.] pathways involved in tissue response to hypoxia and wound repair, and suppresses the production of pro-inflammatory cytokines. Also, in general, oxidative stress is recognised [sic.] to play a role in stem-cell mobilisation [sic.] and promote wound healing.”  (Lansdorp et al., 2020b)

HBO is not something you typically do at home, unless you can afford to buy or rent the special chamber you can crawl inside of, and you just happen to have a tank of oxygen laying around the house. HBO is, however, available at hospitals and clinics all over town.  A prescription is required.  And for the patient with Crohn’s, HBO may just be the ticket to healing stubborn perianal disease.

 

Care Report: Miriam

Having Crohn’s disease is bad enough.  But add perineal disease to the mix, and things go from bad to worse.  Fistulas and abscesses are not a welcome sight.  They are, in fact, hideous.  They make life so difficult.  And they are so difficult to treat.  Meet Miriam.  She can tell you all about it.

Miriam, age 48, presented with “progressively worsening perineal and biopsy-proven cutaneous Crohn’s disease that had been refractory to surgery and medical treatment (sulfasalazine, steroids, 6-mercaptopurine, metronidazole, antibiotics).”   Her history is complex.  Let’s review.

In 1972, Miriam was experiencing weight loss and bloody diarrhea, and the diagnosis or ulcerative colitis was made—based on x-ray and visualization via a proctoscope.  Sulfasalazine was ordered and helpful, but over a two-year period she had two disease flares requiring steroids to bring things under control.  This leads us up to 1974, the year she had surgery for a pelvic mass.  Furthermore, that was the year a careful review of previous biopsies led to her diagnosis being changed from ulcerative colitis to Crohn’s disease.  And trouble in life would continue.

“A rectal stricture requiring repeated dilations and recurrent perirectal abscesses necessitated a diverting colostomy in 1977.  Her symptoms temporarily improved, but by 1979 extensive perineal disease had developed with extension into pelvic, gluteal, and abdominal wall intertriginous areas [skin fold areas].”  (Brady III et al., 1998)

Poor Miriam—and I really mean that!  Her Crohn’s disease is so out of control and clearly out to destroy.  I can only imagine the degree of suffering she is experiencing.  Can you see why I hate this disease?  But I’m not the only one.  Besides Miriam, her doctors hate it, too.  It was resistant to all their efforts.  Medications—everything available at the time—did not prevent the inevitable removal of both rectum and colon.

I’m leaving out a lot of the story . . . purposefully.  I want to spare you the gory details of an 8-year-plus struggle which included dealing with abscess and fistula formation, dealing with the incision and drainage of multiple abscesses, dealing with the side effects of drugs, dealing with pain and embarrassment, dealing with a disease that could not be constrained.  For Miriam, 1983 was a particularly bad year.

In 1982, she received 6-mercaptopurine (100 mg/day) and high-dose steroids (60 mg/day) for two months, but 4 mo after discontinuing these medications her perineal and cutaneous disease again worsened. Within 2 mo of restarting 6-mercaptopurine (125 mg/day), she was admitted for incision and drainage of perirectal and perianal abscesses. Over the next 11 mo, her course was typified by multiple admissions for incision and drainage of sinus tracts, fistula, and pelvic abscesses.  (Brady III et al., 1989)

Fast forward to January 1988 (and leaving a lot of struggle and misery behind):

“In January she experienced her worse flare-up to date with severe dermal necrosis particularly in the intertriginous areas of her abdominal wall and perineum. Intensive daily local care was extremely painful and this time parenteral [e.g., I.V.] antibiotics as well as metronidazole were unsuccessful and the patient was referred for a trial of hyperbaric oxygen therapy.”  (Brady III et al.,1989)    

So, therapy began for Miriam—HBO, 2 hour sessions, six days a week, in addition to daily wound care. So, how did she respond?  “Response was dramatic with almost immediate relief of symptoms and regression with 2.5 mo of wounds that had previously defied therapy.”   This must have been very satisfying, not only to Miriam but also to her physicians.  After multiple HBO sessions, over 100, covering a period of 9 months, “The dramatic resolution of the lesions in this patient suggests that hyperbaric oxygen was a significant factor in the healing process.”

Furthermore:

“The longest interval between treatments has been only 2.5 mo, but the patient has been essentially asymptomatic and the extent of her cutaneous disease has been minimal compared with her condition before hyperbaric oxygen.”  (Brady III et al., 1989)

 

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Reference:

Brady III CE, Cooley BJ, Davis JC. Healing of severe perineal and cutaneous Crohn’s disease with hyperbaric oxygen. Gastroenterology. 1989 Sep 1;97(3):756-60.  https://www.sciencedirect.com/science/article/abs/pii/0016508589906495

Lansdorp CA, Buskens CJ, Gecse KB, D’Haens GR, van Hulst RA. Off‐label use of hyperbaric oxygen therapy in inflammatory bowel disease. Alimentary Pharmacology & Therapeutics. 2020a Jul;52(1):215-6.  https://onlinelibrary.wiley.com/doi/full/10.1111/apt.15775

 

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