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Hold Your Nose – Fecal Transplant Works

A woman pinching her nose. (iStockphoto/Thinkstock)
A woman pinching her nose. (iStockphoto/Thinkstock)

In my last article, I mentioned stool (fecal) transplant being an option in the management of intractable C. difficile-associated diarrhea (CDAD). Your reaction must have been, “Yuck!”

“It’s a nasty topic to discuss but fecal transplants work – and I was not ready to wait any longer.” says a 66 year-old-man from Cape Breton (The Medical Post, April 24, 2012). The man gave himself a fecal infusion to try and rid himself of a C. difficile infection after being turned down for the procedure by Cape Breton Regional Hospital. His doctor’s reaction, “He did it himself? It’s not good to do by himself.”

Stool transplant (also called fecal bacteriotherapy), a procedure related to probiotic research, has preliminarily been shown to cure the disease. The procedure involves infusion of bacterial flora acquired from the feces of a healthy donor to reverse the bacterial imbalance responsible for the recurring nature of the infection in CDAD.

Bacteria make up most of the flora in the colon and up to 60 per cent of the dry mass of feces. Somewhere between 300 and 1000 different species live in the gut, with most estimates at about 500. According to Wikipedia, it is probable that 99 per cent of the bacteria come from about 30 or 40 species. Fungi and protozoa also make up a part of the gut flora, but little is known about their activities.

What is the function of these bacteria in our gut?

Humans and their bacterial flora have a non-harmful coexistence. The microorganisms perform a host of useful functions, such as fermenting unused energy substrates, training the immune system, preventing growth of harmful, pathogenic bacteria, regulating the development of the gut, producing vitamins for the host (such as biotin and vitamin K), and producing hormones to direct the host to store fats.

In fecal transplantation, donor stool is collected from a close relative who has been tested for a wide array of bacterial, viral, and parasitic pathogens. The stool is often mixed with saline or milk to achieve the desired consistency, then delivered through a colonoscope or retention enema, or through a nasogastric or nasoduodenal tube.

The idea is to replace normal, healthy colonic flora that had been wiped out by antibiotics, and reestablishes the patient’s resistance to colonization by Clostridium difficile.

Since 1958, more than 150 papers have been published on this subject. It has a success rate of about 90 per cent. A guide was released in 2010 for home fecal transplantation. Reports from many centres suggest that fecal transplants can be lifesaving for patients with recurrent CDAD.

In November, 2010, Alberta’s Institute of Health Economics released a report (Fecal Transplantation for the Treatment of Clostridium difficile-associated disease and/or ulcerative colitis) concluded that fecal transplant may restore normal bacterial flora, break the cycle of recurrent CDAD, usually after treatment failure with vancomycin therapy.

The report said, “The status of fecal transplantation as an experimental or accepted procedure for patients with recurrent CDAD remains to be determined.”

Currently, there are numerous studies going on to compare fecal transplant with other kinds of therapy in CDAD cases. The safety of the procedure needs to be clarified. Especially, now that the procedures are carried out in people’s homes rather than in the hospitals to avoid bureaucratic battles. Hopefully, we will have a definitive answer in the next few years.

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C. difficile-Associated Diarrhea In Pregnancy – A Complex Clinical Challenge

A pregnant woman touching her belly. (Jupiterimages)
A pregnant woman touching her belly. (Jupiterimages)

Photograph shows colon acutely inflamed - red, swollen with white patches of psuedo membranes. An extreme case of C.difficile colitis - also known as pseudomembranous colitis.
Photograph shows colon acutely inflamed – red, swollen with white patches of psuedo membranes. An extreme case of C.difficile colitis – also known as pseudomembranous colitis.

In 1935, Hall and O’Toole first isolated a bacterium from the stool of healthy newborns. They named it Bacillus difficilis to reflect the difficulties they encountered in its isolation and culture. Now, after 77 years, we are unable to contain the growth and spread of the same bacterium, renamed as Clostridium difficile.

C. difficile is a frequent cause of infectious colitis, usually occurring as a complication of antibiotic therapy. Elderly hospitalized patients and other vulnerable patients are easy victims. Then there is community acquired disease in people who have not taken antibiotics.

This is not surprising, since C. difficile has been cultured from the stool of three per cent of healthy adults and up to 80 per cent of healthy newborns and infants. Patients who are discharged from the hospital or the visitors to the hospitals and nursing homes can pick up these bugs and spread it in the community. Hand hygiene plays an important role in prevention.

