Multimodal Treatment of a Difficult CD Wound

Multimodal Treatment Of A Difficult CD Wound - Case Report
Jason Swoger, MD, Gastroenterology, 05:52PM Dec 4, 2010

Many of the physicians in our group have been working with a 23 year-old female with a complex recent medical presentation. She was diagnose with Cronhs Disease at the age of 15. Prior therapies had included 5-ASA medications, 6-MP, infliximab, and adalimumab. She had complications of infection/sepsis after initiating adalimumab. She eventually underwent colectomy with a Hartman's pouch, complicated by an intrasphincteric fistulas, involving the Hartman's pouch, and necessitating a completion proctectomy in 12/2009. The proctectomy was complicated by wound dehisence and poor wound healing at the umbilicus, as well as in the perineum. Antibiotics and wound debridements were not helpful. She was being treated with low dose methotrexate, as well as low-dose prednisone for secondary adrenal insufficiency. In June 2010, she began hyberbaric oxygen therapy to attempt to improve wound healing. The umbilical wound healed, but the perineal wound continued to be problematic. It was thought that the wound would partially heal, leading to the accumulation of infected fluid in the perineal cavity. An EUA was performed, and found a deep sinus tract reaching into the sacral hollow. Granulation tissue was present, but there was no evidence of healing. The depth of the wound at this time was approximately 22-25cms, and a picture of an endoscopic examination of the wound is seen below.

The patient had not tolerated a wound vac in the past, due to significant pain, especially with dressing changes. However, it was thought that there was potential for the wound to heal. The decision was made to have the patient undergo woundvac changes under propofol sedation. In addition, the tissue in the sinus tract was manipulated using different methods, in order to stimulate the formation of granulation tissue and healing. Scraping and abrasion was performed with a gauze covered hemostat, a biopsy brush through the instrument channel of a endoscope, and APC (argon plasma coagulation). The photo below shows progress about 1/2 way through the treatment sessions, which occurred twice a week, and coincided with woundvac changes.




The wound continued to show improvement, in both size and granulation. At the most recent woundvac changing, the depth of the cavity had improved to only 4-5cm, and a picture of the lining of the sinus tract is below. There has not been much interval change over the past few treatment sessions, and we are considering another trial of hyperbaric oxygen in order to complete the healing process. I though this was an interesting case, using creative and multimodal means to address a very complex and severe Crohn's disease related issue that is not often seen in practice.

Crush Injuries and Hyperbaric Oxygen Treatment

Crush Injuries and Hyperbaric Oxygen Treatment
Crush injury is simply any injury to your body that is a result of trauma. These injuries could range from minor contusions to severe injuries that could damage a limb. It could be several tissues such as the skin, the muscles and tendons to bone and joints. These can result in osteomyelitis, failing union of fractures, failed flaps and amputations. The trauma can also result in skeleton muscle compartment syndrome (SMCS) which targets the muscles and the nerves. It is quite a challenge to manage the SMCS but it does not mean that it cannot be managed. This is where the crush injury hyperbaric becomes handy. It should be used as an adjunct to the management of the crush injuries or SMCS conditions.

We therefore need to consider the two ways by which the crush injury treatment that incorporates the hyperbaric oxygen works. First, it is important to note that during the initial stages of injury perfusion is likely to be inadequate. At such a time, immediate use of the hyperbaric oxygen makes more sense as it would supplement the supply of oxygen. The second way that really makes the use of hyperbaric oxygen useful is that it increases the tissue oxygen tension to the sufficient levels. Increased tissue oxygen in the plasma keeps the tissues alive without the oxygen that is borne from hemoglobin.

When the tension of tissue oxygen is increased, the effects of hypoxia that were initially felt when there was oxygen deficiency is countered. The other advantage that results from crush injury hyperbaric oxygen is the reduction of blood flow by up to 20 percent. The oxygen increases the induction of vasoconstriction and this is what causes the reduction. This in the end reduces edema. The filtration of the fluid that comes from the capillary to the extracellular space is also maintained.

The same treatment regime ensures that there is mitigation of reperfusion. This in turn interrupts the toxic oxygen radicals and the cell membrane. But you may ask how is that possible? Well, it actually perturbs lipid peroxiadation of the cell membrane and prevents the sequestration of neutrophils on the post capillary venules.

The other benefit of crush injury treatment hyperbaric is that it assists in provision of the oxygenated environment. Superoxide dismutase, catalase, peroxidase and glulathione which are useful for detoxification of reactive oxygen species actually depend in such environment to thrive.

When the crush injuries present in their severe forms, you should not think twice. You would be safe if you can quickly make use of the hyperbaric oxygen intervention that is quite effective. It is the only sensible and best way through which you would be able to counteract the pathophysiological events that occur when you have encountered a crush injury. The intervention is the sure way through which you will reduce loss of the muscle functions, the metabolites that come with muscle injury, edema and even muscle necrosis. Of course, this treatment is to be used together with the usual surgical and medical interventions that are in place.