The role of oral vancomycin in inducing remission for biologic-experienced ulcerative colitis with concomitant primary s
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CASE REPORT
The role of oral vancomycin in inducing remission for biologic‑experienced ulcerative colitis with concomitant primary sclerosing cholangitis and liver transplantation Asad Ur Rahman1 · Faisal Inayat2 · Saeed Ali3 · Effa Zahid4 · Roger Charles1 Received: 26 August 2020 / Accepted: 12 October 2020 © Japanese Society of Gastroenterology 2020
Abstract While a minority of patients with ulcerative colitis has primary sclerosing cholangitis (PSC), a significant proportion of patients with PSC have ulcerative colitis. The activity of PSC is usually not commensurate with the degree of concomitant colonic inflammation. Moreover, up to one-third of patients with a history of ulcerative colitis may paradoxically experience worsening of their colonic inflammation despite receiving immunosuppression after liver transplantation for PSC. There is a dearth of data pertaining to the management of ulcerative colitis in this post-transplantation patient population. We hereby delineate the case of a patient with severe refractory ulcerative colitis in the aftermath of liver transplantation due to PSC who eventually responded to oral vancomycin after failure of biologic therapy. Since current data implicate that patients with ulcerative colitis and PSC often present with distinct alterations of their colonic microbiome, oral vancomycin may be conjectured to demonstrate a therapeutic role. In this article, the review of literature suggests that oral vancomycin might indeed be an effective substitute in patients in whom the uptake of biologic agents may be challenging owing to their already immunosuppressed status. Keywords Ulcerative colitis · Primary sclerosing cholangitis · Liver transplantation · Oral vancomycin
Introduction The concomitant presence of primary sclerosing cholangitis (PSC) is noted in merely 5% of all patients with ulcerative colitis (UC) [1]. Conversely, the majority of patients with PSC have underlying UC. Notably, UC associated with PSC (UC-PSC) appears to be a distinct clinical entity and presence of both diseases portends a significantly increased risk of colon cancer and cholangiocarcinoma [2]. However, the disease activity of PSC does not necessarily correlate with the underlying severity of UC [3]. Mild UC may be paradoxically exacerbated in up to one-third of patients after undergoing liver transplantation despite being on systemic * Faisal Inayat [email protected] 1
Cleveland Clinic Florida, Weston, Florida, USA
2
Allama Iqbal Medical College, Lahore, Punjab, Pakistan
3
University of Iowa Health Care, Iowa City, Iowa, USA
4
Services Institute of Medical Sciences, Lahore, Punjab, Pakistan
immunosuppression [4]. We hereby chronicle the case of a patient with severe UC after liver transplantation for PSC who responded to oral vancomycin therapy after failure of treatment with vedolizumab and infliximab. We further substantiate our case with a meticulous perusal of medical literature pertaining to the utility of oral vancomycin in UC-PSC, especially after liver transplan
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