Idiopathic myointimal hyperplasia of the mesenteric veins: A systematic review and individual patient data regression analysis

BACKGROUND AND AIM

Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is an uncommon cause of colonic ischemia for which surgical treatment is typically curative. We describe clinical, radiologic, and endoscopic findings in IMHMV patients to provide clinicians with a framework for pre-surgical identification of this rare disease.

METHODS

We performed a systematic review of seven databases for IMHMV cases and identified additional cases from Yale New Haven Hospital records. To identify features specifically associated with colonic ischemia due to IMHMV, we performed multivariate logistic regression analysis incorporating data from a large cohort of patients with biopsy-proven ischemic colitis.

RESULTS

A total of 124 patients with IMHMV were identified (80% male, mean age 53 years, 56% Caucasian). Presenting symptoms were most commonly abdominal pain (86%) and diarrhea (68%). The most affected areas were the sigmoid colon (91%) and rectum (61%). Complications associated with diagnostic delay occurred in 29% of patients. Radiologic vascular abnormalities including non-opacification of the inferior mesenteric vein were observed in 35% of patients. Of the patients, 97% underwent curative surgical resection. Compared with non-IMHMV colonic ischemia, IMHMV was significantly associated with younger age, male sex, absence of rectal bleeding on presentation, rectal involvement, and mucosal ulcerations on endoscopy.

CONCLUSION

IMHMV is a rare, underreported cause of colonic ischemia that predominantly involves the rectosigmoid. Our findings suggest younger age, rectal involvement, and absence of rectal bleeding as clinical features to help identify select patients presenting with colonic ischemia as having higher likelihood of IMHMV and therefore consideration of upfront surgical management.

Rare, Overlooked, or Underappreciated Causes of Recurrent Abdominal Pain: A Primer for Gastroenterologists

Recurrent abdominal pain is a common reason for repeated visits to outpatient clinics and emergency departments, reflecting a substantial unmet need for timely and accurate diagnosis. A lack of awareness of some of the rarer causes of recurrent abdominal pain may impede diagnosis and delay effective management. This article identifies some of the key rare but diagnosable causes that are frequently missed by gastroenterologists and provides expert recommendations to support recognition, diagnosis, and management with the ultimate aim of improving patient outcomes.

Sex-specific impact of severe obesity in the outcomes of hospitalized patients with COVID-19: a large retrospective study from the Bronx, New York

It has been demonstrated that obesity is an independent risk factor for worse outcomes in patients with COVID-19. Our objectives were to investigate which classes of obesity are associated with higher in-hospital mortality and to assess the association between obesity and systemic inflammation. This was a retrospective study which included consecutive hospitalized patients with COVID-19 in a tertiary center. Three thousand five hundred thirty patients were included in this analysis (female sex: 1579, median age: 65 years). The median body mass index (BMI) was 28.8 kg/m². In the overall cohort, a J-shaped association between BMI and in-hospital mortality was depicted. In the subgroup of men, BMI 35–39.9 kg/m² and BMI ≥40 kg/m² were found to have significant association with higher in-hospital mortality, while only BMI ≥40 kg/m² was found significant in the subgroup of women. No significant association between BMI and IL-6 was noted. Obesity classes II and III in men and obesity class III in women were independently associated with higher in-hospital mortality in patients with COVID-19. The male population with severe obesity was the one that mainly drove this association. No significant association between BMI and IL-6 was noted.

DETECTING NUCLEAR MATERIALS IN URBAN ENVIRONMENTS USING MOBILE SENSOR NETWORKS

Radiation detectors installed at major ports of entry are a key component of the overall strategy to protect countries from nuclear terrorism. While the goal of deploying these systems is to intercept special nuclear material as it enters the country, no detector system is fool proof. Mobile, distributed sensors have been proposed to detect nuclear materials in transit should portal monitors fail to prevent their entry in the first place. In large metropolitan areas a mobile distributed sensor network could be deployed using vehicle platforms such as taxis, Ubers and Lyfts which are already connected to communications infrastructure. However, the potential geographic coverage that could be achieved using a network of sensors mounted on commercial passenger vehicles has not been established. Here we evaluate how a mobile sensor network could perform in New York City using a combination of radiation transport and Geographic Information Systems. The Geographic Information System QGIS is used in conjunction with OpenStreetMap data to isolate roads and construct a grid over the streets. Vehicle paths are built using pickup and drop off data from Uber, and data from the New York State Department of Transportation.

Stool cultures show a lack of impact in the management of acute gastroenteritis for hospitalized patients in the Bronx, New York

Background

Acute gastroenteritis (AGE) is diagnosed with a presentation of > 1 episode of vomiting and > 3 episodes of diarrhea in a 24-h period. Treatment is supportive, however, in severe cases antibacterial treatment may be indicated. Stool cultures can detect the responsible pathogenic bacteria and can guide antibiotic treatment, however, the indication for and efficacy of stool cultures is debatable. This study aimed to address the clinical utility of stool cultures in patients diagnosed with AGE.

Methods

A retrospective, multicenter study was performed in patients admitted for AGE from 2012 to 2014. Patient charts were obtained through hospital software using ICD-9 codes for AGE. Inclusion criteria was a documented diagnosis of AGE, age of 18 years or older, symptoms of both upper GI symptoms of abdominal pain and/or nausea and lower GI symptoms of diarrhea. Patients were classified into two main groups, those in whom (1) stool culture was obtained and (2) those in whom stool culture was not performed. Clinical features and outcomes were compared between groups. The diagnostic yield of stool cultures was assessed. All analysis were conducted using the Statistical Package for Social Science (SPSS).

