Fecal Microbiota Transplantation (FMT) with Colonoscopy Is Superior to Enema and Nasogastric Tube While Comparable to Capsule for the Treatment of Recurrent Clostridioides difficile Infection: A Systematic Review and Meta-Analysis.

BACKGROUND: Several routes of fecal microbiota transplantation (FMT) administration are available for treating recurrent Clostridioides difficile infections (CDI), the most recent of which are capsules. AIM: To assess the efficacy of colonoscopy, capsule, enema, and nasogastric tube (NGT) FMT for the treatment of recurrent CDI. METHODS: We reported clinical outcomes of colonoscopy, capsule, enema, and NGT FMT for the treatment of recurrent CDI according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. During January 2000 to January 2018, three databases were searched: PubMed, EMBASE, and CINAHL. Primary outcome was overall cure rate which was assessed using a random effects model; secondary outcomes included adverse effects as well as subgroup analyses comparing donor relationship, sample preparation, and study design. RESULTS: Twenty-six studies (1309 patients) were included in the study. FMT was administered using colonoscopy in 16 studies (483 patients), NGT in five studies (149 patients), enema in four studies (360 patients), and capsules in four studies (301 patients). The random effects of pooled FMT cure rates were colonoscopy 94.8% (CI 92.4-96.8%; I2 15.6%), capsule 92.1% (CI 88.6-95.0%; I2 7.1%), enema 87.2% (CI 83.4-90.5%; I2 0%), and NGT/NDT 78.1% (CI 71.6-84.1%; I2 0%). On subgroup analysis of colonoscopy FMT, sample preparation methods had comparable cure rates: fresh 94.9% compared to 94.5%. Similarly, cure rates were unaffected by donor relationship: mixed 94.5% compared to unrelated donor 95.7%. CONCLUSION: CDI cure rates with FMT performed with colonoscopy are superior to enema and NGT FMT, while those with FMT with colonoscopy and capsule are comparable.

A Case of Candidal Infection of Large Biloma After CT-Guided Liver Biopsy Confirming Autoimmune Hepatitis.

Bilomas are unexpected post-procedural complications of cholecystectomies, hepatic resections, endoscopic retrograde cholangiopancreatography, and-rarely-liver biopsies. While uncommon, this should remain high on the differential in a patient presenting with sudden postop sepsis even in the absence of significant liver injury. Diagnosis involves coordination between interventional radiology, gastroenterology, and internal medicine. This involves a precise clinical history, invasive radiological techniques, and advanced interventional endoscopic solutions for diagnosis and treatment. This is a case of a biloma that occurred as a consequence of a post-hepatic biopsy and resulted in fungal infection, rather than its more common bacterial counterpart. Due to the unusual circumstances, a more circuitous route to the correct diagnosis and treatment was undertaken.

Endoscopic bariatric therapies for treating obesity: a learning curve for gastroenterologists.

Obesity represents a growing public health threat. Until recently, surgery was the primary means for treating pharmacotherapy resistant obese patients. However, therapeutic endoscopy has evolved as an effective and safe alternative strategy. Particularly, endoscopic bariatric therapy (EBT) can bridge the gap in patients who do not fit the BMI criteria for surgery and fail conservative or medical therapy. Today there are many tools within the realm of EBT available to endoscopists. While there are no formal guidelines for their use, training and use of these tools are limited by the type of institution, preferences of senior endoscopists, cost, and availability. We review different EBT tools available to trainees and gastroenterologist, and the learning curves associated with them.

Calcified Diverticula in the Setting of Per Rectal Bleed.

Diverticula and calcification of tissue are both common processes; however, when occurring synergistically, they present a rare phenomenon. Our case of a 62-year-old female with frank blood per rectum revealed calcified diverticula on a non-contrast computed tomography (CT) scan. This is a diagnosis of exclusion having ruled out differentials such as calcified fecaliths, ingestion of radiopaque liquids, pills or objects, calcified infectious cysts, and neoplastic masses. After resuscitation and stabilization of the patient, the subsequent priority shifted to the assessment of the rebleeding risk. With calcification being a rare occurrence with diverticula, it is unclear how this constant irritating nidus will affect the chances of rebleeding. Thus, for this particular phenomenon, patients with calcified diverticula should be monitored with dedicated surveillance to ascertain rebleeding rates.

