Tag: diarrhea

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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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Diarrheal Diseases are a Scourge to Humanity

Diarrheal diseases have been a scourge to humanity throughout recorded history all over the world. “Infections are estimated to account for three to four billion cases of diarrhea each year, and up to 4.3 million deaths in children under the age of five years,” says an article in the Canadian Journal of Gastroenterology.

Poor countries bear the biggest brunt but developed countries are not spared.

Diarrhea means loose, watery stools and abdominal cramps. Frequency of bowel movements may vary in each case. It may be acute in nature. That means it may last only a few days. It is unpleasant and from time to time almost everyone experiences it.

Most common causes of acute diarrhea are due to infections. Viruses like rotavirus and adenovirus are common examples in young children. Direct contact easily spreads viral diarrhea.
Parasites such as giardia and cryptosporidium can cause diarrhea. Certain bacteria like campylobacter, salmonella, shigella and E. coli can cause diarrhea. The source of infection is contaminated food or water.

Acute diarrhea can also be side effect of many medications, particularly antibiotics. Antibiotics related colitis has been discussed in these columns before. Traveller’s diarrhea can occur in 20 to 50 percent of travellers to tropical countries. Eighty percent of traveller’s diarrhea is due to bacterial infection.

Chronic diarrhea lasts much longer than acute diarrhea. Diarrhea lasting four weeks would probably be considered chronic but six to eight weeks would provide a better distinction.

The prevalence of chronic diarrhea in developed countries seems to be approximately five percent. It can be a sign of a serious disorder like chronic infection, inflammatory bowel disease or poor absorption of nutrients (malabsorption). It may be due to a less serious condition such as irritable bowel syndrome.

Other causes of diarrhea are lactose intolerance (a sugar found in milk and milk products), artificial sweeteners (sorbitol and mannitol), found in chewing gum and other sugar-free products can cause diarrhea.

There are many more causes of chronic diarrhea. They cannot all be mentioned here. To name a few: dumping syndrome, celiac disease, chronic pancreatitis, antacids, alcohol use and diabetes.

In one study, 30 percent of the patients a definite cause of diarrhea was found. In 20 percent of the patients the cause was found to be in laxative and diuretic abuse. In 50 percent of the patients no specific diagnoses was made. They were given the diagnoses of “functional” or “idiopathic” diarrhea.

Most significant complication of diarrhea is dehydration – as suggested by excessive thirst, dry mouth, little or no urination, severe weakness, dizziness or lightheadedness. This can be dangerous especially in children and the elderly. Bloody diarrhea with fever can be dangerous too. One should seek immediate medical help.

Sometimes diarrhea is only an inconvenience. Sometimes it can be life threatening. Sometimes it can be prevented by good preventive measures like washing hands and avoiding potentially contaminated food and water. Sometimes there is not much you can do to avoid it – especially in cases like ulcerative colitis, Crohn’s disease and other medical conditions.

If there is a change in your bowel habit then seek medical attention. It may save your body and your butt lot of grief.

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What do we know about Clostridium difficile colitis?

Few years ago, there was an outbreak of Clostridium difficile (C. difficile) colitis in Canada, the United Kingdom and the United States which killed many patents in hospitals and nursing homes.

C. difficile is a bacterium common in the environment. It is transmitted from person to person by fecal-oral route. That means we ingest food which is contaminated by somebody who handled that food. It comes down to poor hygiene. Remember, hand washing?

The bacterium, in the form of a spore, settles down in the colon (large bowel) and waits there to create trouble. A spore is highly resistant to desiccation and heat and is capable of growing into a new organism. Normally, mature colonic bacterial flora in a healthy adult is generally resistant to C. difficile colonization.  However, if the normal colonic flora is altered, for example, by taking antibiotics, resistance to colonization is lost. If that happens, then there is overgrowth of C. difficile.

What happens then? You may have no symptoms but become a carrier and spread it around if you do not maintain good hygiene. You may have symptoms like watery diarrhea to life- threatening pseudo-membranous colitis. Pseudo-membranous colitis is an inflammatory condition of the colon, also called antibiotic-associated colitis or C. difficile colitis that occurs in some people who have received antibiotics.

Typical clinical features include watery diarrhea, lower abdominal pain and systemic symptoms such as fever, anorexia, nausea and malaise. In severe cases, the colon may perforate, necessitating removal of the colon.

The severity of the colitis depends on many factors: the subset of bacteria (pathogenecity), use of antibiotics, advanced age, underlying illness, poor immune systems or use of chemotherapy. The incubation period from ingestion of C. difficile to onset of symptoms has not been determined. However, time from antibiotic exposure to onset of symptoms has been as short as one day to as long as six weeks or even longer.

You may wonder if you are carrying C. difficile in your colon. The incidence of C. difficile carriage is about one to three per cent among healthy adults. It is higher among hospital employees and those working with susceptible patients. The rate increases to about 20 per cent with antibiotic use. As many as 31 per cent of high- risk patients in hospital are colonized with C. difficile, with only a subset becoming symptomatic, says an article in the Canadian Medical Association Journal (CMAJ).

 Pathogenic strains of C. difficile produce toxins, conventionally identified as A and B. Diagnosis of colitis is generally based on the detection of toxin A or B in stool filtrates. The processing of a single stool specimen for toxin detection at the onset of symptoms is generally sufficient to establish the diagnosis. The results are usually available in 48 hours. . There is no value to testing stools of asymptomatic patients, including follow-up for “test-of-cure,” unless an outbreak is being investigated (CMAJ).

Treatment typically involves cessation of the offending antibiotic, initiation of oral metronidazole or vancomycin therapy, and fluid replacement. Oral metronidazole therapy (250 mg 4 times daily or 500 mg twice daily) given for 10–14 days is recommended as the initial treatment of choice. Vancomycin (125 mg orally 4 times daily for 10–14 days) is the recommended second-line therapy.  

Unfortunately, recurrent C. difficile diarrhea occurs in about five to 20 per cent of patients after treatment with either metronidazole or vancomycin. Metronidazole remains the drug of choice for treatment of an initial recurrence even if this was the original drug used (CMAJ). Additional therapy with probiotics has been found to be effective in some patients.

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