Results

Of 2479 patient charts reviewed, 342 met the above criteria for AGE. 119 patients (34.8%) had stool cultures collected and 223 (65.2%) did not. Demographics, clinical features and serologic lab values are shown in Table 1. Of the 119 stool cultures performed, only 4% (n = 5) yielded growth of pathogenic bacteria (2 Pseudomonas spp, 2 Campylobacter spp, 1 Salmonella spp). The group who underwent stool culture had a higher percentage of patients with fevers (26% vs 13%,p < 0.003) and longer hospital length of stay (3.15 vs 2.28 days, p < 0.001) compared to the group that did not undergo stool cultures.

Conclusion

Stool cultures are commonly ordered when AGE is suspected. In our cohort, stool culture had a very low yield of detecting an underlying pathogen. Although patients who had stool cultures obtained were more likely to be febrile and to have a longer length of hospital stay than were those who did not have stool cultures, for the vast majority of patients, stool culture played little to no role in patient management. Further studies are needed to which patients benefit most from undergoing stool culture.

Chronic Rifaximin Use in Cirrhotic Patients Is Associated with Decreased Rate of C. difficile Infection

BACKGROUND AND AIM

Rifaximin is an antimicrobial which is used for prophylaxis of hepatic encephalopathy in patients with cirrhosis and has known anti-Clostridioides difficile activity. The aim of this study is to assess whether the rate of C. difficile infection (CDI) is decreased in patients with cirrhosis on chronic rifaximin compared with those who are not.

METHODS

We retrospectively identified consecutive patients admitted to Montefiore Medical Center from 2010 to 2014 with cirrhosis and diarrhea who were tested for CDI. Demographics, comorbidities, medication exposure, baseline laboratory data, and outcomes were recorded. Patients with cirrhosis and diarrhea on chronic rifaximin were compared with those not on rifaximin. The chronic rifaximin group was then isolated, and those with and without CDI were compared.

RESULTS

Of 701 patients with cirrhosis and diarrhea, 149 were on chronic rifaximin and 552 were not. 12.8% of patients on chronic rifaximin had CDI compared with 29.7% of those not on rifaximin (P < 0.001). Patients on rifaximin had higher MELD (19.7 vs. 15.5, P < 0.001), 30-day mortality (26.2% vs. 16.1%, P < 0.01), and ICU requirement compared with those not on rifaximin.

CONCLUSION

Patients with cirrhosis who are on chronic rifaximin have decreased rates of CDI compared with those not on this therapy. Despite its risk for promoting resistance, chronic rifaximin use may have a beneficial effect in preventing CDI in patients with cirrhosis.

Older patients are significantly more likely to have colon ischaemia-associated conditions that are chronic and complex

BACKGROUND

Colon ischaemia is a common disease which has been associated with various medications and comorbidities.

AIM

To test the hypothesis that there are differences in the frequencies of these associations in older compared with younger patients.

METHODS

A retrospective cohort study was performed of patients hospitalized with colon ischaemia at two major medical centres from 2005-2017. Clinical, colonoscopic and pathologic criteria were used to identify patients admitted with colon ischaemia; patients with other types of colitis were excluded. Demographic and medical data were extracted. Two cohorts were created: patients aged 18-64 years and patients > 65 years. These were compared using SAS 14.3.

RESULTS

A total of 788 patients were included, of which 271 (34.4%) were of ages 18-64 years, and 517 (66.6%) were 65 years old or older. In the older cohort, constipation-inducing medications (83.8% vs 64.1%; P = <0.0001), diuretics (38.1% vs 25.1%; P = <0.001) and nonsteroidal anti-inflammatory drugs (58% vs 41.5%; P = <0.0001) were more common than in the younger cohort. Antipsychotic medication use was more common in the younger cohort (10.4% vs 5.4%; P = 0.01). There was a higher percentage of younger patients with a history of hypercoaguable state (1.9% vs 0.2%; P = 0.03) and dialysis dependence (22.9% vs 8.7%; P = <0.01), while a higher percentage of patients in the older cohort had a history of chronic obstructive pulmonary disease (12% vs 6.3%; P = 0.01) or atrial fibrillation (18.9% vs 10.3%; P = <0.01).

CONCLUSIONS

Our study shows that older patients are more likely to have colon ischaemia-associated conditions that are chronic and complex, while younger patients are more likely to have acute colon ischaemia-associated conditions.

Microbiome predictors of dysbiosis and VRE decolonization in patients with recurrent C. difficile infections in a multi-center retrospective study

The gastrointestinal microbiome is intrinsically linked to the spread of antibiotic resistance. Antibiotic treatment puts patients at risk for colonization by opportunistic pathogens like vancomycin resistant Enterococcus and Clostridioides difficile by destroying the colonization resistance provided by the commensal microbiota. Once colonized, the host is at a much higher risk for infection by that pathogen. Furthermore, we know that microbiome community differences are associated with disease states, but we do not have a good understanding of how we can use these changes to classify different patient populations. To that end, we have performed a multicenter retrospective analysis on patients who received fecal microbiota transplants to treat recurrent Clostridioides difficile infection. We performed 16S rRNA gene sequencing on fecal samples collected as part of this study and used these data to develop a microbiome disruption index. Our microbiome disruption index is a simple index that is predictive across cohorts, indications, and batch effects. We are able to classify pre-fecal transplant vs post-fecal transplant samples in patients with recurrent C. difficile infection, and we are able to predict, using previously-published data from a cohort of patients receiving hematopoietic stem cell transplants, which patients would go on to develop bloodstream infections. Finally, we also identified patients in this cohort that were initially colonized with vancomycin resistant Enterococcus and that 92% (11/12) were decolonized after the transplant, but the microbiome disruption index was unable to predict such decolonization. We, however, were able to compare the relative abundance of different taxa between the two groups, and we found that increased abundance of Enterobacteriaceae predicts whether patients were colonized with vancomycin resistant Enterococcus. This work is an early step towards a better understanding of how microbiome predictors can be used to help improve patient care and patient outcomes.

