Indirect comparison of various lumen apposing metal stents for EUS-guided biliary and gallbladder drainage: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Studies assessing endoscopic ultrasound guided biliary drainage (EUS-BD) or gallbladder drainage (EUS-GB) using lumen apposing metal stents (LAMS) have shown variable results based on the type of LAMS. We performed a meta-analysis of the available data. METHODS: Multiple online databases were searched for studies using LAMS (AXIOS or SPAXUS) for EUS-BD and EUS-GB. The outcomes of interest were technical success, clinical success and adverse events. Pooled proportions along with 95% confidence intervals (CI) were calculated. RESULTS: A total of 18 observational studies were included: 11 for AXIOS stent (433 patients with mean age 72 years and 54% males) and 7 for SPAXUS stent (242 patients with mean age 74 years and 50% males). The respective pooled outcomes for AXIOS stent (EUS-BD and EUS-GB) were: technical success (96.2% and 96.2%), clinical success (92.8% and 92.7%), total adverse events (10.1% and 23.6%), and bleeding (3.7% and 4.8%). The respective pooled outcomes for SPAXUS stent (EUS-BD and EUS-GB) were: technical success (93.8% and 95.9%), clinical success (90.1% and 94.2%), total adverse events (12.6% and 9.5%), and bleeding (3.1% and 1.8%). CONCLUSION: AXIOS and SPAXUS stents demonstrate similar pooled technical and clinical success rates. Adverse events occurred in 23.6% patients (AXIOS stent) and 9.5% patients (SPAXUS stent) during EUS-GB.

Safety and efficacy of thalidomide in treatment of gastrointestinal bleeding secondary to angioectasias: a systematic review and meta-analysis.

BACKGROUND: Thalidomide has been used for angioectasia-associated refractory gastrointestinal bleeding (GIB), with studies showing variable efficacy and side effects profile. We conducted a meta-analysis to reconcile the data. METHODS: Online databases were searched for studies evaluating thalidomide in patients with refractory/recurrent GIB due to angioectasias. The outcomes of interest were cessation of bleeding, rebleeding, need for blood transfusion, hospitalization and adverse events. Pooled proportions for incidence, and odds ratios (OR) for comparison with control were calculated along with 95% confidence interval (CI). RESULTS: A total of seven studies with 346 patients (n = 269 thalidomide, n = 77 control) were included. Thalidomide dose was usually started at 50-100mg/day. The mean age was 65 years, 45% patients were men, and mean follow-up was 1.8 years. The pooled clinical outcomes with thalidomide were: cessation of bleeding 42.2% (95% CI 36.02 to 48.41), rebleeding 30%, need for blood transfusion 20.1%, hospitalization 40% and adverse events 55.9%. When compared with the control group in 2 studies, patients on thalidomide had significantly higher odds of cessation of bleeding (OR 21.40, 95% CI 5.78 to 79.29, p < 0.00001) and adverse events, with lower need for blood transfusion and hospitalization. DISCUSSION: In patients with angioectasias-related refractory/recurrent GIB, the use of thalidomide results in significantly decreased bleeding risk and may play a role in the management of such patients.

Meta-Analysis of Endoscopic Full-Thickness Resection Versus Endoscopic Submucosal Dissection for Complex Colorectal Lesions.

