Introduction

Faecal microbiota transplantation (FMT) has emerged as a promising therapy for patients with Clostridioides difficile infection (CDI) unresponsive to standard medical therapy. However, data on long-term efficacy and safety are scarce, particularly regarding to real-world data.

Aims & Methods

A single-centre retrospective study was performed on patients treated with FMT for recurrent or refractory CDI. FMT was done according to the institutional protocol and stool material was provided by the same donor, after a careful clinical and analytical workup. The clinical registries of patients with at least six months of follow-up were retrieved to document sustained efficacy, potential adverse events, and antibiotic exposure.

Results

Since June 2014, 47 patients (63.0% female; median age 78.5, interquartile range 69-84) received 54 FMT infusions for CDI (92.6% delivered through esophagogastroscopy). Twenty-three patients had recurrent CDI while 24 had refractory infection. Eight patients were immunosuppressed with either corticosteroids or chemotherapy and 43 had prior antibiotic exposure. The median follow-up duration was 27.5 months (6-105). Short-term efficacy, defined as resolution of diarrhoea without recurrence of CDI within 2 months, was 91,4% (in three cases more than one TMF administration was required), with CDI symptoms resuming after 1.5±0.7 days. Only one late recurrence was registered 7 months after FMT, in a patient that received, once again, broad-spectrum antibiotics. No adverse events were reported during the follow-up.

Conclusion

As far as the authors know, this is the largest cohort of FMT for CDI in a Portuguese hospital. This real-world study demonstrated the high effectiveness of FMT for recurrent and refractory CDI, both in the short- and long-term, with a good safety profile. The 16S rRNA sequencing of our “super donor” microbiome is underway.

Introduction

Different pathophysiological mechanisms are thought to play a role in functional dyspepsia (FD) subgroups defined by Rome IV criteria. Studies are needed to determine whether Rome IV subgroups are linked to distinct pathophysiologies and treatment responses. This study aims to investigate the impact of Helicobacter pylori (H. pylori) infection in the pathogenesis of each FD subgroups, subdivided according to the Rome IV consensus, within a high H. pylori prevalence country, Turkey. The investigation centered on assessing the frequency of H. pylori and examining the impact of eradication therapy on alleviating symptoms, in each Rome IV subgroup.

Aims & Methods

Eradication treatment was applied to cases who were initially diagnosed with FD using the Rome IV criteria and subsequently found to have H. pylori gastritis through endoscopic biopsy. 8-12 weeks after treatment, H. pylori state was evaluated with fecal antigen test. Symptom responses were evaluated in each subgroup at 2, 6, and 12 months post-therapy using a Likert scale and statistically with SPSS version 23.0.

Results

The H. Pylori frequency was statistically more common in individuals with symptoms consistent with epigastric pain syndrome (EPS) (73.1% in EPS, 41% in postprandial distress syndrome (PDS), and 43.9% in overlapping subgroups (p< .001)). With eradication treatment of H. pylori-positive cases, all subgroups demonstrated a significant response and the response rates didn’t exhibit significant difference between subgroups (73.7% in total cases; 70.5% in EPS; 71.4% in PDS; 82.6% in overlapping, in the 12th month (p>0.05)). Eradicated patients showed significant symptomatic improvement with 70.2% in the 12th month. None of the non-eradicated patients experienced symptomatic improvement.

Conclusion

Using Rome IV consensus confirmed the data that H. pylori plays a notable role as a pathogenic factor in FD, particularly in EPS, and it is recommended to screen all FD subgroups, particularly EPS, for H. pylori and eradicate, if detected. Additionally, this study suggests that regions with a high H. pylori prevalence tend to have a higher H. pylori-associated dyspepsia prevalence.