Review article: the pharmacological causes of colon ischaemia

BACKGROUND

Colon ischaemia is the most common ischaemic disorder of the gastrointestinal system, can affect any segment of the colon, and may present with a range of symptoms. Diagnosis can be challenging due to symptom overlap with other conditions, varied aetiology, and often rapid and self-resolving course.

AIM

To review comprehensively the literature regarding the pharmacological aetiologies of colonic ischaemia to enhance the understanding of the various mechanisms of disease, presentations, distribution, and outcomes.

METHODS

A PubMed search for "colon ischaemia" and "ischaemic colitis" alone as well as in combination with various known pharmacologic causes was performed. Only the highest quality and relevant literature was included in this review. The quality of the literature for each association was rated by the authors and a consensus was made when discrepancies were encountered. Only associations that were deemed "moderate" or "strong" were included.

RESULTS

The literature considering pharmacologically associated colonic ischaemia is diverse, lacks codification and is characterised by numerous case reports and case series. Constipation-inducing drugs, digoxin, hormonal therapies, illicit drugs, immunomodulators, laxatives, and NSAIDs were strongly associated with colonic ischaemia. Antimicrobials, appetite suppressants, chemotherapies, decongestants, diuretics, ergot alkaloids, serotonin agents, statins, and vasopressor agents were moderately associated.

CONCLUSIONS

Patients presenting with abdominal pain, diarrhoea, or bloody stool need to be evaluated for the possibility of this condition and treated accordingly. Timely diagnosis is necessary to improve patient outcomes. This review aims to increase awareness among clinicians regarding the presentation of pharmacologically induced colonic ischaemia.

Real-world multicentre experience of the pathological features of colonic ischaemia and their relationship to symptom duration, disease distribution and clinical outcome

AIM

To determine the pathological features of colonic ischaemia (CI) and their relationship to symptom duration, disease distribution and clinical outcome in a real-world, clinical setting.

METHOD

A retrospective, multicentre chart review was performed in patients diagnosed with CI at Montefiore Medical Center (January 2005 to July 2015), and Yale-New Haven Hospital (January 2005 to June 2010). Patients were included if clinical presentation, colonoscopic findings and colonic pathology were all consistent with CI.

RESULTS

Six hundred and sixteen patients with pathologically proven CI were included. Common pathological findings included inflammation (51.1%), ulceration (38.2%), fibrosis (26.0%) and necrosis (20.4%). Infarction and ghost cells were seen in 1.6% and 0.2% of cases, respectively. There was a significant relationship between symptom duration and hyalinization of the lamina propria (P = 0.05) and cryptitis/crypt abscesses (P = 0.01). Patients with isolated right CI (IRCI) were more likely than patients with isolated left CI (ILCI) to exhibit necrosis (P < 0.01), cryptitis/crypt abscess (P < 0.01) and inflammation (P = 0.03). Patients with poor outcomes were more likely to exhibit necrosis (P < 0.01) and capillary fibrin thrombi (P < 0.01) and less likely to exhibit fibrosis (P < 0.01) and epithelial changes (P < 0.01).

CONCLUSION

CI is accompanied by a broad spectrum of pathological findings. The traditional pathognomonic findings of CI are rare and cannot be relied upon to exclude the diagnosis. Patients with IRCI and/or poor outcomes were more likely to have pathological findings of necrosis than patients who had ILCI and/or nonpoor outcomes.

Metastatic adnexal cancer in a man

Primary cutaneous adnexal neoplasms are mostly benign in nature; however, there have been reports of malignant adnexal tumors with distant metastasis to lymph nodes. Adnexal cutaneous malignancy with metastasis to the gastrointestinal tract has never been reported. Here, we present a rare case of a man with primary adnexal cutaneous adenocarcinoma who presented with symptomatic anemia secondary to occult gastrointestinal bleeding, found to be from gastrointestinal metastasis of the adnexal malignancy.

Effect of Fecal Microbiota Transplantation on Recurrence in Multiply Recurrent Clostridium difficile Infection: A Randomized Trial

BACKGROUND

To date, evidence for the efficacy of fecal microbiota transplantation (FMT) in recurrent Clostridium difficile infection (CDI) has been limited to case series and open-label clinical trials.

OBJECTIVE

To determine the efficacy and safety of FMT for treatment of recurrent CDI.

DESIGN

Randomized, controlled, double-blind clinical trial. (ClinicalTrials.gov: NCT01703494).

SETTING

Two academic medical centers.

PATIENTS

46 patients who had 3 or more recurrences of CDI and received a full course of vancomycin for their most recent acute episode.

INTERVENTION

Fecal microbiota transplantation with donor stool (heterologous) or patient's own stool (autologous) administered by colonoscopy.