BACKGROUND: Studies evaluating endoscopic full-thickness resection (EFTR) and endoscopic submucosal dissection (ESD) for complex colorectal lesions have shown variable results. We conducted a meta-analysis of the available data. METHODS: Online databases were searched for studies comparing EFTR versus ESD for complex colorectal lesions. The outcomes of interest were resection rates, procedure time (min), and complications. Pooled odds ratios (OR) and standardized mean difference (SMD) along with 95% CI were calculated. RESULTS: A total of 4 studies with 530 patients (n=215 EFTR, n=315 ESD) were included. The mean follow-up duration was 5 months. The mean age of the patients was 68 years and 64% were men. The EFTR and ESD groups had similar rates of en bloc resection (OR: 1.73, 95% CI: 0.60-4.97, P=0.31) and R0 resection (OR: 1.52, 95% CI: 0.55-4.14, P=0.42). The EFTR group had significantly reduced procedure time (SMD -1.87, 95% CI: -3.13 to -0.61, P=0.004), total complications (OR: 0.24, 95% CI: 0.13-0.44, P<0.00001), perforation (OR: 0.12, 95% CI: 0.03-0.39, P=0.0005) and postresection electrocoagulation syndrome (OR: 0.06, 95% CI: 0.01-0.48, P=0.008). Delayed bleeding was similar in the 2 groups (OR: 0.80, 95% CI: 0.30-2.12, P=0.66). Residual/recurrent lesions were significantly higher in the EFTR group (OR: 4.67, 95% CI: 1.39-15.66, P=0.01). DISCUSSION: This meta-analysis of small studies with high heterogeneity showed that EFTR and ESD have comparable resection rates for complex colorectal lesions. EFTR is faster and has fewer complications, but it increases residual or recurrent lesions.

Conventional Versus Traction Endoscopic Submucosal Dissection for Colorectal Tumors: A Meta-analysis of Randomized Controlled Trials.

INTRODUCTION: Compared with conventional endoscopic submucosal dissection (C-ESD) for colorectal lesions, the traction method (T-ESD) allows the lesion to be stabilized with easier dissection. However, randomized controlled trials (RCTs) have reported conflicting results on the clinical outcomes of T-ESD as compared with C-ESD. We conducted a meta-analysis to compile the data. METHODS: Multiple databases were searched for RCTs evaluating C-ESD versus T-ESD for colorectal tumors. The end points of interest were procedure time (min), resection speed (mm²/min), R0 resection, en bloc resection, delayed bleeding, and perforation. Standard meta-analysis methods were employed using the random-effects model. RESULTS: Six RCTs with a total of 566 patients (C-ESD n=284, T-ESD n=282) were included. The mean age was 67±10 y and 60% were men. As compared with the T-ESD technique, the C-ESD group was associated with longer procedure time (SMD 0.91, 95% CI 0.58 to 1.23, P<0.00001) and lesser resection speed (SMD -1.03, 95% CI -2.01 to -0.06, P=0.04). No significant difference was found in the 2 groups with respect to R0 resection rate (RR 1.00, 95% CI 0.94 to 1.06, P=0.87), en bloc resection (RR 0.99, 95% CI 0.97 to 1.01, P=0.35), delayed bleeding (RR 0.66, 95% CI 0.17 to 2.59, P=0.55) and perforation (RR 2.16, 95% CI 0.75 to 6.27, P=0.16). DISCUSSION: On meta-analysis, pooled procedure time was significantly faster with T-ESD compared with C-ESD. The clinical outcomes, however, were comparable.

Metagenomic strain detection with SameStr: identification of a persisting core gut microbiota transferable by fecal transplantation.

BACKGROUND: The understanding of how microbiomes assemble, function, and evolve requires metagenomic tools that can resolve microbiota compositions at the strain level. However, the identification and tracking of microbial strains in fecal metagenomes is challenging and available tools variably classify subspecies lineages, which affects their applicability to infer microbial persistence and transfer. RESULTS: We introduce SameStr, a bioinformatic tool that identifies shared strains in metagenomes by determining single-nucleotide variants (SNV) in species-specific marker genes, which are compared based on a maximum variant profile similarity. We validated SameStr on mock strain populations, available human fecal metagenomes from healthy individuals and newly generated data from recurrent Clostridioides difficile infection (rCDI) patients treated with fecal microbiota transplantation (FMT). SameStr demonstrated enhanced sensitivity to detect shared dominant and subdominant strains in related samples (where strain persistence or transfer would be expected) when compared to other tools, while being robust against false-positive shared strain calls between unrelated samples (where neither strain persistence nor transfer would be expected). We applied SameStr to identify strains that are stably maintained in fecal microbiomes of healthy adults over time (strain persistence) and that successfully engraft in rCDI patients after FMT (strain engraftment). Taxonomy-dependent strain persistence and engraftment frequencies were positively correlated, indicating that a specific core microbiota of intestinal species is adapted to be competitive both in healthy microbiomes and during post-FMT microbiome assembly. We explored other use cases for strain-level microbiota profiling, as a metagenomics quality control measure and to identify individuals based on the persisting core gut microbiota. CONCLUSION: SameStr provides for a robust identification of shared strains in metagenomic sequence data with sufficient specificity and sensitivity to examine strain persistence, transfer, and engraftment in human fecal microbiomes. Our findings identify a persisting healthy adult core gut microbiota, which should be further studied to shed light on microbiota contributions to chronic diseases. Video abstract.