There is not much information out there on C. difficile-associated diarrhea (CDAD) in pregnancy. I did find one article: Clostridium difficile-associated diarrhea: an emerging threat to pregnant women (American Journal of Obstetrics and Gynecology – June 2008). The article says that largely due to their young age and overall good health, pregnant women have historically been at low risk for developing CDAD.

In a retrospective study of 74,120 admissions to an obstetrics and gynecology service over 10 years, only 18 women (0.02 per cent) developed CDAD. However, a Morbidity and Mortality Weekly Report reported 10 cases of peripartum (occurring during the last month of pregnancy or the first few months after delivery) disease from four states. Among these women, 40 per cent required hospitalization, 50 per cent experienced relapse, and one died.

Since CDAD is not a reportable disease, it is difficult to know the exact incidence of the problem and its complications in pregnant patients. It is a serious problem and CDAD should be taken seriously in this particular population and to raise the level of concern and vigilance among physicians.

Patients with CDAD can have a broad range of symptoms. Patient may be asymptomatic carrier or in an extreme situation may have life-threatening colitis.

Approximately, three per cent of adults and 80 per cent of neonates are infected with C difficile and most remain without symptoms. About 25 to 30 per cent of hospitalized adults are also C difficile carriers. These patients do not require any treatment.

Some patients have mild-to-moderate diarrhea, usually not bloody. At the other extreme, patients can be very seriously sick and have pseudomembranous colitis (see photograph). This is a serious condition and is a systemic illness. Patients have abdominal pain and tenderness, fever, and severe diarrhea that may be bloody. Marked elevations of the white blood count can be observed and may serve as a diagnostic clue. Bowel perforation is a very serious complication.

Oral metronidazole or oral vancomycin remains first-line therapy. Use of metronidazole in pregnancy remains controversial. Oral vancomycin is the only FDA-approved medication for the treatment of CDAD and can be used in pregnancy. Probiotics, to replace the good bugs in the gut, helps. Questran powder can be used to slow down the frequency of bowel movements. For intractable cases, stool transplant is an option.

Regardless, 12 to 24 per cent of patients develop a second episode of CDAD within two months of the initial diagnosis. If a patient has two or more episodes of CDAD, the risk for recurrences increases to 50 to 65 per cent.

Clearly, CDAD and C difficile infection pose a complex clinical challenge to the physician – whether the patient is pregnant or not.

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Surgery Is An Option For Individuals With Intractable Heartburn

A young man suffering from chest pain. (Hemera/Thinkstock)
A young man suffering from chest pain. (Hemera/Thinkstock)

Heartburn afflicts nearly two thirds of adults at some point in their lives, and accounts for millions of physician office visits every year. That adds up to a lot of tax dollars.

Last week we discussed the various aspects of medical treatment for heartburn, also known as gastroesophageal reflux disease (GERD).

There is a small group of patients with GERD who do not respond to medical treatment and they wonder if there is another option to relieve the symptoms and complications. Surgery, of course, is an option. Surgery is also an option for those who do respond to pills but cannot afford to buy them or do not want to be on the pills for the rest of their lives.

In GERD, there is failure of the antireflux barrier, allowing abnormal reflux of stomach contents into the esophagus. It is a mechanical disorder, which is caused by a defective lower esophageal sphincter (valve) at the junction of the esophagus and stomach, a gastric emptying disorder, or failed esophageal peristalsis. But the exact nature of the antireflux barrier is incompletely understood.

Surgery should not be considered without objective evidence of reflux. Based on the available evidence, the diagnosis of GERD can be confirmed if at least one of the following conditions exists: a mucosal break (inflammation and ulceration) seen on endoscopy in a patient with typical symptoms, Barrett’s esophagus on biopsy (considered to be a premalignant condition), a peptic stricture (narrowing due to chronic ulcer) in the absence of malignancy, or positive pH-metry (checks for the presence of acid reflux in the esophagus).

Clinical Guidelines published in 2010 by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) makes the following recommendation regarding surgical management of GERD:

“Surgical therapy for GERD is an equally effective alternative to medical therapy and should be offered to appropriately selected patients by appropriately skilled surgeons. Surgical therapy effectively addresses the mechanical issues associated with the disease and results in long-term patient satisfaction. For surgery to compete with medical treatment, it has to be associated with minimal morbidity and cost.”