References

1. Wauters L, Dickman R, Drug V, et al. United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on functional dyspepsia. United European Gastroenterol J. 2021 Apr;9(3):307-331.
2. Houte KVD, Carbone F, Goelen N, et al. Effects of Rome IV Definitions of Functional Dyspepsia Subgroups in Secondary Care. Clinical Gastroenterology and Hepatology 2021;19:1620–1626.
3. Carbone F, Vanuytsel T, and Tack J. Analysis of Postprandial Symptom Patterns in Subgroups of Patients With Rome III or Rome IV Functional Dyspepsia. Clinical Gastroenterology and Hepatology 2020;18:838–846.
4. Vanheel H, Vanuytsel T, Van Oudenhove L, Farre R, Verbeke K, Tack J. Postprandial symptoms originating from the stomach in functional dyspepsia. Neurogastroenterol Motil 2013;25:911-e703
5. Ford AC, Tsipotis E, Yuan Y, Leontiadis GI, Moayyedi P. Efficacy of Helicobacter pylori eradication therapy for functional dyspepsia: updated systematic review and meta-analysis. Gut. 2022 Jan 12:gutjnl-2021-326583. doi: 10.1136/gutjnl-2021-326583.
6. Kang SJ, Park B, Shin CM. Helicobacter pylori Eradication Therapy for Functional Dyspepsia: A Meta-Analysis by Region and H. pylori Prevalence. J Clin Med. 2019 Aug 28;8(9):1324. doi: 10.3390/jcm8091324.
7. Malfertheiner P, Megraud F, Rokkas T, et al. European Helicobacter and Microbiota Study group. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022 Aug 8:gutjnl-2022-327745. doi: 10.1136/gutjnl-2022-327745.

Disclosure

The authors declare that they have no conflict of interest.

Introduction

The indications for colonoscopy are clearly defined and its main objective is to look for neoplasia or lesions at high risk of colorectal neoplasia, even if benign lesions are much more frequent. Common indications for young adults < 50 years include rectal bleeding and diarrhea, while for subjects over 50 years, the indications may be larger given the risk of colorectal cancer, despite the recent increase in neoplastic lesions in young adults.

Aims & Methods

A retrospective descriptive and analytical study, including 1518 patients, was carried out over 3 and a half years. The patients were divided into 2 groups: group A for patients aged less than 50 years, and group B for patients aged greater than 50 years. We compared epidemiological, clinical, and endoscopic data between the two groups. Patients known to have inflammatory bowel disease (IBD) were excluded from our study. The statistical analysis was carried out by the JAMOVI software.
Our study aims to compare the indications and results of colonoscopy between those under and over 50 years old and to determine the indications associated with a risk of neoplastic lesion.

Results

65.1% of patients were over 50 years old, and 34.9% were under 50 years old. The average age was 37.5 ± 9 years in group A and 64.4 ± 9 years in group B. The female gender predominated among those under 50 years old (55.3%), while the male gender predominated among those over 50 years old (56.3%) (p<0.001).
History of colorectal cancer predominated among those over 50 years old at 10.5% (vs 4.4%; p<0.001). The indications for colonoscopy were dominated by constipation in patients in group B at 29.1% (vs 22%; p=0.01) and by diarrhea in patients in group A at 33.3% (vs 19. 3%; p<0.001).
Colonoscopy was pathological in 49.1% of patients in group B vs 32.9% of patients in group A (p<0.001). It was dominated by colitis or rectocolitis (47.9%) in subjects under 50 years old (vs 11.7%; p<0.001), by polyps (61.5% vs 41.3%; p<0.001) and colorectal neoplasia (16% vs 5%; p=0.002) in older patients.
A higher risk of neoplastic lesions was associated with rectal bleeding and constipation (p < 0.001) in subjects > 50 years old, and with constipation in subjects < 50 years old (p = 0.007).

Conclusion

The presence of neoplastic lesions was strongly associated with the presence of constipation in subjects < 50 years old and with rectal bleeding and constipation in subjects > 50 years old. Early screening with colonoscopy might be beneficial for young individuals with these higher-risk lesions of colorectal cancer.

