Water exchange technique improves colonoscopy in patients with spinal cord injury: Results of a matched cohort study.

Background and study aims Colonoscopies in patients with spinal cord injury (SCI) frequently remain incomplete. This study aimed to evaluate the feasibility and impact of water exchange colonoscopy (WE) in patients with SCI. Patients and methods Three matched groups, each of 31 patients (WE in SCI patients [WE-SCI]) and in the general population (WE-GP), carbon dioxide-based colonoscopy in SCI patients (CO 2 -SCI)) were analyzed retrospectively. Results Intubation of the cecum and the terminal ileum was achieved in every case in both WE groups. The intubations among the CO 2 -SCI patients succeeded in 29 cases (93.5 %, ns) and 20 cases (64.5 %, P <0.001), respectively. The cecal insertion time (23:17 ± 10:17 min vs. 22:12 ± 16:48 min) and bowel preparation during cecal insertion did not differ between WE-SCI groups. Insertion in the general population was faster (13:38 ± 07:00 min, P <.001) and cleanliness was better. Both WE-SCI groups showed significantly better cleansing results during drawback; the improvement in cleanliness was highest in the WE-SCI (based on the five-step scale 1.4 ± 0.8 vs. 0.8 ± 0.8, P = 0.001). Conclusions The WE in SCI patients is feasible and safe and has the potential to improve the quality of colonoscopies substantially.

Minor microbial alterations after faecal diversion do not affect the healing process of anus-near pressure injuries in patients with spinal cord injury - results of a matched case-control study.

STUDY DESIGN: Retrospective matched case-control study including patients with spinal cord injury who presented with an anus-near pressure injury. Two groups were formed based on the presence of a diverting stoma. OBJECTIVES: To evaluate the primary microbial colonisation and secondary infection of anus-near pressure injuries depending on the presence of a pre-existing diverting stoma and to investigate the effect on the wound healing. SETTING: University hospital with a spinal cord injury unit. METHODS: A total of 120 patients who had undergone surgery of an anus-near decubitus stage 3 or 4 were included in a matched-pair cohort study. Matching was realised according to age, gender, body mass index and general condition. RESULTS: The most common species in both groups was Staphylococcus spp.(45.0%). The only significantly different primary colonisation affected Escherichia coli, that was found in the stoma patients less often (18.3 and 43.3%, p < 0.01). A secondary microbial colonisation occurred in 15.8% and was equally distributed, except for Enterococcus spp. that was present in the stoma group only (6.7%, p < 0.05). The time to complete cure took longer in the stoma group (78.5 versus 57.0 days, p < 0.05) and was associated with a larger ulcer size (25 versus 16 cm2, p < 0.01). After correction for the ulcers' size, there was no association to outcome parameters such as overall success, healing time or adverse events. CONCLUSIONS: The presence of a diverting stoma alters the microbial flora of an anus-near decubitus slightly without impact on the healing process.

Mortality rates of severe COVID-19-related respiratory failure with and without extracorporeal membrane oxygenation in the Middle Ruhr Region of Germany.

