Fecal Microbiota Transplantation for Clostridioides Difficile Infection in Patients with Chronic Liver Disease

Background. Fecal microbiota transplantation (FMT) is a well-established therapeutic option for patients with antibiotic resistant Clostridioides difficile infection (CDI). However, the efficacy of FMT in patients with chronic liver disease remains elusive. Aims. We studied the effect of FMT on chronic liver disease (CLD) patients with CDI at our tertiary medical center. Methods. A cohort of all patients who received FMT from December 2012 to May 2014 for refractory or recurrent CDI was identified. Patients were monitored for a year after FMT. Descriptive analysis was conducted to compare the effect of FMT in patients with and without CLD. Results. A total of 201 patients with CDI received FMT, 14 of which had a history of CLD. Nine of these patients exhibited cirrhosis of the liver with a mean Child-Turcotte-Pugh score of 8. CDI development in these patients was associated with recent exposure to antibiotics and was observed to be significantly different between both groups (17% of CLD patients vs. 58% in the general cohort, p=0.01). Four patients with CLD received \u3e1 FMT, of which 2 did not respond to treatment. There was no significant difference between patients with liver disease and the rest of the cohort with regard to FMT response (12/14 (87%) vs. 164/187 (88%), p=0.68). Conclusion. FMT is a safe and effective therapy against CDI for patients with CLD and cirrhosis

Successful outcomes of fecal microbiota transplantation in patients with chronic liver disease

Background: Fecal Microbiota Transplantation (FMT) has been shown to be a promising treatment option for patients with recurrent and/ or refractory Clostridium Difficile Infection (CDI). Despite increasing research on FMT, little is known about outcomes in patients with liver disease or cirrhosis. We aimed to study the outcomes of FMT in patients with chronic liver disease (CLD) at our tertiary medical center. Methods: A cohort of all patients who had undergone FMT from December 2012 to May 2014 for refractory or recurrent CDI was identified. Patients were followed up for 1 year post-FMT. Response to treatment was defined as resolution of symptoms in 7 days. Severe CDI was defined as a rise in creatinine \u3e1.5 times above baseline, WBC ≥ 15,000 cells/mL, or albumin \u3c 1.5 g/ dl within 2 weeks of symptom onset. Descriptive analysis was performed to determine the outcomes of FMT in patients with CLD as compared to the comparison cohort without liver disease. Results: A total of 201 patients underwent FMT for CDI, from which 14 had a history of chronic liver disease. Nine of these patients had cirrhosis with a mean Child-Turcotte-Pugh (CTP) score of 8. One patient was 5 months post-liver transplant at the time of FMT. Mean age of patients in the liver disease cohort was 62 with 71% being female. Recent antibiotic use was a common risk factor related to CDI development and was found to be significantly different between both groups (17% of CLD patients vs 58% in the general cohort, p= 0.01). Although some patients were immunosuppressed due to history of IBD or liver transplant, there was no significant difference between the two groups and their outcomes in terms of immunosuppression, route of FMT delivery, number of CDI infections within the prior 3 months, recent hospitalization, recent surgeries or Charlson comorbidity index. There was no significant difference in the number of patients with severe grading of CDI among patients with CLD and the general cohort (36% vs 24%, p= 0.34). Four patients with CLD received \u3e1 FMT, of which 2 remained non-responders. Overall, there was no significant difference in FMT response between patients with liver disease and the rest of the cohort (12/14, 87% vs 164/187, 88%, p= 0.68). Both patients who failed FMT in the CLD cohort had decompensated cirrhosis with CTP scores of 9 and 12, respectively. Conclusion: Fecal microbiota transplantation is a safe and successful treatment option for patients with recurrent and/or refractory CDI who have stable chronic liver disease or compensated cirrhosis. Recent antibiotic use was less commonly a risk factor for CDI in patients with liver disease

Fecal Microbiota Transplantation for Clostridioides Difficile Infection in Patients with Chronic Liver Disease

Background. Fecal microbiota transplantation (FMT) is a well-established therapeutic option for patients with antibiotic resistant Clostridioides difficile infection (CDI). However, the efficacy of FMT in patients with chronic liver disease remains elusive. Aims. We studied the effect of FMT on chronic liver disease (CLD) patients with CDI at our tertiary medical center. Methods. A cohort of all patients who received FMT from December 2012 to May 2014 for refractory or recurrent CDI was identified. Patients were monitored for a year after FMT. Descriptive analysis was conducted to compare the effect of FMT in patients with and without CLD. Results. A total of 201 patients with CDI received FMT, 14 of which had a history of CLD. Nine of these patients exhibited cirrhosis of the liver with a mean Child-Turcotte-Pugh score of 8. CDI development in these patients was associated with recent exposure to antibiotics and was observed to be significantly different between both groups (17% of CLD patients vs. 58% in the general cohort, p=0.01). Four patients with CLD received >1 FMT, of which 2 did not respond to treatment. There was no significant difference between patients with liver disease and the rest of the cohort with regard to FMT response (12/14 (87%) vs. 164/187 (88%), p=0.68). Conclusion. FMT is a safe and effective therapy against CDI for patients with CLD and cirrhosis

