Efficacy of Fecal Microbiota Transplant in Patients with Moderate or Severe Irritable Bowel Syndrome in India

Background and Aim: To study effect of FMT in patients with moderate or severe IBS. Methods: Patients with IBS for more than one year were offered three sessions of colonoscopicFMT in addition to standard of care. Severity of disease, psychological distress and QOL were assessed by IBS-SSS, HAM-D, HAM-A and WHO-QOL scores. Results: Ten patients with IBS (IBS-D 5, IBS-C 4 and IBS-M 1) were studied. Median IBS-SSS reduced from 313.5 (SD ± 66.8) at baseline to 163 (SD ± 84.5) at 1 week (p = 0.0005), 216 (SD ± 79.3) at 2 weeks (p = 0.003), 201(SD ± 86.6) at 4 weeks (p = 0.005) and 262 (SD ± 69.4) at 8 weeks. Median IBS-SSS at 12 weeks and 24 weeks was not significantly different from baseline. Reduction of IBS-SSS severity was seen in 8 (80%) patients at one week, 6(60%) at 2 and 4 weeks, 3(30%) at 8 weeks and 1(10%) at 12 and 24 weeks. weeks. Of four patients with depression, there was improvement in two patients at 2 and 4 weeks and one at 8 weeks. Quality of life improved in four patients at 2, 4 and 8 weeks, two patients at 12 weeks and one at 24 weeks. Three patients reported marked improvement of symptoms at 12 months along with change in stool odor to donor type. Conclusion: FMT results in short-term improvement in global symptoms of IBS, psychological distress and QOL. Repeat sessions of FMT did not accrue additional benefit.

Role of ultrathin transnasal esophagogastroduodenoscopy: experience with 50 patients.

Conventional gastroscopes have a diameter of 8.8–12 mm; ultrathin endoscopes have an outer diameter of 5.3–5.9 mm. We share our experience with 50 patients who underwent transnasal esophagogastroduodenoscopy using an ultrathin endoscope. The indications included endoscopyassisted nasogastric tube placement in 25 patients, tight lesions not negotiable with conventional endoscope in 9, restricted mouth opening in 9, corrosive injury in 3, restricted cervical spine movement in 2 and altered sensorium following cerebrovascular accident in 2 patients. Transnasal esophageal intubation failed in 1 patient each with oropharyngeal malignancy and lipoma annularis coli. Wire-guided naso-jejunal tube placement was done in 2 patients and transnasal percutaneous endoscopic gastrostomy was done in 1 patient. Two patients developed self-limiting epistaxis. Ultrathin transnasal esophagogastroduodenoscope is a useful tool in endoscopy units, particularly those dealing with oncology patients. Inability to deliver endotherapy due to small diameter of the working channel is a limitation.

Management of hepatitis C in HIV infected and other immunocompromised individuals.

Host immunity is important in determining the natural history of HCV infection. Patients with ineffective polyclonal HCV specific CD4+ response are persistently infected and loss of HCV-specific CD4+ T cells is associated with relapse of viraemia. Weak HCV-specific CD4+ response early in the course of chronic hepatitis C correlates with higher rates of fibrosis during subsequent course of the disease. In HIV co-infected patients, the HCV load is higher by an average of 0.5-1 log than the mono-infected patients. Based on the evidence from randomized control trials, the therapy for chronic hepatitis C in HIV co-infected patients is pegylated interferon and ribavirin for 48 weeks irrespective of genotype. In patients with CD4 counts < 200 cells/l and/or plasma HIV RNA above 100,000 copies/ml, it is recommended to administer HAART before HCV therapy. The sustained viral response rate achieved in the HCV/HIV co-infected patients is lower than that for mono-infected patients. Pre-treatment HCV RNA level and the genotype are the best predictors of sustained viral response. Treatment may be discontinued at 12 weeks if there is no early viral response as the likelihood of sustained viral response in this sub-group is only 2%. Biochemical response may not be relevant in HIV/HCV co-infected patients as a third of them have normal pretreatment ALT and normalization of ALT does not correlate with virological clearance. Histological response may not also correlate with virological response as up to 43% of subjects without sustained viral response may show histological improvement at the end of 48 weeks treatment. Liver disease due to HCV in patients with end stage renal disease on maintenance dialysis, is a significant cause of morbidity. The value of aminotransferases in patients on haemodialysis is lower than in the non-uraemic population and the level may not rise above the 'normal' range despite active liver disease. HCV RNA may be required to diagnose HCV infection, as anti-HCV may not be detectable, in such patients. Weekly pegylated interferon may be effective in them. In renal allograft recipients, paired biopsies may show rapid progression of liver disease in the absence of fibrosing cholestatic hepatitis. Interferon is contraindicated in this population due to increased risk of graft rejection. Following liver transplantation, recurrence of HCV is universal and histological evidence of recurrent infection may occur as early as 1 to 8 weeks after transplantation. Combination therapy with pegylated interferon and ribavirin may be effective in them.

Rapid progression of hepatitis C-induced liver failure in renal allograft recipients.

Early mortality due to hepatitis C virus (HCV)-related liver failure in renal allograft recipients in the absence of fibrosing cholestatic hepatitis is reported infrequently. We report six renal allograft recipients with HCV infection who died of rapid progression to liver failure. Of these, 2 were detected anti-HCV positive at screening prior to kidney transplantation and 4 were diagnosed after transplantation following derangement of liver function (HCV RNA positive in all 4, anti-HCV positive in 2). Median interval between kidney transplantation and derangement of liver function was 11.8 months (range 2 to 25) and median interval between transplant and death was 27 months (range 11 to 53). Liver biopsy performed during the terminal illness in 3 patients and post-mortem liver histology in 2 patients showed chronic hepatitis with mean grade of 10.2 (range 9 to 12) and stage 2.4 (range 2 to 3). None had features of fibrosing cholestatic hepatitis.

Intestinal lipoma: a rare cause of lower gastrointestinal haemorrhage.

Lower gastrointestinal bleeding from submucosal lipomas of the intestine is very rare. We report our experience with 3-patients presenting with lower gastrointestinal haemorrhage who were detected to have no cause other than intestinal lipomas. In two of these patients, the lipoma was in the small intestine and presented with chronic blood loss or recurrent episodes of bleeding. The third patient presented with massive haematochyzia and had a number of lipomas in the cecum and right colon. The diagnosis was established by laparotomy and intraoperative enteroscopy in 2 cases, and by colonoscopy and laparotomy in the third. Surgical excision of the lipoma led to cure in all the patients. We conclude that when laparotomy and intraoperative enteroscopy fail to show any cause for bleeding other than an innocuous-looking lipoma, it should be excised. The literature has been reviewed.