S4848 Success of Oral Vancomycin in Treatment of Refractory Inflammatory Bowel Disease in Setting of Post-Liver Transplant for Primary Sclerosing Cholangitis: A Case Report

Introduction: Inflammatory Bowel Disease (IBD) is a chronic inflammatory condition of the gastrointestinal tract that often requires advanced therapies with immunosuppressive properties to achieve remission. Primary sclerosing cholangitis (PSC) is an extraintestinal manifestation of IBD that can progress to cirrhosis and orthotopic liver transplant (OLT). IBD has a variable course after transplant. Treatment of active IBD in the setting of post-transplant immunosuppression is complex due to concomitant post-transplant immunosuppression. The phenotype of IBD in patients with history of PSC is unique with prior studies showing use of oral vancomycin as a treatment for PSC and IBD. We present a case of active IBD refractory to treatment in a post-OLT PSC patient who achieved remission with oral vancomycin. Case Description/Methods: A 44-year-old White man with indeterminate colitis involving the right colon and ileum and history of orthotopic liver transplant for PSC presented with increased stool frequency, right lower quadrant pain, weight loss, and fatigue. His stool calprotectin was 900 mcg/g and colonoscopy showed discontinuous ulceration, friability and erythema on ascending and transverse colon with normal-appearing distal colon. Biopsy results revealed mild to moderately active chronic colitis with ulceration. His post-transplant immunosuppression included tacrolimus, low dose oral prednisone, and mycophenolate mofetil. His IBD therapy included adalimumab for 3 months and oral mesalamine. After 3 months of oral vancomycin 500 mg oral 3 times per day he achieved clinical, biochemical and endoscopic remission. Adalimumab and oral mesalamine were then withdrawn while vancomycin was continued, and he has remained in IBD remission for 3 years. Discussion: Management of active IBD in the setting of post-liver transplant immunosuppression is challenging with advanced therapies adding additional risk of infection and cost. Oral vancomycin has been shown to be effective for patients with PSC and IBD. This case is a unique case using oral vancomycin as a treatment for refractory IBD in a post-transplant patient. Active IBD responsive to oral vancomycin allowed for withdrawal of adalimumab. Oral vancomycin remains a promising therapeutic option for refractory IBD in post-OLT due to PSC.