The use of extracorporeal membrane oxygenation (ECMO) is discussed to improve patients' outcome in severe COVID-19 with respiratory failure, but data on ECMO remains controversial. The aim of the study was to determine the characteristics of patients under invasive mechanical ventilation (IMV) with or without veno-venous ECMO support and to evaluate outcome parameters. Ventilated patients with COVID-19 with and without additional ECMO support were analyzed in a retrospective multicenter study regarding clinical characteristics, respiratory and laboratory parameters in day-to-day follow-up. Recruitment of patients was conducted during the first three COVID-19 waves at four German university hospitals of the Ruhr University Bochum, located in the Middle Ruhr Region. From March 1, 2020 to August 31, 2021, the charts of 149 patients who were ventilated for COVID-19 infection, were included (63.8% male, median age 67 years). Fifty patients (33.6%) received additional ECMO support. On average, ECMO therapy was initiated 15.6 ± 9.4 days after symptom onset, 10.6 ± 7.1 days after hospital admission, and 4.8 ± 6.4 days after the start of IMV. Male sex and higher SOFA and RESP scores were observed significantly more often in the high-volume ECMO center. Pre-medication with antidepressants was more often detected in survivors (22.0% vs. 6.5%; p = 0.006). ECMO patients were 14 years younger and presented a lower rate of concomitant cardiovascular diseases (18.0% vs. 47.5%; p = 0.0004). Additionally, cytokine-adsorption (46.0% vs. 13.1%; p < 0.0001) and renal replacement therapy (76.0% vs. 43.4%; p = 0.0001) were carried out more frequently; in ECMO patients thrombocytes were transfused 12-fold more often related to more than fourfold higher bleeding complications. Undulating C-reactive protein (CRP) and massive increase in bilirubin levels (at terminal stage) could be observed in deceased ECMO patients. In-hospital mortality was high (Overall: 72.5%, ECMO: 80.0%, ns). Regardless of ECMO therapy half of the study population deceased within 30 days after hospital admission. Despite being younger and with less comorbidities ECMO therapy did not improve survival in severely ill COVID-19 patients. Undulating CRP levels, a massive increase of bilirubin level and a high use of cytokine-adsorption were associated with worse outcomes. In conclusion, ECMO support might be helpful in selected severe cases of COVID-19.

Argon Plasma Coagulation of Gastric Inlet Patches of the Cervical Esophagus Relieves Vocal and Respiratory Symptoms in Selected Patients.

OBJECTIVES: Argon plasma coagulation (APC) of gastric inlet patches of the cervical esophagus (GIP) has been shown to relieve the globus sensation. This study aimed to investigate the long-term effects of APC therapy on a variety of laryngopharyngeal symptoms. METHODS: Patients with laryngopharyngeal symptoms who had undergone endoscopic GIP eradication via APC therapy were eligible for a retrospective observational cohort study. Symptom relief was assessed by a five-grade scale during a structured interview. Statistical analysis included ANOVA, the chi-squared and t-test. RESULTS: A total of 45 patients (61.0 (52.0; 69.0) years, 26 (57.8%) female) were included after a follow-up time of 85.0 (55.3; 111.0) months. Symptoms included dysphagia (56.0%), dysphonia (51.0%), hoarseness (76.0%), the necessity of throat clearing (73.0%), globus sensation (56.0%) and heartburn (71.0%). Complete GIP eradication was achieved after one session in 25 (55.6%), repetitive sessions were needed in the remaining cases. Fourteen patients (31.1%) reported a very strong, 11 (24.4%) a strong and 8 patients (17.8%) an intermediate improvement; five patients did not benefit. The most apparent improvement was seen regarding hoarseness (from 2.6 ± 1.7 to 1.2 ± 1.3), the necessity of throat clearing (from 2.6 ± 1.7 to 1.1 ± 1.3), globus sensation (from 2.0 ± 1.9 to 0.9 ± 1.3) and heartburn (from 2.5 ± 1.8 to 1.4 ± 1.6). Adverse events included post-endoscopic pain (n = 6, 13.3%) and purulent pharyngitis (n = 2, 4.4%). CONCLUSIONS: The APC therapy of GIP is safe and leads to long-term relief of laryngopharyngeal symptoms in carefully selected patients.

Tube removal, tailored antibiotic treatment and endoscopic suturing effectively treats peristomal infection and consecutive persisting gastrostomy fistula - a case series.

