Severe and severe-complicated Clostridium difficile infection (CDI) is associated with high morbidity and mortality. Colectomy is standard of care; however, post-surgical mortality rates approach 50%. Case reports suggest fecal microbiota transplant (FMT) is a promising treatment of severe and severe-complicated disease but there is a paucity of data. Here, we present a single center experience with a novel sequential FMT protocol for patients refractory to maximal medical therapy. This approach consists of at least one FMT delivered via colonoscopy with criteria for repeat FMT and continued vancomycin therapy based on clinical response and pseudomembranes. Our cohort included 57 consecutive inpatients diagnosed with severe or severe-complicated CDI and treated with FMT. Overall, 91% (52/57) experienced clinical cure at 1 month with a 100% cure rate among severe CDI (n = 19) patients and an 87% cure rate for severe-complicated CDI (n = 33) patients. For the cohort, the survival rate was 94.7% at 1 month and 78.6% at 3 months. There were no serious adverse events related to FMT including no procedure-related complications or perforation. There was no difference in outcome between fresh or frozen fecal material. Sequential FMT for inpatients with severe or severe-complicated CDI is promising and may be preferred over colectomy in certain patients.

Small intestinal bacterial overgrowth (SIBO) can result from failure of the gastric acid barrier, failure of small intestinal motility, anatomic alterations, or impairment of systemic and local immunity. The current accepted criteria for the diagnosis of SIBO is the presence of coliform bacteria isolated from the proximal jejunum with >10(5) colony-forming units/mL. A major concern with luminal aspiration is that it is only one random sampling of the small intestine and may not always be representative of the underlying microbiota. A new approach to examine the underlying microbiota uses rapid molecular sequencing, but its clinical utilization is still under active investigation. Clinical manifestations of SIBO are variable and include bloating, flatulence, abdominal distention, abdominal pain, and diarrhea. Severe cases may present with nutrition deficiencies due to malabsorption of micro- and macronutrients. The current management strategies for SIBO center on identifying and correcting underlying causes, addressing nutrition deficiencies, and judicious utilization of antibiotics to treat symptomatic SIBO.

Alimentary Pharmacology and Therapeutics INTRODUCTIONEosinophilic oesophagitis (EoO) is a chronic inflammatory disorder of the oesophagus characterised by the proton pump inhibitor-refractory accumulation of eosinophils in the oesophageal epithelium [>15 intraepithelial eosinophils ⁄ high powered field (eos ⁄ hpf)] in combination with a range of symptoms including dysphagia, food impaction, chest pain, abdominal pain and vomiting. [1][2][3] The clinical manifestations of EoO vary with age. Nearly all adults complain of solid food dysphagia with many being 'slow eaters' who meticulously chew their food. More than 50% give a history of food impaction.The endoscopic features of EoO suggest a chronic disease with inflammatory features of furrows, microabscesses and plaques seen predominantly in paediatric patients and oesophageal remodelling characterised by the narrow calibre oesophagus, strictures and ring formation more commonly seen in adult EoO patients. Most likely these changes are progressive in nature, but this is a speculation yet to be defined with serial studies from childhood to adulthood. The treatments for these early inflammatory changes are anti-inflammatory medications (swallowed fluticasone, budesonide, prednisone) or restrictive and elemental diets. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] On the other hand, adult EoO patients typically show less active inflammation and more fibrotic changes due to collagen deposition in the epithelium and submucosa. Straumann et al. 19 performed a randomised, double-blind placebocontrolled trial with 36 adults and adolescents treating them with swallowed budesonide for 15 days. On followup oesophagogastroduodenoscopy, the oesophageal eosinophilia and furrowing drastically improved, but the corrugated rings persisted. Oesophageal dilation is often necessary to correct this fixed stenosis, which relieves the solid food dysphagia and alleviates the fear of food impaction, improving quality of life. Potential side effects of too aggressive dilation are concerning, but the longterm relief seems to outweigh these complications. This systematic narrative review will discuss the pathophysiology producing remodelling and strictures, review the available case series, discuss the technique of oesophageal dilation in the management of adult EoO patients and its potential complications. PathophysiologyOesophageal remodelling in EoO patients is a major factor contributing to the clinical complaint of solid food dysphagia. The process begins with an influx of inflammatory cells, especially eosinophils into the mucosa of the oesophagus. Over time, numerous microscopic changes occur including basal cell hyperplasia, elongated rete pegs, smooth muscle hypertrophy ⁄ hyperplasia, and lamina propria ⁄ subepithelial fibrosis. 20 These histopathologic changes are evident on endoscopy as strictures, narrowing and rings and on endoscopic ultrasound as diffuse thickening of all layers of the oesophagus. 21 Most of what we know about the remodelling process in EoO is based u...

We developed and validated a scoring system to identify patients with CD most likely to respond to 26 weeks of vedolizumab therapy. Further studies are needed to optimize its accuracy in select populations and determine its cost-effectiveness.

In this large real-world cohort we observed that VDZ was well tolerated and effective in achieving key clinical outcomes.