MEASUREMENTS

The primary end point was resolution of diarrhea without the need for further anti-CDI therapy during the 8-week follow-up. Safety data were compared between treatment groups via review of adverse events (AEs), serious AEs (SAEs), and new medical conditions for 6 months after FMT. Fecal microbiota analyses were performed on patients' stool before and after FMT and also on donors' stool.

RESULTS

In the intention-to-treat analysis, 20 of 22 patients (90.9%) in the donor FMT group achieved clinical cure compared with 15 of 24 (62.5%) in the autologous FMT group (P = 0.042). Resolution after autologous FMT differed by site (9 of 10 vs. 6 of 14 [P = 0.033]). All 9 patients who developed recurrent CDI after autologous FMT were free of further CDI after subsequent donor FMT. There were no SAEs related to FMT. Donor FMT restored gut bacterial community diversity and composition to resemble that of healthy donors.

LIMITATION

The study included only patients who had 3 or more recurrences and excluded those who were immunocompromised and aged 75 years or older.

CONCLUSION

Donor stool administered via colonoscopy seemed safe and was more efficacious than autologous FMT in preventing further CDI episodes.

PRIMARY FUNDING SOURCE

National Institute of Diabetes and Digestive and Kidney Diseases.

The Role of Stress, Social Support, and Family Environment in Adolescent Mothers' Parenting

This study assessed the role of stress, social support, and family environment on adolescent mothers'parenting behaviors. Seventy-five African American, mother-infant pairs participated in the study. Mothers were administered questionnaires and were each observed in a 10-minute teaching task with their babies. Findings revealed that the adolescent mother's own mother was the mostfrequent provider of support. The baby's fatherwas identified as the mostfrequent source of conflict. Mothers who identified more individuals as a source of conflict tended to have less positive parenting behaviors. Analyses revealed that child age and interpersonal conflict were significant predictors of maternal behavior In addition, social support moderated the effects of interpersonal conflict when conflicted networks were large. Parenting stress, per se, was not a significant predictor of maternal behavior.

Update on Colon Ischemia: Recent Insights and Advances

Colon ischemia (CI) is the most common manifestation of ischemic injury to the gastrointestinal (GI) tract. This usually self-limited disease is being diagnosed more frequently, and the list of known causes is increasing. Local hypoperfusion and reperfusion injury are both thought to contribute to the disease process, which manifests with a wide spectrum of injury including reversible colopathy (subepithelial hemorrhage and edema), transient colitis, chronic colitis, stricture, gangrene, and fulminant universal colitis. The distribution is usually segmental with left-sided disease (e.g., inferior mesenteric artery distribution) being more frequently observed than right-sided involvement (e.g., superior mesenteric artery distribution). Any portion of the colon can be affected, but the anatomic distribution of CI recently has been shown to be associated with outcome. Patients with isolated-right colon ischemia (IRCI) have a different presentation and worse outcomes than other distributions of disease. Although somewhat variable depending on disease location, CI presents with cramping abdominal pains over the segment of colon involved followed by a short course of bloody diarrhea. Diagnosis is usually made clinically and is supported with serologic, radiologic, and colonoscopic findings. Colonoscopy is the most accurate diagnostic study. Most patients respond to conservative supportive therapy although some with more severe disease require antimicrobials and/or surgical intervention.

Features and Outcomes of Patients With Ischemia Isolated to the Right Side of the Colon When Accompanied or Followed by Acute Mesenteric Ischemia

BACKGROUND & AIMS

Patients with ischemia isolated to the right side of the colon (IRCI) frequently have poor outcomes. IRCI and acute mesenteric ischemia (AMI) are caused by reductions in blood supply from the superior mesenteric artery and its branches. We investigated a group of patients with IRCI associated with AMI that developed initially or shortly thereafter, and compared outcomes of patients with IRCI and AMI vs those with only IRCI.

METHODS

We performed a retrospective study of data collected from 313 consecutive patients with colonic ischemia who were hospitalized at Montefiore Medical Center in New York from 1998 through 2009. Based on colonoscopy, biopsy analyses, and surgery reports, we identified patients with IRCI with concurrent or proximately developing AMI (IRCI+AMI) and those with only IRCI. Demographics, evaluation, disease distribution, and outcome data were compared between groups.

RESULTS

Of 313 patients with colonic ischemia, 20.8% had IRCI; of these, 84.6% had only IRCI and 15.4% had IRCI+AMI. Chronic obstructive pulmonary disease was found more frequently in patients with IRCI+AMI (40.0%) than in patients with IRCI alone (12.7%; P < .05). At the time of IRCI diagnosis, mean levels of blood urea nitrogen were significantly higher in patients with IRCI+AMI than with IRCI alone (37.9 ± 14.4 mEq/L vs 26.4 ± 18.8 mEq/L; P < .05), as were mean white blood cell counts (20.3 ± 12.1 vs 12.7 ± 6.8 × 10(3)/μL; P < .01). A higher proportion of patients with IRCI+AMI underwent surgery than patients with only IRCI (100.0% vs 43.1%; P = .001), and 30-day mortality was higher among patients with IRCI+AMI (70.0% vs 14.5% for patients with only IRCI; P < .001).

CONCLUSIONS

Based on an analysis of 313 patients with colonic ischemia, patients with IRCI+AMI have even more severe disease than those with IRCI alone. Chronic obstructive pulmonary disease was observed more frequently in patients with IRCI+AMI. Patients with IRCI+AMI had increased levels of blood urea nitrogen and/or white blood cell counts. Patients with IRCI should undergo vascular imaging analyses immediately to detect AMI; patients without AMI should be monitored closely for its subsequent development.