Introduction

In Crohn’s disease (CD), 10% of patients present with fibrostenosis with a further 10% progressing from inflammatory to a fibrostenotic disease behaviour over 7 years^[1]. The prevalence of CD fibrostenosis is >20%^[2]. 40% of fibrostenotic CD patients need surgery at 5 years compared to ~10% with inflammatory disease^[2]. Fibrotic tissues exhibit excessive accumulation of collagen type 1 and 3, with amide protons in the collagen backbone showing potential for quantification using MT imaging [3].
GI-Seg by Motilent is a tool that uses advanced image analysis algorithms to segment the gastrointestinal tract in MRI scans. The software creates a three-dimensional model of the GI tract, allowing clinicians to visualize and analyse the structure and volume of the organs in detail. GI-Seg is designed to save clinicians time and increase the accuracy of their diagnoses by automating the segmentation process, which can be a time-consuming and error-prone task when done manually.

Aims & Methods

The primary objective of this study is to undertake biological validation of the candidate MRI measures as independent imaging biomarkers of histological fibrosis with the primary outcome being the correlation between MRI measures and histological fibrosis measures. Patients with CD histological diagnosis and in need of surgical resection for stenosis attended a one-hour 3T MRI scanning session within 12 weeks prior to their intestinal resection surgery.
After the surgical resection, consecutive sections were cut in the sample and scored by a specialized gastrointestinal pathologist for inflammation, fibrosis, and muscular hypertrophy. A global score was derived for these variables for each individual bowel wall layer and for the whole bowel wall.
An expert radiologist with the help of the histopathologist located the strictures on the magnetisation transfer (MT) and T2 weighted scans. Z-spectrum quantification involved fitting z-spectra to a three-pool model using the Levenberg-Marquardt algorithm, with voxel-wise mapping of the fitted parameters. The GI-seg tool was also used to generate a 3D model of the stricture on T2 weighted scans measuring bowel wall volume and mean signal intensity of each stricture.
Pearson correlation coefficient was used to quantify the correlation between the variables.

Results

A total of 8 CD (19 strictures) patients were recruited. Strictures were identified in histopathology and located on the in-vivo T2 weighted and MT scans by the radiologist. Out of the 8 patients, 6 were used for Z-spectrum quantification. Bowel wall volumes in mm³ and Mean signal intensity were calculated using the GI-seg tool.
MT Z- spectrum amplitude fit showed a high correlation with global fibrosis (r(10) = .775, p = .008), and inflammation scores (r(10) = .824, p = .003).
Mean T2 signal intensity measured using GI-Seg highly correlated with global fibrosis scores (r(19) = .617, p = .005) , global inflammation scores (r(19) = .692, p = .001) and MT Z- spectrum amplitude fit (r(10) = .941, p < .001).
The volume of each stricture showed a moderate correlation to global fibrosis scores (r(19) = .383, p = .106), global inflammation scores (r(19) = .425, p = .069) and muscular hyperplasia (r(19) = .404, p = .086).

Conclusion

This study reveals a strong correlation between mean T2 signal intensity and global fibrosis, muscular hyperplasia, and inflammation scores in CD strictures. The GI-seg tool accurately measured bowel wall volume and signal intensity, indicating potential as independent imaging biomarkers for fibrosis, inflammation, in CD strictures.

References

[1] Lo B, Vester-Andersen MK, Vind I, et al. Changes in Disease Behaviour and Location in Patients With Crohn's Disease After Seven Years of Follow-Up: A Danish Population-based Inception Cohort. J Crohns Colitis 2018;12:265-272.
[2] Moran GW, Dubeau MF, Kaplan GG, et al. Phenotypic features of Crohn's disease associated with failure of medical treatment. Clin Gastroenterol Hepatol 2014;12:434-42.e1.
[3] Fang ZN, Li XH, Lin JJ, Huang SY, Cao QH, Chen ZH, Sun CH, Zhang ZW, Rieder F, Rimola J, Chen MH, Li ZP, Mao R, Feng ST. Magnetisation transfer imaging adds information to conventional MRIs to differentiate inflammatory from fibrotic components of small intestinal strictures in Crohn's disease. Eur Radiol. 2020 Apr;30(4):1938-1947.