OBJECTIVES: Peristomal leakage, infection, and persisting fistula after tube removal are rare, but well-known complications in long-term percutaneous endoscopic gastrostomies (PEG). A standard treatment procedure is missing. This case series describes a procedure of tube removal, tailored antibiotic therapy and endoscopic closure with a gastropexy device after mechanical de-epithelialization of the fistulous tract. CASE PRESENTATION: Three patients with infected long-standing PEG (4 to 21 years) were included. The tubes were removed endoscopically and tailored antimicrobial therapy was administered over 10 to 14 days. The persisting fistula was de-epithelialized mechanically and sutured under endoscopic control with a dedicated gastropexy device 11 to 25 days thereafter. A new PEG tube was placed in the same session on a different site. After 30 days the fistula had healed completely, and the PEG worked well in all subjects. CONCLUSIONS: Endoscopic sealing of a persisting fistula with a dedicated gastropexy device after thorough de-epithelialization is a promising technique that needs confirmation by larger studies.

Fecal diversion does not support healing of anus-near pressure ulcers in patients with spinal cord injury-results of a retrospective cohort study.

STUDY DESIGN: Retrospective cohort study including spinal cord injured patients with anus-near pressure ulcers. OBJECTIVE: The primary objective was to evaluate the impact of stool diversion via stoma on the decubital wound healing. Secondary objectives included the risk of complications and ulcer recurrence. Associations between the wound healing and potentially interfering parameters were determined. SETTING: University hospital with a spinal cord injury unit. METHODS: A total of 463 consecutive patients who presented with a decubitus were retrospectively included. Patients with and without a stoma were compared using descriptive and explorative statistics including multiple regression analysis. RESULTS: The severity of the pressure ulcers was determined as stage 3 in two-thirds and stage 4 in one-third of all cases. The wound healing lasted longer in the 71 stoma-presenting patients than in the 392 patients with undeviated defecation (77 vs. 59 days, p = 0.02). The age (regression coefficient b = 0.41, p = 0.02), the ASA classification (b = 16.04, p = 0.001) and the stage of the ulcers (b = 19.65, p = 0.001) were associated with prolonged ulcer treatment in the univariate analysis. The multiple regression analysis revealed that the fecal diversion (b = -18.19, p = 0.03) and the stage of the ulcers (b = 21.62, p = 0.001) were the only predictors of delayed wound healing. CONCLUSION: The presence of a stoma is not related to improved wound healing of ulcers near the anus. On the contrary, stoma patients needed more time until complete wound healing, conceivably related to selection bias. Nonetheless, we currently do not recommend fecal diversion to be the standard concept for decubitus treatment.

Similar Adenoma Detection Rates in Colonoscopic Procedures of Patients with Spinal Cord Injury Compared to Controls.

BACKGROUND: Cancer is a major cause of death in patients with spinal cord injury (SCI). Preventive strategies, such as colonoscopy, deal with higher burdens that may lead to lower quality. AIMS: The primary objective was to evaluate the adenoma detection rate. Secondary objectives were to investigate other quality indicators regarding bowel preparation, sedation, and endoscopy. METHODS: Consecutive SCI patients who had undergone colonoscopy from 2003 to 2014 were assigned to a control group matched for age, gender, and year of procedure and reviewed retrospectively. RESULTS: Bowel preparation lasted longer (3.6 ± 1.5 vs. 1.2 ± 0.6 days, p = 0.001), achieved unsatisfactory cleansing results more often (23.7 vs. 3.6%) and caused more adverse events in 236 SCI compared to 414 control patients. Colonoscopy needed a longer time (36.9 vs. 25.0 min) and remained incomplete more often (24.6 vs. 4.6%), resulting in more re-colonoscopies (14.8 vs. 4.3%). Endoscopy- and sedation-related adverse events were equal. However, neither overall nor size-dependent polyp (30.9 vs. 34.8%), adenoma (21.2 vs. 21.0%), advanced adenoma (6.8 vs. 7.2%), or cancer (1.7 vs. 2.0%) detection rates differed. CONCLUSION: Despite intensified protocols, bowel preparation shows inferior results in SCI patients; colonoscopy needs more effort to succeed but achieves a comparable quality.

Phenotype of histologically suspected drug-induced colitis; results of a comparative, retrospective cohort study.