Prevalence of Gastrointestinal Symptoms, Hepatic Dysfunction, and Outcomes in Hospitalized Patients With COVID-19 Infection: An Early Experience.

Background and objective Coronavirus disease 2019 (COVID-19) was first reported in China two years ago as primarily a lung infection associated with cough and fever. It spread rapidly across the world and was declared a pandemic in early 2020, with 131 million people infected and 2.85 million deaths worldwide. To date, approximately 550,000 deaths have occurred due to COVID-19 in the United States and the numbers continue to rise. The extrapulmonary manifestations of this disease such as acute kidney injury (AKI), cardiovascular events, and gastrointestinal (GI) indications were not emphasized initially. However, subsequent studies from the United States and Canada have noted GI involvement in this disease in a large number of cases. Our group, taking care of these patients during the early phase of the pandemic in 2020, observed the frequent presentations of GI symptoms such as diarrhea and hepatic dysfunction and this study examines the same. Methods We undertook a retrospective study of 184 consecutive adult patients who were hospitalized at our center with confirmed COVID-19 infection, with a view to further elucidate the GI and hepatic involvement during the early breakout (March 17-May 17, 2020) of this illness. Results Major comorbidities associated with this illness in our cohort of patients included hypertension (HTN, 66%), diabetes mellitus (DM, 44%), obesity (41%), and chronic kidney disease (CKD, 17%). The most common GI manifestation was diarrhea (25%) and, interestingly, more than two-thirds of the patients had at least one liver function abnormality. The most common liver function abnormality was elevated serum aspartate aminotransferase (AST). Elevated AST was significantly correlated (p<0.05) with inflammatory markers such as D-dimer, lactate dehydrogenase (LDH), and ferritin, as well as AKI by bi-variate analysis. Salient observations from our study include higher mortality, frequent AKI, and cardiovascular events in male patients (p<0.05).  The liver injury in our cohort was suspected to be multifactorial, involving excessive cytokine release, viral infiltration of the hepatocytes, and cholangiocytes playing a role in transaminitis. The mean (±SD) duration of hospital stay was 13.5 ±15 days with 33% admissions to the ICU. The overall mortality was around 27%, with no significant difference between African Americans and Caucasians. However, patients admitted to the ICU had a very high mortality rate (54%) compared to those admitted to intermediate care (IMC)/acute care who had less severity of illness and associated pulmonary complications. Conclusions This study evaluates the presence of comorbidities such as DM, HTN, and obesity in patients hospitalized with COVID-19 at a community hospital in the Mid-Atlantic region of the United States. Statistical analysis of the data obtained for this cohort revealed a high frequency of GI symptoms, with diarrhea as the predominant common initial manifestation of the disease. Serum AST elevations were common and correlated with inflammatory markers and AKI. Male gender was also significantly associated with the development of AKI, higher frequency of cardiovascular events, and increased mortality. Overall mortality was noted to be 27%, with higher mortality in patients admitted to the ICU (54%) as compared to the IMC/floor (13%). These observations should spur future investigations into the role of these comorbidities, development of diarrhea, and hepatic dysfunction in COVID-19.

Identification and engraftment of new bacterial strains by shotgun metagenomic sequence analysis in patients with recurrent Clostridioides difficile infection before and after fecal microbiota transplantation and in healthy human subjects.