Is fecal microbiota transplantation (FMT) an effective treatment for patients with functional gastrointestinal disorders (FGID)?

BACKGROUND

Despite its high prevalence and significant effect on quality of life, the etiology of functional gastrointestinal disorders (FGID), and specifically irritable bowel syndrome (IBS), has yet to be fully elucidated. While alterations in immunity, motility, and the brain-gut axis have been implicated in disease pathogenesis, the intestinal microbiota are increasingly being shown to play a role and numerous studies have demonstrated significant differences from normal in the intestinal flora of patients with FGID, and between types of FGID. Fecal microbiota transplantation (FMT) is a curative therapy for Clostridium difficile infection (CDI), a disease hallmarked by intestinal dysbiosis, and FMT is now being explored as a means to also restore intestinal homeostasis in FGID.

PURPOSE

This review aims to investigate the role of intestinal microbiota in the pathogenesis of FGID, the implications of FMT for the treatment of FGID, and the challenges encountered in measuring response to a specific intervention in patients with FGID.

Intestinal microbiota and the efficacy of fecal microbiota transplantation in gastrointestinal disease

Fecal microbiota transplantation (FMT) refers to the infusion of a fecal suspension from a healthy person into the gastrointestinal (GI) tract of another person to cure a specific disease. FMT is by no means a new therapeutic modality, although it was only relatively recently that stool was shown to be a biologically active, complex mixture of living organisms with great therapeutic potential for recurrent Clostridium difficile infection and perhaps other GI and non-GI disorders. The published revelations about the human microbiome are bringing the strength of science to clinical observation and enhancing the understanding of not only disease but also how much of a person's daily function and health depends on the microorganisms living in intimate relationship with each cell in the body.

Effect of propofol anesthesia on force application during colonoscopy

BACKGROUND

Sedation is frequently used during colonoscopy to control patient discomfort and pain. Propofol is associated with a deeper level of sedation than is a combination of a narcotic and sedative hypnotic and, therefore, may be associated with an increase in force applied to the colonoscope to advance and withdraw the instrument.

OBJECTIVE

To compare force application to the colonoscope insertion tube during propofol anesthesia and moderate sedation.

DESIGN

An observational cohort study of 13 expert and 12 trainee endoscopists performing colonoscopy in 114 patients. Forces were measured by using the colonoscopy force monitor, which is a wireless, handheld device that attaches to the insertion tube of the colonoscope.

SETTING

Community ambulatory surgery center and academic gastroenterology training programs.

PATIENTS

Patients undergoing routine screening or diagnostic colonoscopy with complete segment force recordings.

MAIN OUTCOME MEASUREMENTS

Axial and radial forces and examination time.

RESULTS

Axial and radial forces increase and examination time decreases significantly when propofol is used as the method of anesthesia.

LIMITATIONS

Small study, observational design, nonrandomized distribution of sedation type and experience level, different instrument type and effect of prototype device on insertion tube manipulation.

CONCLUSIONS

Propofol sedation is associated with a decrease in examination time and an increase in axial and radial forces used to advance the colonoscope.

Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections

Clostridium difficile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratified depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mild-to-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classification of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI.

American Journal of Gastroenterology Lecture: Intestinal microbiota and the role of fecal microbiota transplant (FMT) in treatment of C. difficile infection

The vital roles that intestinal flora, now called microbiota, have in maintaining our health are being increasingly appreciated. Starting with birth, exposure to the outside world begins the life-long intimate association our microbiota will have with our diet and environment, and initiates determination of the post-natal structural and functional maturation of the gut. Moreover, vital interactions of the microbiota with our metabolic activities, as well as with the immunological apparatus that constitutes our major defense system against foreign antigens continues throughout life. A perturbed intestinal microbiome has been associated with an increasing number of gastrointestinal and non-gastrointestinal diseases including Clostridium difficile infection (CDI). It has become recognized that fecal microbiota transplantation (FMT) can correct the dysbiosis that characterizes chronic CDI, and effect a seemingly safe, relatively inexpensive, and rapidly effective cure in the vast majority of patients so treated. In addition, FMT has been used to treat an array of other gastrointestinal and non-gastrointestinal disorders, although experience in these other non-CDI diseases is in its infancy. More work needs to be done with FMT to ensure its safety and optimal route of administration. There is a conceptual sea change that is developing in our view of bacteria from their role only as pathogens to that of being critical to health maintenance in a changing world. Future studies are certain to narrow the spectrum of organisms that need to be given to patients to cure disease. FMT is but the first step in this journey.

Segmental increases in force application during colonoscope insertion: quantitative analysis using force monitoring technology

BACKGROUND

Colonoscopy is a frequently performed procedure that requires extensive training and a high skill level.

OBJECTIVE

Quantification of forces applied to the external portion of the colonoscope insertion tube during the insertion phase of colonoscopy.

DESIGN

Observational cohort study of 7 expert and 9 trainee endoscopists for analysis of colonic segment force application in 49 patients. Forces were measured by using the colonoscopy force monitor, which is a wireless, handheld device that attaches to the insertion tube of the colonoscope.

SETTING

Academic gastroenterology training programs.

PATIENTS

Patients undergoing routine screening or diagnostic colonoscopy with complete segment force recordings.

MAIN OUTCOME MEASUREMENTS

Axial and radial force and examination time.

