الفهرس 
ULCERATIVE COLITISOnly 14 pages are availabe for public view
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Abstract
UC is a chronic idiopathic IBD of the colon causing a
superficial mucosal inflammation in a continuous fashion
extending from the rectum to the more proximal colon with it’s
peak age of onset is 30–40 years old, men and women are
affected equally (Ungaro et al., 2017).
The main symptoms of UC include bloody diarrhea with
rectal urgency and tenesmus. Although the etiology of UC
remains unclear but many theories revealed environmental
factors, and less likely intestinal dysbiosis in genetically
susceptible individuals, but increasing evidence suggests that it
is an autoimmune condition (Halling et al., 2017).
Severe UC is a medical emergency characterized by>6
bloody stools/day with one of the following: tachycardia >90
beat per minute, fever>37.8°C hemoglobin<10.5 gm/dL, and/or
ESR>30 mm/hour (Truelove and Witt’s criteria), Other indices
for defining severity include modified Mayo’s classification
which is a combination of clinical and endoscopic finding
(D’Haens et al., 2007).
HBOT is a treatment in which patients breathe 100%
oxygen while inside a hyperbaric chamber pressurized to
greater than sea level. For clinical efficacy, pressures applied
usually range from 2-3 ATA, which is delivered in multiplace
or monoplace chambers (Frank et al., 2017).HBOT has potent anti-inflammatory effect and may
normalize oxygen level in ischemic tissues (Al-Waili and
Butler, 2006). It increases the oxygen content of blood
reaching inflamed bowel. It alters signaling pathways involved
in the tissue response to hypoxia and wound repair, notably
HIF and heme-oxygenase pathways (Peng et al., 2008).
This study composed of 20 Egyptian patients who had
severe UC flare according to truelove and witt’s criteria and
admitted to gastroenterology department at Air force general
hospital in Cairo, Egypt for 14 days from the period of January
2019 to January 2020. Patients divided into two groups each
one composed of 10 patients, group I composed of 10 patients
managed by 10 sessions of HBOT in multiplaced chamber
(Model: HAUX-STARMED 2300) each session lasted 60
minutes with a 5 minutes break at 30 minutes to minimize risks
for CNS toxicity at pressure depth 2.8 ATA (equivalent to 18
meters) five times per week for two consecutive weeks plus
400 mg hydrocortisone intravenous daily and intravenous fluids
while group II composed of 10 patients managed by 400 mg
hydrocortisone intravenous daily plus intravenous fluids. All
patients included in the study followed standard of care for
treatment of hospitalized UC flares with pre-treatment
evaluations for infections and colonic dilation (on abdominal
imaging) and assessment for progression to second-line therapy
by clinical examination and laboratory investigations.In this study we included patients from both gender aged
≥18years old who had severe UC according to Truelove and
Witt’s criteria (>6 bloody stools/day with one of the following:
tachycardia> 90 beat per minute, fever> 37.8°C hemoglobin <
10.5gm/dL, and/or ESR > 30 mm/hour.
We excluded patients who cannot tolerate HBO
chambers such as (history of barotrauma, congestive heart
failure, chronic obstructive pulmonary disease patients, recent
surgeries, claustrophobic and upper respiratory tract infection
patients) we also excluded patients less than 18 years old, any
patient developed toxic megacolon or had>6 motions per day or
CRP>45 mg/dL at day 3 of admission for rescue therapy with
ciclosporin or biological therapy.
This study did not expose the patients to any risk or
complications. A written informed consent was taken from all
patients before their participation. Approval of the Institutional
Review Board was taken before starting the study. Privacy of
all data was guaranteed.