BACKGROUND: Recurrent Clostridioides diffícile infection (RCDI) is associated with major bacterial dysbiosis and colitis. Fecal microbiota transplantation (FMT) is a highly effective therapeutic modality for RCDI. While several studies have identified bacterial species associated with resolution of symptoms in patients, characterization of the fecal microbiome at the bacterial strain level in RCDI patients before and after FMT and healthy donors, has been lacking. The aim of this study was to examine the ability of bacterial strains from healthy donors to engraft in the gastrointestinal tract of patients with RCDI following FMT. METHODS: Fecal samples were collected from 22 patients with RCDI before and after FMT and their corresponding healthy donors. Total DNA was extracted from each sample and analyzed by shotgun metagenomic sequencing. The Cosmos-ID analysis platform was used for taxonomic assignment of sequences and calculation of the relative abundance (RA) of bacterial species and strains. From these data, the total number of bacterial strains (BSI), Shannon diversity index, dysbiosis index (DI), and bacterial engraftment factor, were calculated for each strain. FINDINGS: A marked reduction (p<0·0001) in the RA of total and specific bacterial strains, especially from phylum Firmicutes, was observed in RCDI patients prior to FMT. This change was associated with an increase in the DI (p<0·0001) and in pathobiont bacterial strains from phylum Proteobacteria, such as Escherichia coli O157:H7 and Klebsiella pneumoniae UCI 34. BSI was significantly lower in this group of patients as compared to healthy donors and correlated with the Shannon Index. (p<0·0001). Identification and engraftment of bacterial strains from healthy donors revealed a greater diversity and higher relative abundance of short-chain fatty acid (SCFA)-producing bacterial strains, including Lachnospiraceae bacterium 5_1_63FAA_u_t, Dorea formicigenerans ATCC 27755, Anaerostipes hadrusand others, in RCDI patients after FMT. INTERPRETATION: These observations identify a group of SCFA-producing bacterial strains from healthy donors that engraft well in patients with RCDI following FMT and are associated with complete resolution of clinical symptoms and bacterial dysbiosis.

Superiority of Higher-Volume Fresh Feces Compared to Lower-Volume Frozen Feces in Fecal Microbiota Transplantation for Recurrent Clostridioides Difficile Colitis.

GOALS: To compare the clinical outcomes of different protocols for fecal microbiota transplantation (FMT) in two community hospitals with similar patient demographics. BACKGROUND: FMT is commonly performed for recurrent or refractory Clostridioides difficile infection (rCDI). The clinical efficacy of FMT for this indication has been well established. However, there has been no standardization or optimization of the amount of fecal material, method of feces preparation, or route of delivery for FMT. STUDY: In this retrospective study, patients with rCDI received FMT using commercially available frozen fecal preparation (22.7 g) at Center A and locally prepared fresh fecal filtrate (30-50 g) at Center B. The primary outcome was defined as complete resolution of clinical symptoms related to rCDI after at least 8 weeks of follow-up. RESULTS: Fifty patients from each center were included in the study. Clinical success after initial FMT with lower-volume frozen fecal preparation at Center A was 32/50 (64.0%) compared to 49/50 (98.0%) with higher-volume fresh fecal filtrate at Center B (p < 0.0001). Seventeen patients in Center A and 1 patient in Center B underwent at least one repeat FMT. Overall clinical success was achieved in 43/50 (86%) of patients in Center A and 50/50 (100%) in Center B (p = 0.012). CONCLUSIONS: Our results suggest superior clinical efficacy of a larger amount of fresh fecal filtrate over a smaller amount of commercially available frozen fecal preparation. Further studies are needed to examine the effect of varying amounts of feces and the optimal protocol for FMT in patients with rCDI.

Magnesium Citrate Capsules in Colonoscopy Preparation: A Randomized Controlled Trial.