RESULTS

Both axial and radial force increased significantly as the colonoscope was advanced from the rectum to the cecum. Analysis of variance demonstrated highly significant operator-independent differences between segments of the colon (zones) in all axial and radial forces except average torque. Expert and trainee endoscopists differed only in the magnitude of counterclockwise force, average push/pull force rate used, and examination time.

LIMITATIONS

Small study, observational design, effect of prototype device on insertion tube manipulation.

CONCLUSION

Axial and radial forces used to advance the colonoscope increase through the segments of the colon and are operator independent.

Long-term follow-up of colonoscopic fecal microbiota transplant for recurrent Clostridium difficile infection

OBJECTIVES

Clostridium difficile infection (CDI) has increased to epidemic proportions over the past 15 years, and recurrence rates of 30-65% with failure to respond to multiple courses of antimicrobials are common. The aim of this study was to report the efficacy of fecal microbiota transplantation (FMT) in patients with recurrent CDI in five geographically disparate medical centers across the United States.

METHODS

A multicenter long-term follow-up study was performed on the use of FMT for recurrent CDI. We were able to contact 77 of 94 eligible patients who had colonoscopic FMT for recurrent CDI ≥ 3 months before. Respondents completed a 36-item questionnaire via mail and/or phone that solicited pre-FMT, post-FMT, and donor data. Study outcomes included primary cure rate (resolution of symptoms without recurrence within 90 days of FMT) and secondary cure rate (resolution of symptoms after one further course of vancomycin with or without repeat FMT).

RESULTS

Seventy-three percent of patients were women and the average age was 65 years. The long-term follow-up period ranged from 3 to 68 months between FMT and data collection (mean: 17 months). The majority of patients were living independently at the time of FMT; however, 40% were ill enough to be hospitalized, homebound, or living in a skilled nursing facility. Spouses and partners accounted for 60% of donors and 27% were either first-degree relatives or otherwise related to the patient. The average symptom duration before FMT was 11 months and patients had failed an average of five conventional antimicrobial regimens; nonetheless, 74% of patients had resolution of their diarrhea in ≤ 3 days. Diarrhea resolved in 82% and improved in 17% of patients within an average of 5 days after FMT. The primary cure rate was 91%. Seven patients either failed to respond or experienced early CDI recurrence (≤ 90 days) after FMT. Four of these patients were successfully treated with vancomycin with or without probiotics; two patients were treated unsuccessfully with vancomycin, but subsequent FMT was successful; one patient was not treated and died in hospice care of unclear cause. The secondary cure rate was 98%. All late recurrences of CDI occurred in the setting of antimicrobial therapy for treatment of infections unrelated to C. difficile. In all, 53% of patients stated they would have FMT as their preferred first treatment option if CDI were to recur. While no definite adverse effects of FMT were noted, two patients had improvement in a pre-existing medical condition and four patients developed diseases of potential interest after FMT.

CONCLUSIONS

FMT is a rational, durable, safe, and acceptable treatment option for patients with recurrent CDI.

The intestinal microbiota and obesity

Obesity has been and continues to be an epidemic in the United States. Obesity has been addressed in multiple health initiatives, including Healthy People 2010, with no state meeting the proposed goal of a prevalence of obesity < 15% of the adult population. In contrast, obesity rates have continued to increase, with the self-reported prevalence of obesity among adults increasing by 1.1% from 2007 to the present. Indeed, since 2009, 33 states reported obesity prevalences of 25% or more with only 1 state reporting prevalence < 20%. There have been multiple approaches for the treatment of obesity, including fad diets, incentive-based exercise programs, and gastric bypass surgery; none of which have been optimal. In a murine model, it was shown that the majority of the intestinal microbiome consists of two bacterial phyla, the Bacteroidetes and the Firmicutes, and that the relative abundance of these two phyla differs among lean and obese mice; the obese mouse had a higher proportion of Firmicutes to Bacteroidetes (50% greater) than the lean mouse. The same results were appreciated in obese humans compared to lean subjects. The postulated explanation for this finding is that Firmicutes produce more complete metabolism of a given energy source than do Bacteroidetes, thus promoting more efficient absorption of calories and subsequent weight gain. Researchers were able to demonstrate that colonizing germ-free mice with the intestinal microbiome from obese mice led to an increased total body fat in the recipient mice despite a lack of change in diet. The converse, that, colonizing germ-free obese mice with the intestinal microbiome of thin mice causing a decreased total body fat in the recipient mice, has not yet been done. Other possible mechanisms by which the intestinal microbiome affects host obesity include induction of low-grade inflammation with lipopolysaccharide, regulation of host genes responsible for energy expenditure and storage, and hormonal communication between the intestinal microbiome and the host. The following review discusses the microbiome-obesity relationship and proposed mechanisms by which the intestinal microbiota is hypothesized to influence weight gain.

Treating Clostridium difficile infection with fecal microbiota transplantation

Clostridium difficile infection is increasing in incidence, severity, and mortality. Treatment options are limited and appear to be losing efficacy. Recurrent disease is especially challenging; extended treatment with oral vancomycin is becoming increasingly common but is expensive. Fecal microbiota transplantation is safe, inexpensive, and effective; according to case and small series reports, about 90% of patients are cured. We discuss the rationale, methods, and use of fecal microbiota transplantation.

Clinical patterns and outcomes of ischaemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study)

BACKGROUND

There is a lack of prospective studies evaluating the natural history of colonic ischaemia (CI). We performed such a study to evaluate the clinical presentation, outcome, and mortality as well as clinical variables associated with poor prognosis.