Background/aims: Drug-induced colitis (DiC) is a rarely reported form of colonopathy and data about the clinical and endoscopic characteristics are scarce. The aim was to investigate the phenotype of DiC. Methods: Patients in a retrospective case control study were assigned to either DiC or one of two age- and gender-matched control groups (non-inflammatory controls and inflammatory colitis from other causes) based on histopathological findings. Patients' basic characteristics, symptoms, biochemical results and endoscopic appearance were collected. Statistical analysis included ANOVA, the chi-squared test and two-tailed t-test. Results: A total of 211 patients with DiC were included (97 males, age 62.1 ± 16.1 years, BMI 25.9 ± 6.1 kg m-2). In comparison to both control groups, DiC patients presented higher ASA and ECOG-scores and more particularly atherosclerotic comorbidities. The most abundant symptoms were abdominal pain (51.8%), diarrhoea (50.7%) and haematochezia (24.3%). The red blood cell count demarcated anaemia (12.7 ± 2.3 mg/dl) and C-reactive protein was slightly elevated (2.7 ± 5.2 mg/dl). The endoscopic features included erythema (46.9%), oedema (29.9%), erosions (29.9%) and ulcers (14.7%). The inflammation affected the rectum rarely (2.4%) but affected the rest of the colon without predilection in a segmental manner (p<.05). The severity of DiC was mostly mild (85.7%). Conclusions: The phenotype of DiC differs slightly from that of colitis from other causes. Taking the clinical features into account might help to confirm drug-induced aetiology once the pathologist has raised the suspicion.

Triggers of histologically suspected drug-induced colitis.

BACKGROUND: Drug toxicity is a common and even serious problem in the gastrointestinal tract that is thought to be caused by a broad spectrum of agents. Although withdrawal of the causative agent would cure the disease knowledge is scarce and mostly derives from case reports and series. AIM: To investigate potential triggers of drug-induced colitis (DiC). METHODS: We conducted a retrospective, observational case control study. Patients were assigned to DiC or one of two age- and gender-matched control groups (non-inflammatory controls and inflammatory colitis of another cause) based on histopathological findings. Histopathology was reassessed in a subset of patients (28 DiC with atherosclerosis, DiC without atherosclerosis and ischaemic colitis each) for validation purposes. Medical history was collected from the electronic database and patient records. Statistical analysis included chi-squared test, t-test, logistic and multivariate regression models. RESULTS: Drug-induced colitis was detected in 211 endoscopically sampled biopsy specimens of the colon mucosa (7% of all screened colonoscopic biopsy samples); a total of 633 patients were included equally matched throughout the three groups (291 males, mean age: 62.1 ± 16.1 years). In the univariate analysis, DiC was associated with diuretics, dihydropyridines, glycosides, ASS, platelet aggregation inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs), statins and fibrates, and with atherosclerosis, particularly coronary heart disease, and hyperlipoproteinaemia. Echocardiographic parameters did not show substantial differences. In the multivariate analysis only fibrates [odds ratio (OR) = 9.1], NSAIDs (OR = 6.7) and atherosclerosis (OR = 2.1) proved to be associated with DiC. Both DiC reassessment groups presented milder inflammation than ischaemic colitis. The DiC patients with atherosclerosis exhibited histological features from both DiC without atherosclerosis and ischaemic colitis. CONCLUSION: Several drugs indicated for the treatment of cardiovascular and related diseases are associated with DiC. Atherosclerosis and microcirculatory disturbances seem to play an important pathogenetic role.

Creeping Fat Assessed by Small Bowel MRI Is Linked to Bowel Damage and Abdominal Surgery in Crohn's Disease.

