Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection in the Elderly: Long-Term Outcomes and Microbiota Changes

BACKGROUND AND AIMS

Fecal microbiota transplantation (FMT) has become the cornerstone in management of recurrent Clostridium difficile infection (RCDI) in adults. However, data on efficacy, safety, long-term outcomes, and microbiota alterations are limited in elderly patients (>65 years).

METHODS

Twenty-nine consecutive elderly patients with RCDI underwent FMT with combined jejunal and colonic method and monitored for long-term outcomes. Fecal samples from five elderly RCDI patients (G65) were subjected to genomic analysis before and after FMT, and microbiota changes were compared with matched RCDI patients below 65 years (L65).

RESULTS

FMT resulted in marked improvement in all clinical parameters, including abdominal pain, bloating, and diarrhea in all elderly RCDI patients. Fecal C. difficile toxin was positive in all 29 patients and turned negative in all 27 patients, who agreed to undergo this test after FMT. Statistically significant improvement in leukocytosis was noted (p < 0.05). Only adverse events reported were transient mild fever (2/29) and bloating (3/29). Long-term follow-up over 25.4 ± 12.8 months did not reveal any additional adverse events or RCDI recurrence. Genomic analysis suggested that overall microbiota diversity increased post-FMT in elderly RCDI patients. However, this response was less robust than the younger group. While Firmicutes did not change markedly, Proteobacteria decreased significantly in post-FMT samples in elderly RCDI patients.

CONCLUSIONS

These observations suggest that FMT in elderly patients with RCDI appears to be highly efficacious with no recurrence of infection over long-term follow-up. Alterations in microbiota in this group of patients are characterized by less robust increase in microbial diversity and marked reduction in phylum Proteobacteria.

Clinical predictors of fulminant colitis in patients with Clostridium difficile infection

BACKGROUND/AIM

Clostridium difficile infection (CDI) can affect up to 8% of hospitalized patients. Twenty-five percent CDI patients may develop C. difficile associated diarrhea (CDAD) and 1-3% may progress to fulminant C. difficile colitis (FCDC). Once developed, FCDC has higher rates of complications and mortality.

PATIENTS AND METHODS

A 10-year retrospective review of FCDC patients who underwent colectomy was performed and compared with randomly selected age- and sex-matched non-fulminant CDAD patients at our institution. FCDC (n=18) and CDAD (n=49) groups were defined clinically, radiologically, and pathologically. Univariate analysis was performed using Chi-square and Student's t test followed by multivariate logistic regression to compute independent predictors.

RESULTS

FCDC patients were significantly older (77 ± 13 years), presented with triad of abdominal pain (89%), diarrhea (72%), and distention (39%); 28% had prior CDI and had greater hemodynamic instability. In contrast, CDAD patients were comparatively younger (65 ± 20 years), presented with only 1 or 2 of these 3 symptoms and only 5% had prior CDI. No significant difference was noted between the 2 groups in terms of comorbid conditions, use of antibiotics, or proton pump inhibitor. Leukocytosis was significantly higher in FCDC patients (18.6 ± 15.8/mm³ vs 10.7 ± 5.2/mm³; P=0.04) and further increased until the point of surgery. Use of antiperistaltic medications was higher in FCDC than CDAD group (56% vs 22%; P=0.01).

CONCLUSIONS

Our data suggest several clinical and laboratory features in CDI patients, which may be indicative of FCDC. These include old age (>70 years), prior CDI, clinical triad of increasing abdominal pain, distention and diarrhea, profound leukocytosis (>18,000/mm³), hemodynamic instability, and use of antiperistaltic medications.

Endoscopic management of post-liver transplant biliary complications

Biliary complications are being increasingly encountered in post liver transplant patients because of increased volume of transplants and longer survival of these recipients. Overall management of these complications may be challenging, but with advances in endoscopic techniques, majority of such patients are being dealt with by endoscopists rather than the surgeons. Our review article discusses the recent advances in endoscopic tools and techniques that have proved endoscopic retrograde cholangiography with various interventions, like sphincterotomy, bile duct dilatation, and stent placement, to be the mainstay for management of most of these complications. We also discuss the management dilemmas in patients with surgically altered anatomy, where accessing the bile duct is challenging, and the recent strides towards making this prospect a reality.

Role of endoscopic ultrasound/SpyScope in diagnosis and treatment of choledocholithiasis in pregnancy

Cholelithiasis and choledocholithiasis occur frequently in pregnancy and their management can be complicated. Traditional endoscopic retrograde cholangiopancreatography (ERCP) is the first line treatment for choledocholithiasis, but in addition to its baseline risks, fluoroscopy poses an additional radiation risk to the fetus. Endoscopic ultrasound (EUS) is an accurate modality for detecting common bile duct stones, but its role has not been defined in pregnancy. We describe an alternative management strategy to conventional ERCP in a pregnant patient with choledocholithiasis and cholangitis detected using EUS and choledochoscopy.