Disclosure

Prof Gordon W Moran is in receipt of research funding from Astra Zeneca, Johnson and Johnson and Bristol Myers Squibb. He is also a consultant for Alimentiv Inc.
Dr Alex Menys and Dr Andrew Bard are employed by Motlient.

Introduction

Clostridioides difficile infection (CDI) represents the predominant cause of nosocomial diarrhea, with its incidence having significantly increased over recent decades, both within hospital environments and in the community (1). Fecal microbiota transplantation (FMT) is recognized as a highly effective and safe intervention for recurrent Clostridioides difficile infection (rCDI), and our center has been providing an FMT program since 2013. This study aims to assess the efficacy and safety of FMT in patients with CDI since the start of our FMT program.

Aims & Methods

Our aim was to report outcomes of FMT in patients with rCDI treated at our centre from June 2013 to September 2024. CDI and rCDI were defined according to international guidelines. Data were collected on patient demographics and CDI characteristics, including disease severity, risk factors, and concomitant diseases. Enrolled patients were followed up to 90 days after the last FMT. Patients who were not assessed at both 8 weeks and 90 days post-procedure were excluded from the analysis, as were those for whom the required data were unavailable. The primary outcome was the clinical resolution of CDI at 8 weeks post-FMT, while secondary outcomes included the identification of risk factors for FMT failure, overall survival at 90 days, and the safety of FMT. Donor stools were screened following international guidelines. Prior to fecal infusion, all patients underwent a 3-day antibiotic pre-treatment regimen with oral vancomycin or fidaxomicin, as well as bowel cleansing. FMT procedures were conducted via colonoscopy using a single-donor solution of at least 50 grams of fresh or frozen feces. A sequential FMT approach was planned for patients with pseudomembranous colitis (PMC) until the disappearance of pseudomembranes, or for patients who experienced diarrhea with persistent C. difficile toxin in stool samples after the first FMT.

Results

A total of 374 patients were enrolled (231 female, mean age 71 years). One hundred and ten patients had severe CDI (29.4%), and 15 had severe complicated CDI (4%). Among them, 73 patients had pseudomembranous colitis (19.5%). The median number of CDI recurrences was 2. A sequential FMT protocol was performed in 92 patients (24.6%), resulting in a total of 524 FMT procedures. Among risk factors for CDI, the most frequent were hospitalization (245 patients – 65.5%), antibiotic use in the 30 days prior to infection (212 patients – 56.7%), chronic therapy with proton pump inhibitors (186 patients – 49.7%), and enticement (76 patients – 20.3%). The median Charlson Comorbidity Index (CCI) was 5. Overall, 337 patients (90.1%) experienced resolution of CDI (97 with severe CDI and 11 with severe-complicated CDI). Twenty-five patients (6.6%) died within the follow-up period, with no deaths attributable to FMT. Severe adverse events occurred in 23, and 9 were potentially associated with FMT and/or failure to cure CDI.

Conclusion

In the experience of our large-volume FMT center, FMT was an highly effective and safe treatment for rCDI.

References

1. Liu C, Monaghan T, Yadegar A, Louie T, Kao D. Insights into the Evolving Epidemiology of Clostridioides difficile Infection and Treatment: A Global Perspective. Antibiotics (Basel). 2023 Jul 1;12(7).

Introduction

Dietary regimens for symptom management in irritable bowel syndrome (IBS) include a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) diet and a gluten-free diet. However, scientific evidence supporting these dietary recommendations for managing IBS symptoms is weak: trials have been non-blinded and underpowered, while mechanistic understanding and objective markers of response remain scarce.