METHODS

An open, prospective, and multicentre study was conducted in 24 Spanish hospitals serving a population of 3.5 million people. The study included only patients who met criteria for definitive or probable CI. A website (www.colitisisquemica.org) provided logistical support.

RESULTS

A total of 364 patients met criteria for inclusion. CI was suspected clinically in only 24.2% of cases. The distribution of clinical patterns was as follows: reversible colopathy (26.1%), transient colitis (43.7%), gangrenous colitis (9.9%), fulminant pancolitis (2.5%), and chronic segmental colitis (17.9%). A total of 47 patients (12.9%) had an unfavorable outcome as defined by mortality and/or the need for surgery. Multivariate analysis identified the following signs as independent risk factors for an unfavorable outcome: abdominal pain without rectal bleeding [odds ratio (OR) 3.9; 95% confidence interval (CI) = 1.6-9.3], non-bloody diarrhoea (OR 10; 95% CI = 3.7-27.4), and peritoneal signs (OR 7.3; 95% CI = 2.7-19.6). Unfavorable outcomes also were more frequent in isolated right colon ischaemia (IRCI) compared with non-IRCI (40.9 vs. 10.3%, respectively; p < 0.0001). The overall mortality rate was 7.7%.

CONCLUSIONS

The clinical presentation of CI is very heterogeneous, perhaps explaining why clinical suspicion of this disease is so low. The presence of IRCI, and occurrence of peritoneal signs or onset of CI as severe abdominal pain without bleeding, should alert the physician to a potentially unfavorable course.

Mesenteric venous thrombosis

First differentiated from arterial causes of acute mesenteric ischemia 75 years ago, acute mesenteric venous thrombosis (MVT) is an uncommon disorder with non-specific signs and symptoms, the diagnosis of which requires a high index of suspicion. The location, extent, and rapidity of thrombus formation determine whether intestinal infarction ensues. Etiologies, when identified, usually can be separated into local intra-abdominal factors and inherited or acquired hypercoagulable states. The diagnosis is most often made by contrast-enhanced computed tomography, though angiography and exploratory surgery still have important diagnostic as well as therapeutic roles. Anticoagulation prevents clot propagation and is associated with decreased recurrence and mortality. Thrombectomy and thrombolysis may preserve questionably viable bowel and should be considered under certain circumstances. Evidence of infarction mandates surgery and resection whenever feasible. Although its mortality rate has fallen over time, acute MVT remains a life-threatening condition requiring rapid diagnosis and aggressive management. Chronic MVT may manifest with complications of portal hypertension or may be diagnosed incidentally by noninvasive imaging. Management of chronic MVT is directed against variceal hemorrhage and includes anticoagulation when appropriate; mortality is largely dependent on the underlying risk factor.

Colon ischemia: recent insights and advances

Ischemic colitis is the most common manifestation of ischemic injury to the gastrointestinal tract, and the variety of defined causes is increasing. Local hypoperfusion and reperfusion injury are both thought to contribute to the disease process, which manifests with a wide spectrum of injury including reversible colopathy (subepithelial hemorrhage and edema), transient colitis, chronic colitis, stricture, gangrene, and fulminant universal colitis. The distribution is typically segmental. Older studies showed that any portion of the colon can be involved; recently, it was established that the site of involvement and prognosis can be correlated. In particular, isolated involvement of the right side of the colon was shown to have a different presentation and worse outcome than ischemic colitis involving other segments. Diagnosis is usually made clinically and supported by radiologic imaging and colonoscopic evaluation. Most patients respond to conservative supportive therapy, although some with severe disease require surgical intervention.

Anatomic patterns, patient characteristics, and clinical outcomes in ischemic colitis: a study of 313 cases supported by histology

OBJECTIVES

Previous reports on the anatomic portions of colon involved in cases of supposed ischemic colitis (IC) have been limited by the absence of confirmation of the true nature of the disease. This is the first anatomic study to define the patterns of colon involvement in which only cases with biopsy-proven or -compatible IC and in which the entire colon had been visualized at surgery or at colonoscopy were included. The aims of this study were to re-examine patterns of colonic involvement in IC using only cases in which the diagnosis was biopsy proven or compatible, and to examine the clinical features and outcomes with regard to the segments of colon involved.

METHODS

A retrospective study was undertaken of patients with IC who were hospitalized at Montefiore Medical Center from 1998 to 2009. Patients were identified using computerized searches of ICD-9 (International Classification of Diseases, ninth revision) codes for colon ischemia, and patterns of colon involvement were then tabulated and categorized into five major groups: right colon, transverse colon, left colon, distal colon, and pancolon involvement. Patterns were classified based on the most proximal location of injury. Major anatomic patterns were then subcategorized into more specific segments of involvement. Only biopsy-proven or -compatible cases of IC in which the entire colon had been visualized at surgery or at colonoscopy were used in this study.

RESULTS

A total of 313 cases of biopsy-proven or -compatible IC were identified. Patterns and frequencies of involvement were: right colon, 25.2%; transverse colon, 10.2%; left colon, 32.6%; distal colon, 24.6%; and pancolon, 7.3%. Compared with all other patterns of IC, the right colon pattern was more likely to be associated with coronary artery disease (39.2 vs. 21.4%) or end-stage kidney disease requiring dialysis (20.3 vs. 7.7%), a longer hospitalization (median stay, 10 vs. 6 days), a greater need for surgery (44.3 vs. 11.5%), and the highest mortality rate (20.3 vs. 9%). Patients with a left colon pattern were less likely to be operated upon, and had a shorter length of stay than any other pattern of IC. Hyperthyroidism, stroke, and chronic obstructive pulmonary disease (COPD) were statistically significant independent predictors of mortality.