Splenic Artery Embolization for Treatment of Refractory Ascites After Liver Transplantation

Post-transplantation refractory ascites is uncommon; however, it can be a serious problem, increasing both morbidity and mortality in patients. Despite scant literature available, splenic artery embolization (SAE) has been shown to be an effective treatment for refractory ascites after cadaveric orthotopic liver transplantation (OLT). We report a successful use of therapeutic SAE for refractory ascites post-OLT

Splenic Artery Embolization for Treatment of Refractory Ascites After Liver Transplantation

Post-transplantation refractory ascites is uncommon; however, it can be a serious problem, increasing both morbidity and mortality in patients. Despite scant literature available, splenic artery embolization (SAE) has been shown to be an effective treatment for refractory ascites after cadaveric orthotopic liver transplantation (OLT). We report a successful use of therapeutic SAE for refractory ascites post-OLT

Hepatitis C Virus-Associated Aortitis Caused by Type I Cryoglobulins

Chronic hepatitis C virus infection (HCV) can present with cryoglobulinemic vasculitis, which is primarily associated with type II/III cryoglobulins. Type I cryoglobulins are usually seen in lymphoproliferative disease, and large vessel involvement with this type of vasculitis is rare. A 70-year-old man with chronic HCV presented with abdominal pain, leukocytosis, and rash. Computed tomography angiography showed thickening of the abdominal aorta consistent with large-vessel vasculitis. He was found to have type I cryoglobulinemia and was treated with corticosteroids and ledipasvir/sofosbuvir with rapid resolution of his aortitis. This case emphasizes the need to recognize HCV as a potential etiology of large-vessel vasculitis

Splenic Artery Embolization for Treatment of Refractory Ascites After Liver Transplantation

Post-transplantation refractory ascites is uncommon; however, it can be a serious problem, increasing both morbidity and mortality in patients. Despite scant literature available, splenic artery embolization (SAE) has been shown to be an effective treatment for refractory ascites after cadaveric orthotopic liver transplantation (OLT). We report a successful use of therapeutic SAE for refractory ascites post-OLT

A Perplexing Case of Abdominal Pain That Led to the Diagnosis of Zollinger-Ellison Syndrome

Zollinger-Ellison syndrome (ZES) is a rare clinical disorder, characterized by hypersecretion of gastric acid and multiple ulcers distal to the duodenal bulb. This occurs via the release of gastrin by neuroendocrine tumors known as gastrinomas. Patients with ZES present with nonspecific GI symptoms, which often leads to a delay in diagnosis. Our patient is a 55-year-old female with chronic abdominal pain, nausea, and diarrhea. She underwent EGD, EUS, MRCP, CT scans, and cholecystectomy, which did not reveal the cause of her symptoms. Repeat EGD showed a cratered ulcer in the second portion of the duodenum, suspicious for ZES. Serum gastrin was initially only moderately elevated while on PPI therapy, but chromogranin A was also elevated. Repeat gastrin level after stopping PPI therapy was 1639 pg/mL. Somatostatin receptor scintigraphy was obtained, which showed two small lesions in the gastrinoma triangle. She subsequently underwent a Whipple pancreaticoduodenectomy and pathology was positive for four microscopic foci of a neuroendocrine tumor. She reported improvement in her symptoms after surgery. This case highlights the need for increased awareness of ZES in patients with unexplained GI complaints and emphasizes the use of multiple modalities in the diagnosis of ZES

A Perplexing Case of Abdominal Pain That Led to the Diagnosis of Zollinger-Ellison Syndrome

Zollinger-Ellison syndrome (ZES) is a rare clinical disorder, characterized by hypersecretion of gastric acid and multiple ulcers distal to the duodenal bulb. This occurs via the release of gastrin by neuroendocrine tumors known as gastrinomas. Patients with ZES present with nonspecific GI symptoms, which often leads to a delay in diagnosis. Our patient is a 55-year-old female with chronic abdominal pain, nausea, and diarrhea. She underwent EGD, EUS, MRCP, CT scans, and cholecystectomy, which did not reveal the cause of her symptoms. Repeat EGD showed a cratered ulcer in the second portion of the duodenum, suspicious for ZES. Serum gastrin was initially only moderately elevated while on PPI therapy, but chromogranin A was also elevated. Repeat gastrin level after stopping PPI therapy was 1639 pg/mL. Somatostatin receptor scintigraphy was obtained, which showed two small lesions in the gastrinoma triangle. She subsequently underwent a Whipple pancreaticoduodenectomy and pathology was positive for four microscopic foci of a neuroendocrine tumor. She reported improvement in her symptoms after surgery. This case highlights the need for increased awareness of ZES in patients with unexplained GI complaints and emphasizes the use of multiple modalities in the diagnosis of ZES