Aims & Methods

We therefore conducted a large double-blind study to investigate the effect of FODMAPs and gluten on symptomatic and molecular data including gut microbiota and the metabolome, both at a group and subgroup (differential response) level. Moreover, the accuracy of the Bristol Stool Form Scale (BSFS) used in IBS subtype diagnosis was assessed, and thus overcome the lack of objective evaluation of IBS symptoms. The results were recently collected in a doctoral thesis.

Results

Trial data revealed that gluten caused no symptoms and that FODMAPs triggered only modest symptoms of IBS. Subjective reporting according to the BSFS conformed only modestly with stool water content. FODMAPs increased saccharolytic microbial genera, phenolic-derived metabolites and 3-indolepropionate, but decreased bile acids. Saccharolytic genera correlated with increased plasma concentrations of phenolic-derived metabolites and 3-indolepropionate, metabolites related to decreased risk of incident type 2 diabetes and inflammation. Indeed, among FODMAP-related metabolites, only weak correlations to IBS symptoms were detected, as with 3-indolepropionate to abdominal pain and interference with quality of life, warranting further investigation. Gluten displayed a modest effect on metabolites involved in lipid metabolism, but with no interpretable link to health. No molecular biomarkers of a differential response to the challenges were found, despite comprehensive exploration with multiple analytical approaches. This could be explained by the absence of baseline variables, such as other omics layers or psychological factors, that could have determined the difference.

Conclusion

Diet only had a modest effect on IBS symptoms. Caution should be taken when subtyping IBS with BSFS.

Introduction

Low fermentable oligo-, di-, and monosaccharides and polyol (FODMAP) diet is currently recommended for the treatment of irritable bowel syndrome (IBS). However, long-term adherence is not high due to its complex nature.
Recently, ChatGPT (OpenAI, San Francisco, California, USA), a large scale unsupervised language model, was introduced as an easily accessible internet based chat, and demonstrated unprecedented capabilities of processing natural conversations and the ability to provide insightful and comprehensive replies.

Aims & Methods

In this brief proof of concept study, we aimed to evaluate the feasibility of using ChatGPT as a readily available guide for adherence to a low FODMAP diet.
We presented ChatGPT with 3 sets of questions concerned with low FODMAP:
(1) 10 questions in the form of “is Bⁱ low FODMAP” were prompted to ChatGPT in which Bⁱ is the i element of a list of 10 base products, 5 of which are considered low FODMAP, and 5 high FODMAP; We chose base products upon which there was unanimous agreement among different available lists of FODMAP-containing foods.
(2) 10 questions in the form of “is Dⁱ low FODMAP” were prompted to ChatGPT in which Dⁱ is the i element of a list of 10 popular dishes, 5 of which are considered low FODMAP, and 5 high FODMAP
(3) 7 questions in the form of “suggest a low FODMAP Cⁱ recipe” were prompted to ChatGPT in which Cⁱ is the I course of a traditional 7 course meal.
Questions and answers were then presented to two dietitians from our gastroenterology institute (M.D and C.P), both experienced in the care of IBS patients and low FODMAP guidance.
Dietitians were independently asked to grade each answer as correct or incorrect, and check whether they would use this answer as future recommendation for patients.

Results

A complete agreement between the two dietitians was observed (100% same review of chatGPT answers).
Out of the 27 submitted questions, 22 answers were reviewed as correct (81%).
From the 5 answers that were deemed as wrong, 4 (80%) were from the base products list, and 3 of these 4 were of high FODMAP base products. The additional wrong answer was from the popular dishes list, in which, a dish that contained high FODMAP ingredients was suggested as low FODMAP by the ChatGPT answer.
In the dishes and recipes section ChatGPT provided suggestions for alternative ingredients and food preparation techniques that would make the dishes low FODMAP. All the suggestions were deemed as correct by both dietitians.

Conclusion

ChatGPT perfomed well in answering questions regarding low FODMAP diet. It could possibly be used as an auxiliary tool for daily decisions on low FODMAP diet.