CONCLUSIONS

IC is typically a segmental disease, flanked by normal colon on either side of the affected area. Comorbid disease associations and severity of disease as reflected by length of hospitalization, need for surgery, and mortality vary with the segment involved. IC isolated to the right side of the colon is a more severe disease than IC affecting any other segment of colon.

On the role of ischemia in the pathogenesis of IBD: a review

Inflammatory bowel disease (IBD) is a chronic intestinal disorder comprising 2 distinct but often overlapping diseases: Crohn's disease and ulcerative colitis. Although much research to identify the etiology of IBD has focused on genetic constitution, infectious causes, and immune dysregulation, its exact cause and pathogenesis remain incompletely understood. Mesenteric blood flow, the intestinal microcirculation, and intestinal ischemia also have been proposed as etiologic, although they remain less-explored themes despite evidence suggesting a contributory role in IBD pathogenesis. The anatomy, architecture, and function of the splanchnic microcirculation will be reviewed here with regard to the development of intestinal microvascular ischemia, a pathologic process that appears to precede the classic changes that characterize IBD.

The efficacy of probiotics in the treatment of irritable bowel syndrome: a systematic review

INTRODUCTION

Probiotics may benefit irritable bowel syndrome (IBS) symptoms, but randomised controlled trials (RCTs) have been conflicting; therefore a systematic review was conducted.

METHODS

MEDLINE (1966 to May 2008), EMBASE (1988 to May 2008) and the Cochrane Controlled Trials Register (2008) electronic databases were searched, as were abstracts from DDW (Digestive Diseases Week) and UEGW (United European Gastroenterology Week), and authors were contacted for extra information. Only parallel group RCTs with at least 1 week of treatment comparing probiotics with placebo or no treatment in adults with IBS according to any acceptable definition were included. Studies had to provide improvement in abdominal pain or global IBS symptoms as an outcome. Eligibility assessment and data extraction were performed by two independent researchers. Data were synthesised using relative risk (RR) of symptoms not improving for dichotomous data and standardised mean difference (SMD) for continuous data using random effects models.

RESULTS

19 RCTs (18 papers) in 1650 patients with IBS were identified. Trial quality was generally good, with nine reporting adequate methods of randomisation and six a method of concealment of allocation. There were 10 RCTs involving 918 patients providing outcomes as a dichotomous variable. Probiotics were statistically significantly better than placebo (RR of IBS not improving=0.71; 95% CI 0.57 to 0.88) with a number needed to treat (NNT)=4 (95% CI 3 to 12.5). There was significant heterogeneity (chi(2)=28.3, p=0.001, I(2)=68%) and possible funnel plot asymmetry. Fifteen trials assessing 1351 patients reported on improvement in IBS score as a continuous outcome (SMD=-0.34; 95% CI -0.60 to -0.07). There was statistically significant heterogeneity (chi(2)=67.04, p<0.001, I(2)=79%), but this was explained by one outlying trial.

CONCLUSION

Probiotics appear to be efficacious in IBS, but the magnitude of benefit and the most effective species and strain are uncertain.

Postoperative Clostridium difficile-associated diarrhea

BACKGROUND

Abdominal surgery is thought to be a risk factor for Clostridium difficile-associated diarrhea (CDAD). The aims of this study were to discern pre-operative factors associated with postoperative CDAD, examine outcomes after postoperative CDAD, and compare outcomes of postoperative versus medical CDAD.

METHODS

Data from 3904 patients who had abdominal operations at Montefiore Medical Center were extracted from Montefiore's clinical information system. Cases of 30-day postoperative CDAD were identified. Pre-operative factors associated with developing postoperative CDAD were identified using logistic regression. Medical patients and surgical patients with postoperative CDAD were compared for demographic and clinical characteristics, CDAD recurrence, and 90-day postinfection mortality.

RESULTS

The rate of 30-day postoperative CDAD was 1.2%. After adjustment for age and comorbidities, factors significantly associated with postoperative CDAD were: antibiotic use (OR: 1.94), proton pump inhibitor (PPI) use (OR: 2.32), prior hospitalization (OR: 2.27), and low serum albumin (OR: 2.05). In comparison with medical patients with CDAD, postoperative patients with CDAD were significantly more likely to have received antibiotics (98% vs 85%), less likely to have received a PPI (39% vs 58%), or to have had a prior hospitalization (43% vs 67%). Postoperative patients with CDAD had decreased risk of mortality when compared with medical patients with CDAD (HR 0.36).

CONCLUSION

CDAD is an infrequent complication after abdominal operations. Several avoidable pre-operative exposures (eg, antibiotic and PPI use) were identified that increase the risk of postoperative CDAD. Postoperative CDAD is associated with decreased risk of mortality when compared with CDAD on the medical service.

Report of the multisociety task force on GI training

In summary, the task force recommends that the 4 gastroenterology/hepatology societies work with the ABIM to develop a competency-based curriculum that incorporates the Maintenance of Certification process to accommodate the need and desire for training and subsequent practice in specific areas of gastroenterology/hepatology. Given the increasing complexity of treating digestive diseases, allowing trainees the opportunity to develop enhanced ability and experience in specific disease areas or procedures will benefit patients. By developing these training pathways, training programs will need to measure the achievements of trainees in terms of specific defined competencies rather than the duration of training alone.