BACKGROUND: Crohn's disease (CD) leads to bowel damage and surgery in a significant proportion of patients. AIMS: The aim of the study was to evaluate the predictive value of creeping fat assessed by small bowel MRI in CD patients. METHODS: CD patients undergoing small bowel MRI were included in a retrospective observational cohort study. Clinical findings were extracted and correlated with radiological outcome measures. Logistic regression analysis was performed to assess predictors associated with a complicated course and surgery within 2 years and long-term follow-up. RESULTS: Ninety patients (49% female, median follow-up 93 months) were included. Creeping fat was identified in 21.1%. Of these patients, 68% and 79% developed bowel damage (p < .05) and 42% and 63% of patients revealing creeping fat underwent surgery within 2 years following MRI and total follow-up, respectively. The presence of creeping fat [odds ratio (OR) 4.0], inflammatory stenosis (OR 3.7), multisegmental (small) bowel (OR 4.5 and 3.8), and proximal small bowel inflammation (OR 5.0) were associated with inferior outcome (p < .05) in a univariate analysis. Creeping fat was independently associated with a disabling course, bowel damage, and surgery (OR 3.5 each, p < .05) in a multivariate analysis model. CONCLUSION: Creeping fat identified by small bowel MRI is associated with a complicated course and abdominal surgery in CD. Our data adds evidence that small bowel MRI facilitates risk stratification in order to define a patient at risk of disease-related complications in CD. [DRKS00011727, www.germanctr.de/ ].

Propofol sedation during gastrointestinal endoscopy arouses euphoria in a large subset of patients.

BACKGROUND: Propofol is recommended for sedation in gastrointestinal endoscopy (GE), but preliminary data suggest addictive potentials. OBJECTIVE: The objective of this article is to evaluate the frequency of predominantly euphoric reaction after GE and patients' subsequent reminiscences. METHODS: Eighty-two patients undergoing elective GE under propofol sedation were enrolled in a prospective observational study. The grade of anxiety, expectation or relief about the examination's result and affective state in terms of cheerfulness, relaxation, activation, sedation and anxiety were surveyed using a numeric rating scale (1 to 10) immediately before (t1), after GE (t2) and seven days (t3) later. Statistics: hierarchical cluster analysis, heat map, χ2 test and paired t test. RESULTS: Mean propofol dosage was 264 ± 120 mg. Two clusters of mood changes emerged (t1 vs. t2). One (n = 46, 56.1%) was characterized by an unease reaction pattern with equal values regarding cheerfulness, relaxation and anxiety, while relaxation decreased; the other cluster showed a euphoric reaction pattern (n = 36, 43.9%) with markedly increased cheerfulness, relaxation and decreased anxiety. These effects intensified at recall (t3). Despite similar endoscopy results, euphoric cluster patients rated these more positively. CONCLUSION: Propofol induces euphoria in nearly half of the patients undergoing elective GE with persisting, even enhanced reminiscence (germanctr.de, trial number DRKS00011202).

Gastrointestinal endoscopy under sedation is associated with pneumonia in older inpatients-results of a retrospective case-control study.

BACKGROUND AND AIMS: Apparent aspiration is a notable adverse event during gastrointestinal endoscopy under sedation (GIES), but data about inapparent aspiration are scarce. Generally, particularly older patients are at higher risk of suffering from adverse events. OBJECTIVE: The objective of this article is to determine the risk of pneumonia, lower respiratory tract infection (LRI) and systemic inflammatory activation after GIES, especially in patients of at least 65 years. METHODS: The retrospective case-control study included 250 patients undergoing GIES and assigned age-, gender- and time of performance-matched controls without invasive procedure or sedation (ratio 1:1). RESULTS: On day 3 patients of advanced age presented with both pneumonia and LRI more often (2.6 vs. 0.0%, p = 0.041 and 7.8 vs. 2.5%, p = 0.034, respectively). In general, several inflammatory parameters increased significantly after GIES (i.e. white blood cell count (increase of ≥ 25%) 18.6 vs. 6.9%, p < 0.001), leading to more frequent antibiotic treatment (6.8 vs. 1.6%, p = 0.004). The effects were less pronounced on day 7. CONCLUSIONS: Patients of advanced age carry an increased risk of pneumonia and LRI after GIES. Patients are generally more likely to feature inflammation and to receive antibiotic treatment.

