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Excerpt
A 15 yr. old male (Case 1) with colitis and sclerosing cholangitis for 2.5 yrs., a 14 yr. old female (Case 2) with Crohn's disease of the large and small bowel and sclerosing cholangitis for 9 yrs., and 14 yr. old male (Case 3) with Crohn's disease of the stomach, small bowel, and colon and sclerosing cholangitis for 3 yrs. were treated with oral vancomycin, 20 to 40 mg/kg/day, for 6 weeks while they continued previous medications. During the 6 weeks on vancomycin, the gamma glutamyl transpeptidase fell from 520, 818, and 350 IU/L to 125 IU/L in Case 2 and to normal levels (< 80 IU/L) in the other 2 cases, the alanine aminotransferase fell from 210, 85, and 499 IU/L to normal levels (< 45 IU/L), and the sedamentation rates (ESR) fell from 80, 60, and 84 mm/hr to 8, 30, and 10 mm/hr with normal (<20 mm/hr). In all 3 cases, stool cultures and clostridia difficele toxins were negative for pathogens and while on vancomycin nausea, abdominal pain, and diarrhea resolved. One child (Case 1) had ERCP and liver biopsies before and after vancomycin which showed significant improvement. Over the past 3 yrs., all three cases have had recurrent symptoms and abnormal blood tests (liver enzymes and ESR) which normalized on vancomycin. One child (Case 3), who was steroid dependent for 3 yrs., has been off of steroids, has been asymptomatic, and has had normal blood tests for 6 months.
We conclude that in these 3 patients with primary sclerosing cholangitis, symptoms and blood test of liver injury improved on oral vancomycin. We postulate that oral vancomycin killed enteric bacteria which produced biliary toxic agents that were absorbed into the portal circulation. Recurrence off vancomycin suggests that the antibiotic did not completely irradicate the infection or there was reinfection. Further, prospective studies are needed to determine the long-term benefits of this therapy.