All participants were subjected to history taking, clinical
examinations, Abdominal X-ray on admission to exclude toxic
megacolon, laboratory investigations to exclude other causes of
bloody diarrhea, routine labs as CBC, liver and renal profile
plus inflammatory markers as ESR, CRP and faecal
calprotectin at day 1, 3, 7 and 14 of the study to assess patient’s
response and the need for rescue therapy.We used Mayo scoring system Table (1) for assessment
of UC severity and the efficacy of therapeutic strategy for both
groups in this study. It is composed of the RBS, SFS, MES and
physician global score to formulate the score which ranges
from 0 to 12, with higher scores indicates disease severity. We
used only the first 3 components of Mayo score (RBS, SFS and
MES) and didn’t use physician global score as it’s a subjective
one. We calculated RBS and SFS at day 1, day 7 and day 14 of
the study to detect disease severity before treatment and assess
patient’s response to the therapeutic strategy in both groups.
Patients of both groups underwent colonoscopy (Model:
Fujifilm EC-590WL4) at day 14 of the study to calculate their
MES.
The results of the study were tabulated and statistically
analyzed. Numerical data was expressed as mean ± standard
deviation, median and range. Chi-square test was used to
examine the relation between qualitative variables. For
quantitative data, comparison between two groups was done
using parametric or non-parametric t-test. A p-value ≤ 0.05 was
considered significant.
This study revealed that there was highly statistically
significant reduction in mean ESR level in group I in
comparison to group II at day 7 and day 14 of the study. there
was also highly statistically significant reduction between the
two groups in mean ESR at day 14 in comparison to 1st day of
the study with (26.80 ± 3.77 mm/h in group I vs 15.30 ± 2.54 mm/h in group II) and higher mean ESR daily reduction in
group I (1.91 ± 0.27 mm/h) vs (1.10 ± 0.18 mm/h) in group II.
Regarding CRP, we detected highly statistically
significant difference between the two groups at day 7 and day
14 of the study with lower mean value of CRP level in group I
in comparison to group II. We also observed that there was
highly statistically significant reduction between the two
groups in mean CRP at day 14 in comparison to 1st day of the
study (24.80 ± 4.52 mg/dL in group I vs 14.70 ± 2.75 mg/dL in
group II) and higher mean CRP daily reduction in group I (1.77
± 0.32 mg/dL) vs (1.05 ± 0.19 mg/dL) in group II.
Regarding faecal calprotectin, we concluded that there
was highly statistically significant difference between the two
groups at day 14 of the study with lower mean faecal
calprotectin level =288.00 ± 20.94 in group I vs 503.80 ± 77.81
μg/mg in group II. We also noted that there was highly
statistically significant reduction between them in mean fecal
calprotectin at day 7 and day 14 from 1st day of the study with
higher mean faecal calprotectin reduction in group I in
comparison to group II at day 7 (174.10 ± 38.71 μg/mg vs
66.20±15.84μg/mg) and day 14 (365.60 ± 71.96 μg/mg vs
128.60±24.78μg/mg), there was a higher mean faecal
calprotectin daily reduction in group I in comparison to group
II (26.12 ±5.14μg/mg vs 9.19 ±1.77μg/mg).We also noted that there was highly statistically
significant reduction in mean RBS and mean SFS at day 14 of
the study between the two groups as they were markedly
reduced in group I in comparison to group II (mean RBS in
group I= 0.30 ± 0.48 points vs 1.30 ±0.68 points in group II,
while mean SFS at group I=0.30 ± 0.48 points vs 1.30 ±0.68
points in group II), we also concluded that there was highly
statistically significant reduction in mean RBS and mean SFS
at day 14 from the 1st day of the study between the two groups
(mean RBS in group I=2.00 ± 0.0 points vs 1.00 ± 0.47 points
in group II, while mean SFS in group I=2.1 ± 0.32 points vs
1.20 ± 0.42 points in group II).
Finally, to calculate MES, patients from the two groups
underwent colonoscopy at day 14 of the study after completion
of HBO sessions and steroid therapy. we observed that there
was statistically significant difference between them (pvalue=0.044) and marked lower mean MES in group I in
comparison to group II (1.00 ± 0.67 points vs 1.60 ± 0.52
points).