INTRODUCTION: Screening colonoscopies are recommended for the detection and prevention of colon cancer. Liquid colonoscopy preparations may be poorly tolerated. We evaluated the adequacy and tolerability of a novel low-cost colonoscopy preparation consisting of magnesium citrate capsules and bisacodyl (MCCB). METHODS: This is a single-center, assessor-blinded, randomized controlled trial of 51 patients undergoing screening colonoscopies, who received a bowel preparation of either 4 liters of GoLYTELY (Braintree Laboratories, Inc., Braintree, MA) or MCCB. The primary outcome was the rate of adequate colon cleanliness, defined as a total score ≥ 6 on the Boston Bowel Preparation Scale and no colon segment with a score of zero. The secondary outcome was patient satisfaction, assessed by a validated questionnaire. RESULTS: A total of 100% of patients in both arms achieved adequate colon cleanliness, and the magnesium citrate arm had superior patient satisfaction (mean satisfaction score: 54.8 vs. 172.8; p < 0.001). CONCLUSIONS: A pill-based colonoscopy preparation of MCCB may be a low-cost option for patients reluctant to consume a liquid preparation.

Potential clinical application of an automated fluorescent microbial cell counter in the detection of urinary tract infection.

BACKGROUND: Urinary tract infections (UTI) account for millions of office visits and approximately 400 000 hospital admissions every year in the United States; as a result, the cost burden of UTI in the USA is estimated at approximately $2.8 billion. There is a great deal of interest in finding newer, faster, and more reliable methods for diagnosing UTI as compared to the standard urine culture. METHODS: An automated fluorescent microbial cell counter was used to compare urine samples found to be positive for Escherichia coli UTI via cell culturing (n = 11) with UTI-negative samples (n = 10). RESULTS: Patients with a positive urine culture had significantly higher cell count results using the microbial cell counter (1.01 × 108 cells/mL) as compared to the negative samples (2.35 × 106 cells/mL; P = .0022). CONCLUSIONS: These observations suggest that automated microbial cell counters may serve as a rapid, objective method for the detection of bacteriuria in urine samples submitted for evaluation of suspected UTI.

Parkinson's Disease: The Emerging Role of Gut Dysbiosis, Antibiotics, Probiotics, and Fecal Microbiota Transplantation.

The role of the microbiome in health and human disease has emerged at the forefront of medicine in the 21st century. Over the last 2 decades evidence has emerged to suggest that inflammation-derived oxidative damage and cytokine induced toxicity may play a significant role in the neuronal damage associated with Parkinson's disease (PD). Presence of pro-inflammatory cytokines and T cell infiltration has been observed in the brain parenchyma of patients with PD. Furthermore, evidence for inflammatory changes has been reported in the enteric nervous system, the vagus nerve branches and glial cells. The presence of α-synuclein deposits in the post-mortem brain biopsy in patients with PD has further substantiated the role of inflammation in PD. It has been suggested that the α-synuclein misfolding might begin in the gut and spread "prion like" via the vagus nerve into lower brainstem and ultimately to the midbrain; this is known as the Braak hypothesis. It is noteworthy that the presence of gastrointestinal symptoms (constipation, dysphagia, and hypersalivation), altered gut microbiota and leaky gut have been observed in PD patients several years prior to the clinical onset of the disease. These clinical observations have been supported by in vitro studies in mice as well, demonstrating the role of genetic (α-synuclein overexpression) and environmental (gut dysbiosis) factors in the pathogenesis of PD. The restoration of the gut microbiome in patients with PD may alter the clinical progression of PD and this alteration can be accomplished by carefully designed studies using customized probiotics and fecal microbiota transplantation.

Uncommon Endoscopic Findings in a Tylosis Patient: A Case Report.

Palmoplantar tylosis is a focal non epidermolytic palmoplantar hyperkeratosis and is associated with a very high lifetime risk of developing squamous cell carcinoma of the esophagus (OSCC). It is generally inherited as an autosomal dominant trait with complete penetrance involving the RHBDF2 gene located on 17q25.1. The data regarding endoscopic appearance of the mucosa in patients with tylosis before development of cancer is limited. Surveillance endoscopy is recommended in family members which include annual esophagogastroscopy with biopsy of suspicious lesion with quadratic biopsies from upper, middle and lower esophagus. We describe characteristic endoscopy findings in a tylosis with no evidence of cancer. Prospective documentation of endoscopic findings of similar mucosal changes and disease process to establish a better screening protocol and supplemental intervention with agents like carotenoids (beta-carotene, alpha-carotene, lycopene, beta-cryptoxanthin, lutein, and zeaxanthin) may delay the progression and possibly revert to normal.

