Conference Coverage

Consider hyperbaric oxygen for inflammatory ileal pouchitis


 

REPORTING FROM ACG 2019

A course of hyperbaric oxygen appears to be safe and effective for the treatment of medically refractory inflammatory ileal pouch disorders, Hamna Fahad, MD, reported at the annual meeting of the American College of Gastroenterology.

Dr. Hamna Fahad of the Cleveland Clinic Bruce Jancin/MDedge News

Dr. Hamna Fahad

Dr. Fahad, of the Cleveland Clinic, presented a retrospective case series of 21 consecutive clinic patients who presented with inflammatory bowel disease, a surgically created ileal pouch–anal anastomosis, and medically refractory pouchitis. All patients received 30 hyperbaric oxygen treatment sessions, each an hour long, over the course of 2 months. This intensive regimen worked out to 3-5 sessions per week involving 100% oxygen pressurized to 2.4-3.0 ATA.

Overall, 19 of 21 patients experienced improvement in their modified Pouchitis Disease Activity Index (mPDAI) score. The mean total mPDAI at baseline was 8.71, improving significantly to 5 post treatment. The mPDAI symptoms subscore also showed significant improvement in response to a course of hyperbaric oxygen therapy, decreasing from 4 points to 2. The cuff subscore fell from 3 to 0, and the pouch body subscore improved from 3 to 2.

Thirteen of 21 patients reported subjective symptomatic improvement in stool frequency, bleeding, urgency, and fevers, including 6 with complete symptomatic remission. Seventeen patients demonstrated significant endoscopic improvement upon blinded assessment. Seven of 9 patients with fistulae experienced healing of the fistula tract.

The treatment entailed no side effects. However, the benefits weren’t uniformly durable. Several patients underwent a second 30-session round of hyperbaric oxygen therapy within a year because of recurrent pouchitis symptoms refractory to corticosteroids, biologics, and other medications.

Dr. Fahad said the mechanism of benefit for hyperbaric oxygen in the treatment of chronic inflammatory pouchitis is probably severalfold: reversal of a disordered microbiome through inhibition of the growth of anaerobes, reduced production of tumor necrosis factor–alpha and other inflammatory cytokines, and increased plasma oxygen, which reduces ischemia at the tissue level, thereby promoting tissue healing.

Audience members had a practical question: How can they get this treatment paid for? One gastroenterologist said she has encountered considerable payer resistance when she has sought coverage of hyperbaric oxygen for patients with ulcerative colitis and fistulae, even though there is already published evidence of benefit. But Dr. Fahad’s groundbreaking study provides the first such evidence in pouchitis. So how did she and her coworkers do it? Eighty percent of the pouchitis patients obtained payer approval only upon appeal, which was readily granted, she explained.

Dr. Fahad reported having no financial conflicts regarding her study, conducted without commercial support.

SOURCE: Fahad H. ACG 2019 Abstract 38.

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