Utility and performance characteristics of a novel submucosal injection agent (EleviewTM) for endoscopic mucosal resection and endoscopic submucosal dissection

BACKGROUND

Submucosal injection of a lifting agent is a critical step in endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD). Literature suggests superiority of other viscous solutions over normal saline (NS), but research to determine the ideal submucosal injection is still ongoing. In this prospective cohort study, we evaluated the utility and performance characteristics of a novel submucosal injection agent (EleviewTM) for EMR and ESD.

METHODS

Twelve consecutive patients referred for EMR/ESD to a tertiary referral center with experienced large polyp expert were prospectively enrolled. Ten patients with large colon polyps (mean age 66.3 years), and one patient each with esophageal and gastric lesions were included. EleviewTM was injected as submucosal lifting agent, and EMR/ESD performed. Main outcome measurements included the duration of submucosal elevation, volume and number of injections required to maintain cushion, and complications.

RESULTS

Single injection of 3-5 cc of EleviewTM outlasted the duration of EMR. However, mean duration of cushion achieved during longer procedures (ESD) was 12.5 min, requiring several additional injections. R0 resection was achieved in 10/12 patients. One patient had minor bleeding which was managed intra-operatively.

CONCLUSIONS

EleviewTM was successful in achieving long duration of submucosal elevation, allowing safe and efficient performance of EMR as a single injection, but needed repeated injections during longer ESD procedures. Prospective controlled trials are required to compare its performance to other available viscous submucosal solutions.

Management of gastric variceal bleeding: Role of endoscopy and endoscopic ultrasound

Gastric varices (GVs) are notorious to bleed massively and often difficult to manage with conventional techniques. This mini-review addresses endoscopic management principles for gastric variceal bleeding, including limitations of ligation and sclerotherapy and merits of endoscopic variceal obliteration. The article also discusses how emerging use of endoscopic ultrasound provides optimism of better diagnosis, improved classification, innovative management strategies and confirmatory tool for eradication of GVs.

Awareness of neurocysticercosis: A study from northwest India

BACKGROUND

Neurocysticercosis (NCC) is a common cause of epilepsy in developing countries. In order to plan and implement prevention programs, it is essential to study the awareness of NCC.

OBJECTIVE

To study the awareness of NCC among patients with NCC and compare with age- and gender-matched controls without NCC.

SETTING AND DESIGN

Hospital based case-control study.

MATERIALS AND METHODS

Two hundred and fourteen subjects were studied (109 NCC patients, and 105 age- and gender-matched controls without NCC). The participants were selected from neurology and medical wards of a tertiary referral hospital in northwest India. They were interviewed by trained medical interns using a questionnaire.

RESULTS

64.2% of the NCC patients and 19% of control group had heard about NCC (P < 0.001). Knowledge regarding organ affected by NCC in the NCC group was 61.4% and in the control group was 80% (P = 0.09). Only 12.9% of the NCC group and none in the control group identified tape worm as a causative agent for NCC (P = 0.092). Negative effects of NCC on marriage and social life were more often cited by the NCC group but in the control group it was towards education (P = 0.004).

CONCLUSIONS

The awareness of NCC was poor in both the groups. Educational programs are needed to improve the awareness about NCC among the patients and the public.

Endoscopic ultrasound-guided transesophageal thoracic duct puncture in a Swine model: a survival study

BACKGROUND AND STUDY AIMS

The study of lymph as a biofluid is lacking because of absence of a safe site and technique for lymph acquisition. Injury to the thoracic duct during surgery is known to cause chylothorax. The aim of this interventional study was to puncture the thoracic duct under endoscopic ultrasound (EUS) guidance and observe for complications in a swine model.

SUBJECTS AND METHODS

Three female Yorkshire pigs underwent EUS. The thoracic duct was identified by the previously described technique, punctured, and confirmed with a lymphangiogram. Postoperatively, animals were fed and monitored closely for any complications or signs of abnormal behavior indicating pain and/or disease. The animals were euthanized at 1 week, and necropsy was performed per protocol. Main outcome measurements included complications (chylothorax, mediastinitis, perforation, and hemorrhage) during the post-EUS-guided thoracic duct puncture period.

RESULTS

No animals developed any complications during the survival period. The thoracic duct was identified and punctured in all animals. A lymphangiogram was additionally obtained to confirm ductal access. No chylothorax, mediastinitis, hematoma, abscess, or fistula formation was identified in any animal on necropsy.