Safety and efficacy of fecal microbiota transplant in 9 critically ill patients with severe and complicated Clostridium difficile infection with impending colectomy.

OBJECTIVE: Significant data support the efficacy and safety of fecal microbiota transplant (FMT) in recurrent Clostridium difficile infection (CDI). The objective of our study was to determine the success rate of FMT in patients diagnosed with severe and complicated CDI with impending colectomy in the intensive care setting. METHODS: This was a 2-center study of 9 patients who met the criteria for severe and complicated CDI and had an impending colectomy. All 9 patients had failed conventional antibiotic therapy and were deemed too unstable to undergo a colectomy. Hence, FMT was considered to be the next step in managing their condition. RESULTS: Following FMT there was marked improvement in the patients' clinical status, with the resolution of diarrhea, reduced requirement for vasopressor, and the reduction in abdominal distention and pain. The primary cure rate of our study after a single round of FMT was 78% (7/9). Of the 9 patients 8 (88.88%) avoided a colectomy during the same hospital admission. the CDI-related death rate was 12.5% (1/9) and that of non-CDI was 12.5% (1/9). CONCLUSION: Our success with FMT in fulminant CDI shows that this therapeutic modality is a promising alternative to a colectomy and could be a potential bowel-saving intervention.

Marked Inhibition of Cellular Proliferation in the Normal Human Esophageal Epithelial Cells and Human Esophageal Squamous Cancer Cells in Culture by Carotenoids: Role for Prevention and Early Treatment of Esophageal Cancer

Background: Globally Esophageal cancer is a common cancer arising from human esophageal mucosal tissue. Epidemiological studies suggest inverse correlation between carotenoid intake and incident risk of this devastating malignancy. Methods: In an effort to examine the modulatory role of carotenoids in human esophageal carcinogenesis at a cellular level, we examined the effects of α-carotene and ß-carotenes, on cell proliferation and DNA synthesis in human esophageal epithelial (HEE) cells and human esophageal squamous cancer (HESC) cells in in-vitro cultures. HEE and HESC cells were incubated with different concentrations of α- and ß-carotenes both individually and in combination. Results: Both Carotenes significantly inhibited (p<0.05) cellular proliferation and decreased DNA synthesis in HEE and HESC cells. The effect of α- and ß-carotene together on DNA synthesis in HEE and HESC cells was significantly greater than either carotenoid alone, suggesting a synergistic effect. Greater magnitude of cellular inhibition of DNA synthesis was observed on HEE cells than HESC cells. Conclusion: Our results suggest that a combination of α-and ß-carotene may provide a novel strategy for prevention and treatment of esophageal and upper aero digestive tract cancer in humans.

Pancreatic Extramedullary Plasmacytoma Presenting as a Pancreatic Mass.

Extramedullary plasmacytomas (EMP) are a subcategory of plasma cell neoplasm that involves organs outside the bone marrow. Involvement of the pancreas is relatively rare, reported in only 2.3% of autopsies. Radiologic findings in plasmacytoma are nonspecific, but endoscopic ultrasound fine-needle aspiration is a fast and reliable technique to acquire a histologic sample for initial diagnosis. Recently, the use of fluorine-18 fluorodeoxyglucose PET/CT has been recommended in patients with active multiple myeloma and solitary plasmacytoma. We present an interesting case of primary EMP in the pancreatic body encasing the portal vein as well as the celiac artery, which was detected before the patient was diagnosed of multiple myeloma.

A Case of Acute Severe Hepatotoxicity and Mild Constriction of Common Bile Duct Associated With Ingestion of Green Tea Extract: A Clinical Challenge.