[Cost assessment for endoscopic procedures in the German diagnosis-related-group (DRG) system - 5 year cost data analysis of the German Society of Gastroenterology project]. / Kosten endoskopischer Leistungen der Gastroenterologie im deutschen DRG-System ­ 5-Jahres-Kostendatenanalyse des DGVS-Projekts.

Background In the German hospital reimbursement system (G-DRG) endoscopic procedures are listed in cost center 8. For reimbursement between hospital departments and external providers outdated or incomplete catalogues (e. g. DKG-NT, GOÄ) have remained in use. We have assessed the cost for endoscopic procedures in the G-DRG-system. Methods To assess the cost of endoscopic procedures 74 hospitals, annual providers of cost-data to the Institute for the Hospital Remuneration System (InEK) made their data (2011 - 2015; §â€Š21 KHEntgG) available to the German-Society-of-Gastroenterology (DGVS) in anonymized form (4873 809 case-data-sets). Using cases with exactly one endoscopic procedure (n = 274 186) average costs over 5 years were calculated for 46 endoscopic procedure-tiers. Results Robust mean endoscopy costs ranged from 230.56 € for gastroscopy (144 666 cases), 276.23 € (n = 32 294) for a simple colonoscopy, to 844.07 € (n = 10 150) for ERCP with papillotomy and plastic stent insertion and 1602.37 € (n = 967) for ERCP with a self-expanding metal stent. Higher costs, specifically for complex procedures, were identified for University Hospitals. Discussion For the first time this catalogue for endoscopic procedure-tiers, based on §â€Š21 KHEntgG data-sets from 74 InEK-calculating hospitals, permits a realistic assessment of endoscopy costs in German hospitals. The higher costs in university hospitals are likely due to referral bias for complex cases and emergency interventions. For 46 endoscopic procedure-tiers an objective cost-allocation within the G-DRG system is now possible. By international comparison the costs of endoscopic procedures in Germany are low, due to either greater efficiency, lower personnel allocation or incomplete documentation of the real expenses.

Levothyroxine therapy and impaired clearance are the strongest contributors to small intestinal bacterial overgrowth: Results of a retrospective cohort study.

AIM: To identify a set of contributors, and weight and rank them on a pathophysiological basis. METHODS: Patients who have undergone a lactulose or glucose hydrogen breath test to rule out small intestinal bacterial overgrowth (SIBO) for various clinical symptoms, including diarrhoea, weight loss, abdominal pain, cramping or bloating, were seen as eligible for inclusion in a retrospective single-centre study. Clinical data such as co-morbidities, medication, laboratory parameters and other possible risk factors have been identified from the electronic data system. Cases lacking or with substantially incomplete clinical data were excluded from the analysis. Suspected contributors were summarised under four different pathophysiological pathways (impaired gastric acid barrier, impaired intestinal clearance, immunosuppression and miscellaneous factors including thyroid gland variables) and investigated using the χ2 test, Student's t-test and logistic regression models. RESULTS: A total of 1809 patients who had undergone hydrogen breath testing were analysed. Impairment of the gastric acid barrier (gastrectomy, odds ratio: OR = 3.5, PPI therapy OR = 1.4), impairment of intestinal clearance (any resecting gastric surgery OR = 2.6, any colonic resection OR = 1.9, stenosis OR = 3.4, gastroparesis OR = 3.4, neuropathy 2.2), immunological factors (any drug-induced immunosuppression OR = 1.8), altered thyroid gland metabolism (hypothyroidism OR = 2.6, levothyroxine therapy OR = 3.0) and diabetes mellitus (OR = 1.9) were associated significantly to SIBO. Any abdominal surgery, ileocecal resection, vagotomy or IgA-deficiency did not have any influence, and a history of appendectomy decreased the risk of SIBO. Multivariate analysis revealed gastric surgery, stenoses, medical immunosuppression and levothyroxine to be the strongest predictors. Levothyroxine therapy was the strongest contributor in a simplified model (OR = 3.0). CONCLUSION: The most important contributors for the development of SIBO in ascending order are immunosuppression, impairment of intestinal clearance and levothyroxine use, but they do not sufficiently explain its emergence.