The antireflux surgery is done laparoscopically or by open method by surgeons thoroughly trained in this technique. Laparoscopic technique requires a short hospital stay and early return to work compared to open technique which requires a long abdominal incision and longer hospital stay with about six weeks of post op recovery. The two approaches have been demonstrated to have similar postoperative outcomes at the reported follow-up intervals (range three to 24 months) including reflux recurrence, dysphagia (difficulty swallowing), bloating, and reoperation rates.

SAGES recommendation says laparoscopic fundoplication should be preferred over its open alternative as it is associated with superior early outcomes (shorter hospital stay and return to normal activities, and fewer complications) and no significant differences in late outcomes (failure rates). If you are referred to a surgeon for this procedure then you should carefully discuss pros and cons of medical vs. surgical treatment. Your case may be different than your neighbour’s. What is good for your neighbour may not be good for you.

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Medical Treatment of Heartburn is Not Always Satisfactory

Heartburn (Hemera)
Heartburn (Hemera)

In the last column, we discussed the long term consequences of untreated heartburn. Also known as gastroesophageal reflux disease (GERD). But, you may ask, “Doctor, is there a satisfactory medical treatment for this problem?”

There are three main goals to achieve when treating GERD: symptom control, the healing of the damaged esophagus (reflux esophagitis) and prevention of complications like stricture (narrowing) and cancer.

For the most part patient satisfaction is achieved by symptom control. First by lifestyle change: losing weight, eating small meals, avoid food which triggers heartburn, avoid bending, maintain good posture, no smoking, no alcohol, and the most important is to keep the head end of the bed elevated at night.

Quite often patients treat themselves with the help of antacids. Antacids can be bought over-the-counter (Maalox, Diovol Tums, Rolaids and others). Antacids neutralize excess stomach acid to relieve heartburn. Some antacids also contain simethicone, an ingredient that helps eliminate excess gas. Antacids do not heal ulcers. They provide temporary symptomatic relief.

Some antacids contain magnesium or sodium bicarbonate, ingredients that may have a laxative effect. Overuse of antacids can result in constipation, diarrhea, white or pale bowel movements and stomach cramps.

The next line of treatment is the use of pills called histamine H2-blockers (Pepcid, Tagamet, Zantac 75, and Axid). Some of these are available over-the-counter. These medicines reduce the production of stomach acid; treat stomach or duodenal ulcers, esophagitis, and GERD.

The side effects of histamine H2-blockers are not very common, but may cause confusion, chest tightness, bleeding, sore throat, fever, irregular heartbeat, weakness, and unusual fatigue. Other less serious side effects include headache, dizziness, and diarrhea, which are usually temporary and will likely go away on their own.

Proton pump inhibitors (PPIs) are the most advanced level of medications so far for treating GERD. PPIs reduce release of stomach acid by blocking a membrane protein called a proton pump. PPIs available in Canada include: esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Losec), pantoprazole (Pantoloc), rabeprazole (Pariet).

PPIs can provide resolution of heartburn. PPI does not fix the primary problem which is the incompetent valve at the junction of the stomach and esophagus. So, you have to take the pills on a regular basis to relieve the symptoms.

The typical side effects of PPIs may include abdominal pain, nausea, diarrhea, headache, dizziness, and itching. PPIs have the potential to interact with some other medications. If you are taking medications other than a PPI, be sure that your doctor and pharmacist are aware.

If you are not responding to the above medications then your doctor may decide to add a promotility agent (prokinetic drugs). Promotility drugs enhance the emptying of the stomach and/or gut and enhance the contractions/co-ordination of the gut. It will make you pass lot of gas. Make sure you look over your shoulder before you let it out. You don’t want your mother-in-law behind you. If your wife is behind you then you are dead.

Commonly used promotility drugs are: domperidone (Motilium), metoclopromide (Reglan, Maxeran). These pills block the dopamine receptors in the brain and the stomach. Blocking dopamine can also have an effect on increased prolactin secretions. Prolactin is a hormone which increases milk supply in the breasts – milk leakage (galactorrhea), may be a problem.

Other side effects of promotility drugs are bothersome central nervous system side effects – depression, an overall feeling of restlessness, restless legs (akathisia), tremors and rigidity (Parkinsonism), and insomnia. One very serious side effect is called tardive dyskinesia (tardive meaning late onset, and dyskinesia meaning abnormal muscle movements).

If none of the above treatment works for you or you have complications related to esophagitis then surgery is an option. Stay tuned.

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