Consumption of herbal and dietary supplements (HDS) has increased worldwide as potential treatment for weight reduction and metabolic enhancement. However, it has been reported that HDS can cause liver injury which accounts for 20% of hepatotoxicity in the United States. Prevention of HDS induced liver injury remains a challenge due to difficulties in identifying the hepatotoxins in these preparations and lack of federal regulations for dietary supplements. We report a case of acute severe hepatic necrosis presumably due to consumption of nutritional supplement advertised to boost vitality and stem cells in human body.

EUS-guided colo-enterostomy as a salvage drainage procedure in a high surgical risk patient with small bowel obstruction due to severe ileocolonic anastomotic stricture: a new application of lumen-apposing metal stent (LAMS).

We submit the first case report of a successful EUS-guided transmural LAMS placement to drain the small bowel directly into the transverse colon in a high surgical risk patient with obstruction due to severe anastomotic stricture. We describe our technique for endoscopic colo-enterostomy and are hopeful that this will become a viable option to manage non-operable high-grade distal small bowel obstruction.

Unexplained Portal Gas in a Patient with an Esophageal Ulcer.

Emphysematous gastritis is the infection of gastric mucosa by gas producing microorganisms. It is a rare infection with less than 100 cases reported in the literature. The association of portal venous gas along with emphysematous gastritis is a rare entity. The concomitant portal venous gas worsens the outcome and warrant for surgical treatment. Our case has portal venous gas on CT scan along with suspicion of emphysematous gastritis and an esophageal ulcer on upper GI endoscopy. Medical treatment was given in our case of portal venous gas with the esophageal ulcer. Our case is unique because our patient responded to the conservative management. The patient presented with past history of polysubstance abuse and chronic kidney disease presented with symptoms of acute abdomen. CT scan revealed portal venous gas and suspicion of gastric emphysema. In addition, few foci of gas are seen along the vessels traversing between the stomach and liver. Endoscopy with gastric mucosa biopsy showed Candida albicans. Subsequently, antifungals were started. There was improvement in clinical condition of the patient. We, hereby, also summarize all the reported cases of emphysematous gastritis with treatment and outcome in each case. There has been change in trend from surgical to medical treatment.

Effect of Aging on the Composition of Fecal Microbiota in Donors for FMT and Its Impact on Clinical Outcomes.

BACKGROUND: Fecal microbiota transplantation (FMT) is emerging as an effective therapy for the treatment of recurrent Clostridium difficile infection (RCDI). Selecting an appropriate donor is vital to the success of FMT. However, the relationship between age of donors and the efficacy of FMT has not been examined to date. The aim of this study was to examine the effect of age of healthy donors on their fecal microbiota and assess the impact of these changes on the clinical efficacy of FMT. MATERIALS AND METHODS: This IRB-approved prospective study enrolled donors who were deemed healthy for FMT after careful detailed screening for infectious diseases per institutional protocol. The study was conducted between January 2011 and October 2014. Fecal samples were processed and analyzed using 16S rRNA gene amplicon sequencing. Differences in relative abundance and diversity of the donor fecal microbiota were analyzed in donors above and below 60 years of age. Effect of fecal microbiota from donors of different age groups on the efficacy of FMT was also evaluated. RESULTS: Twenty-eight healthy human subjects from ages 20-82 years were enrolled as donors for FMT. All patients receiving FMT from their respective donors had resolution of RCDI symptoms and had a negative C. difficile toxin test 4-12 weeks after FMT. Genomic analysis showed that the relative abundance of phylum Actinobacteria and family Bifidobacteriaceae was reduced in the donors ≥60 years of age (p < 0.05). However, Bacteroidetes-to-Fermicutes ratio did not demonstrate a significant change between the two groups. Furthermore, microbial diversity did not change significantly with advancing age. CONCLUSION: These observations suggest that aging in healthy donors is associated with compositional alterations in the fecal microbiome without change in the overall microbial diversity. These changes do not seem to affect the clinical efficacy of FMT in RCDI patients over 12 months.

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.