Impact of Small Bowel MRI in Routine Clinical Practice on Staging of Crohn's Disease.

BACKGROUND AND AIMS: Small bowel visualisation is a complex diagnostic approach, but mandatory for risk stratification and stage-adjusted therapy in Crohn's disease. Current guidelines favour transabdominal ultrasound and small bowel MRI as methods of choice, although their clinical impact in daily practice remains controversial. The aim of this study was to evaluate the diagnostic benefit of small bowel MRI in Crohn's disease according to Montreal Classification, in routine practice. METHODS: Patients who underwent MR-enterography [MRE] or MR-enteroclysis [MRY] were included in a retrospective single-centre study. MRI findings were correlated with results from clinical work-up and evaluated in terms of [1] diagnostic yield, [2] significant additional information, and [3] alterations in the assessment of disease behaviour and location according to Montreal Classification. RESULTS: A total of 347 small bowel MRI examinations were analysed [MRE: 49 / MRY: 298]. MRI had an average sensitivity/specificity of 82.5% and 99.9% [positive predictive value: 99.8% / negative predictive value: 91.1%] respectively. In every second patient, new relevant diagnostic information was provided. Incorporation of the MRI results caused significant shifts in Montreal Classification, specifically higher L-levels [+21.2%; p < 0.05] and higher B-levels: [+24.6%; p < 0.05]. CONCLUSIONS: Even in routine practice, small bowel MRI is a powerful and reliable technique in small bowel work-up. Since MRE and MRY presented high diagnostic yields, often detected significant additional information, and significantly caused shifts in Montreal Classification, both techniques are confirmed to be excellent tools in diagnosing and monitoring Crohn's disease in its daily course.

Complicated fecal microbiota transplantation in a tetraplegic patient with severe Clostridium difficile infection.

A 65-year-old male suffering from acute spinal cord injury leading to incomplete tetraplegia presented with severe recurrent Clostridium difficile (C. difficile) infection subsequent to antibiotic treatment for pneumonia. After a history of ineffective antimicrobial therapies, including metronidazole, vancomycin, fidaxomicin, rifaximin and tigecycline, leading to several relapses, the patient underwent colonoscopic fecal microbiota transplantation from his healthy son. Four days subsequent to the procedure, the patient showed a systemic inflammation response syndrome. Without detecting an infectious cause, the patient received antimicrobial treatment, including tigecycline, metronidazole, vancomycin via polyethylene glycol and an additional enema for a period of seven days, leading to a prompt recovery and no reported C. difficile infection relapse during a 12 wk follow up.

Successful treatment of life-threatening bleeding from a duodenal posterior bulb peptic ulcer by an over-the-scope-clip.

Bleeding of peptic ulcer at the posterior duodenal bulb still is a particular endoscopic challenge with increased risk of treatment failure and worse outcome. In this article, we report successful treatment of an actively bleeding peptic ulcer located at the posterior duodenal wall, using an over-the-scope-clip in the case of a 54-year-old male patient with hemorrhagic shock. Incident primary hemostasis was achieved and no adverse events occurred during a follow-up of 60 d.

Gastrointestinal bleeding 30 years after a complicated cholecystectomy.

Gastrointestinal bleeding from small-bowel varices is a rare and difficult to treat complication of portal hypertension. We describe the case of a 79-year-old female patient with recurrent severe hemorrhage from small-bowel varices 30 years after a complicated cholecystectomy. When double balloon enteroscopy was unsuccessful to reach the site of bleeding, a rendezvous approach was favored with intraoperative endoscopy. Active bleeding from varices within a biliodigestive anastomosis was found and controlled by endoscopic injection of cyanoacrylate. Intraoperative endoscopy should be considered in the case of life-threatening gastrointestinal hemorrhage that is not accessible by conventional endoscopy.