A Rare Case of Ibuprofen-induced Acute Liver Injury.

Idiosyncratic drug-induced liver injury (iDILI) is the second-most-common cause of acute liver injury. When it is caused by ibuprofen, it is quite rare, especially when not accompanied by systemic signs or symptoms. A young female patient presented with an ibuprofen overdose suicide attempt and then developed an acute liver injury within a few days. Given its rarity, ibuprofen-induced iDILI was initially a secondary differential, but when her course did not improve as expected, she was quickly evaluated for liver transplant. She fully recovered without needing the transplant, but this case highlights the importance of not only early suspicion/detection but also early referral to a transplant hepatology service.

Hepatitis C virus genotype 3: clinical features, current and emerging viral inhibitors, future challenges.

Hepatitis C virus (HCV) represents a global burden on healthcare that affects over 150 million people worldwide. In the past, HCV genotype 3 was considered difficult to treat relative to other genotypes. Genotype 3 has been associated with a higher rate of complications, including fatty liver disease, fibrosis, hepatocellular carcinoma and mortality. However, with the advent of first- and second-generation direct-acting antivirals, genotype 3 can be treated effectively. Additionally, these new drugs are well tolerated by patients and have significantly fewer side effects compared to ribavirin and interferon-based regimens. However, while great strides have been made in overcoming biological barriers, our next challenge lies in overcoming economic and financial obstacles if we are to eradicate HCV genotype 3. Herein, we review the clinical features associated with HCV genotype 3, current and emerging treatment regimens, and challenges associated with treatment.

Pepto-Bismol Tablets Resembling Foreign Bodies on Abdominal Imaging.

A 28-year-old female presented to the emergency department (ED) with a one-day history of severe, diffuse abdominal pain of sudden onset. In the ED, an abdominal x-ray was done, which showed two hyperdense disc-shaped structures. When her abdominal pain did not subside, the ED performed a computerized tomography (CT) scan of the abdomen and pelvis with contrast, which showed the two previously noted 16 mm disc-shaped objects to actually be located within the cecum. Based on the history and imaging, it was deduced that the two discs were likely to be Pepto-Bismol tablets (Proctor & Gamble Co., Cincinnati, OH). Most medications are radiolucent, but there are some that are radiopaque, including Pepto-Bismol (also known as bismuth subsalicylate). While quite a rare occurrence, it is important to know about since it can lead to unnecessary endoscopy and patient anxiety.

Dilated Thoracic Esophagus Presenting with Painful Progressive Persistent Dysphagia and Leukocytosis of Unknown Origin.

Esophageal cancer is the eighth-most common cause of cancer-related mortality worldwide. The most common presenting symptom in advanced distal esophageal cancer is the sensation of sticking food, but it may sometimes present with bleeding and related complications, or asymptomatic leukocytosis. We present the case of a 77-year-old afebrile man with chronic alcoholism and a dilated thoracic esophagus with painful, progressive, and persistent dysphagia and leukocytosis of unknown origin. A 77-year-old man with a past medical history of hypertension and colonic cancer status post right hemicolectomy (surveillance negative) presented to the emergency department with painful, progressive, persistent, and worsening dysphagia for the past three weeks. It was associated with an unintentional weight loss of ten pounds in one month and nausea with non-bilious and non-bloody vomiting for several days. He denied fever, diarrhea, hoarseness of voice, change in bowel movement, hematemesis, hematochezia, melena, orthopnea, dyspnea at rest, palpitation, and abdominal pain. A chest x-ray (lateral view) showed debris in a dilated thoracic esophagus with fluid. An esophagogram showed a 10 x 3 cm obstructive mass with irregular mucosa within the proximal esophagus from the thoracic vertebra levels four to ten. A computed tomography scan of the chest with contrast showed long segment dilatation of the upper and mid-thoracic esophagus with generalized circumferential thickening of the distal esophagus. He was empirically on cefazolin and metronidazole but later switched to piperacillin, tazobactam, and fluconazole. Cardiac risk stratification was done for an esophagogastroduodenoscopy. However, the patient and the family opted for palliative care and agreed to a do-not-resuscitate/do-not-intubate status. In esophageal cancers, tumor-related leukocytosis and neutrophilia are common presentations. However, there is no standardized routine screening test for esophageal cancers. Thus, when asymptomatic afebrile elderly patients present with leukocytosis of unknown origin, clinicians should have suspicions of occult malignancy such as esophageal cancers, gastric cancer, and pancreatic cancer.