CONCLUSIONS

EUS-guided transesophageal thoracic duct puncture is safe as demonstrated by this survival study.

EUS-guided transesophageal study of the human thoracic duct diameter after instillation of intraduodenal fatty acids (EUS-TEST study)

INTRODUCTION

The accession of the thoracic duct (TD) may be vital for obtaining lymph samples, which may be potentially important for early detection of gastrointestinal cancers. The feasibility and safety of endoscopic ultrasound (EUS)-guided TD puncture were recently demonstrated in a swine model. However, the actual process of lymph aspiration is difficult because of small TD diameter (TDD) as well as sluggish flow. This study was designed to examine the change in TDD following intraduodenal instillation of fatty acids (Intralipid(®); manufactured by Fresenius Kabi [Uppsala, Sweden] for Baxter Healthcare [Deerfield, IL]) in patients undergoing diagnostic EUS.

PATIENTS AND METHODS

Ten patients undergoing EUS for routine indications were enrolled in this interventional study at a tertiary-care center in the United States. Baseline TDD was first recorded with EUS in the mediastinum, and the endoscope was advanced into the second part of the duodenum, where 20% Intralipid was instilled. Patients then underwent the complete EUS procedure, and TDD was again measured at 30, 45, 60, 75, and 90 minutes.

RESULTS

Mean age of the patients was 63 years (range, 46-83 years). The mean (±2 standard deviation) TDD at baseline was 0.17±0.04 cm (range, 0.11-0.23 cm). Values for TDD at 30 minutes (0.22±0.03 cm; P=.11), 60 minutes (0.35±0.08 cm; P=.0007), and 90 minutes (0.27±0.08 cm; P=.04) were all higher than the baseline measurement. Maximum increase in TDD was observed at 60 minutes, after which TD started returning toward baseline.

CONCLUSIONS

TDD increases after intraduodenal instillation of Intralipid in human subjects. This change was statistically most significant at 60 minutes. These observations may be critical for aspiration of lymph samples for early detection of gastrointestinal cancers in humans.

When Experts Fail: Use of a Short Turning Radius Colonoscope Facilitates Successful Completion of Colonoscopy in Patients with Bowel Fixity

BACKGROUND

Rates of incomplete colonoscopy in non-expert settings range up to 13%. Expert colonoscopists can complete ~ 95% colonoscopies when other endoscopists fail; however, a small number remain incomplete even in expert hands, typically due to bowel fixity.

AIMS

Pentax Retroview™ (EC-3490TLi) is a new slim colonoscope with a short turning radius (STR) and greater tip deflection (210°), which allows easy maneuverability across sharply angulated/fixed colonic bends. We evaluated the utility of this colonoscope for completing colonoscopies that fail even in the hands of expert colonoscopists.

METHODS

Retrospective chart review was performed, and main outcomes measured included cecal intubation rate, lesions detected, dosage of sedation used, and complications.

RESULTS

Using the STR colonoscope, complete colonoscopy to the cecum was possible in 34/37 patients (91.9%). No loss of lumen/blind advancement was necessary in any of the procedures. No adverse events occurred. Among the completed colonoscopies, 6/34 (17.6%) patients had adenomas, all proximal to the site of prior failure, including one advanced adenoma. All failures (n = 3, 8.1%) had a history of cancer surgeries, with peritoneal carcinomatosis/extensively fixed/frozen bowel (two patients) and an additional diverticular stricture with colo-vesical fistula (one patient).

CONCLUSION

STR colonoscope facilitates completion of a high proportion (91.9%) of colonoscopies that previously failed in expert hands. Its STR allows easy maneuverability across segments of sharp angulation with bowel fixity without need for blind advancement. The use of this colonoscope led to the detection of adenomas in 17.6% of patients, all proximal to the site of prior failed colonoscopy.

Atypical gastric ulcer with characteristic eschar appearance

Cocaine is a known potent vasoconstrictor known to cause various complications ranging from nasal septum perforations to myocardial ischemia. Many gastrointestinal effects of cocaine are reported, including bowel ischemia and gangrene. The knowledge on endoscopic appearance of cocaine-induced gastric ulcers is limited, mainly due to presentation of patients with frank perforations. We report a case of 48 year old male, a non-smoker but chronic substance abuser, who presented with abdominal pain, mainly epigastric with radiation to the back. Abdominal CT scan was normal, and endoscopy showing a single chronic non-bleeding ulcer at the incisura. The ulcer due to large sized, round in shape with irregular borders and thick eschar appearance is characteristic of cocaine-induced ulcer. It is important for physicians to remain cognisant of gastrointestinal complications of cocaine, recognise these ulcers endoscopically and prevent perforations in these subsets of patients.