Improving the Laboratory Add-On Process and Increasing Housestaff Satisfaction with an EMR Intervention.

At a community hospital in Brooklyn, New York, the process for ordering add-on testing to drawn blood tubes involved filling out a paper sheet, then faxing and bulleting that sheet to the lab. It was a very inefficient, cumbersome, and unsatisfactory way of completing the process. In light of this, an EMR intervention was implemented in which the add-on order was placed as an EMR order. The study spanned over almost five years, over a year of which was post-intervention. There was a statistically significant increase in the number of add-on orders being placed as a result of the intervention. This has greatly improved housestaff satisfaction with the overall process. In conclusion, the project was a great success and met its goals of simplifying a difficult and cumbersome process while increasing user satisfaction.

Hepatitis C: improving the quality of screening in a community hospital by implementing an electronic medical record intervention.

Both the Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force (USPSTF) have recommended that adults born between the years of 1945-1965 should receive one-time testing for Hepatitis C Virus (HCV). In fact, Governor Andrew Cuomo of the State of New York had signed a bill on October 23, 2013 which mandated NY hospitals and healthcare providers to offer HCV testing to all "Baby Boomers." For our project, we wanted to increase our community hospital's compliance with this law and improve the quality of patient care in doing so. An electronic medical record intervention was implemented in conjunction with our information technology services department. This intervention would flag eligible patients and would run them through a predetermined algorithm to see if they needed HCV testing. Multiple plan, do, study, act (PDSA) cycles were run during the length of the study and many changes were made in order to achieve maximum effect. We ended up increasing our HCV testing rate from 47.2% (pre-intervention) to 87.9% (final month of the study), which was statistically significant with a p-value of <0.0000001. We also ended up with a framework that is both generalizable to other projects and is also self-sustaining, so that it can continue to run itself once all the project members have finished working there as house staff.

High value cost conscious care for diabetic patients at a community hospital.

At New York Methodist Hospital (Brooklyn, NY), the pattern of ordering glucose testing was studied by a multidisciplinary committee because the medicine residents were placing inpatient chemstrip orders at their own discretion. It was found that chemstrip orders were being placed at inappropriate frequencies, and occasionally on inappropriate patients. The staff and residents were educated on daily rounds in order to achieve the goal of reducing unwarranted fingersticks, consequently increasing patient satisfaction and reducing wasted time, resources, and costs. From April 2014 through March 2015 there were 274,889 fingersticks in the inpatient setting and following the intervention the number of fingersticks had decreased to 238,187, representing a significant decrease.

Gastrointestinal stromal tumour (GIST) in a young man with unprovoked haematemesis.

This case involves a 27-year-old Hispanic man who presented to the emergency department with two episodes of haematemesis with no other associated symptoms. In addition, he has no medical history, denies alcohol abuse, denies non-steroidal anti-inflammatory drug use and has never experienced these episodes before. Esophagogastroduodenoscopy evaluation showed a large gastric mass, and histological results obtained from several biopsies of the mass supported a diagnosis of gastrointestinal stromal tumour. His abdominal CT scan also supported this finding. However, the unprovoked haematemesis and young age of the patient does not fit the typical presentation of a gastrointestinal stromal tumour.