Background: Fecal microbiota transplantation (FMT) is a successful therapy for Clostridioides difficile infection (CDI). FMT from overweight donors is speculated to influence the recipient’s body mass index (BMI) after administration for CDI. Objectives: We investigated changes in the recipient’s BMI after FMT in relation to the donor’s BMI. Design: We conducted a retrospective cohort study involving patients who underwent FMT for recurrent CDI at Mayo Clinic between 2012 and 2019. Methods: We analyzed demographic and donor data for patients undergoing FMT at Mayo Clinic (2012–2019). Recipient BMI (pre- and post-FMT) and donor BMI were extracted from medical records. Mixed-effects linear regression was used to evaluate the impact of donor BMI, donor BMI category, recipient baseline BMI, time before and after FMT, and interactions between these variables on overall BMI change and BMI change per month. Kaplan–Meier curves were used to assess BMI changes (⩾5 units) based on the last recorded post-FMT BMI. Results: We analyzed data from 401 patients with recorded BMI measurements before and after FMT. The median age of the recipients at the time of FMT was 59.1 years (interquartile range (IQR): 40.5–70.1 years), with 61.6% being female. The median BMI for recipients prior to FMT was 26.7 kg/m² (IQR: 22.7–31.6 kg/m²), while the median BMI of the donors was 24.5 kg/m 2 (IQR: 23.9–27.5 kg/m 2 ). Stool from donors with a normal BMI was used for 58.2% of recipients, while 41.8% received stool from pre-obese donors. Donor BMI data were missing for 3.2% of recipients. Donor BMI was not significantly associated with changes in recipient BMI; for each 1-unit increase in donor BMI, a 0.01-unit monthly increase was observed (95% confidence interval: −0.0003, 0.02; p = 0.11). The log-rank test for BMI increases (⩾+5) and decreases (⩽−5) revealed no significant differences among the donor BMI groups (Chi-squared = 4.4, p = 0.1 for increases, Chi-squared = 2, p = 0.4 for decreases). Conclusion: The lack of impact of donor BMI on BMI changes post-FMT suggests that these changes are more dependent on the recipient’s metabolic profile. Prospective, controlled trials are required to analyze these results more comprehensively.
Introduction: A 73-year-old male with a history of hiatal hernia and short-segment Barrett’s esophagus presented with complaints of nausea, vomiting, and acute, stabbing abdominal pain thirty minutes after eating. He also endorsed the sensation of food being stuck in his chest, but no hematemesis, melena, odynophagia, weight loss, fevers, or chills. On exam, vitals were within normal limits, abdomen was soft, non-distended, and tender to palpation in the upper epigastrium without rebound or rigidity. Cardiopulmonary exam was unremarkable. Laboratory studies revealed lactate of 3.32 mmol/L (ref 0.6-2.3 mmol/L) and lipase of 107 U/L (10-73 U/L). Further evaluation with CT abdomen revealed a very large hiatal hernia with an upside down intrathoracic stomach that was mildly to moderately distended and worrisome for delayed gastric emptying. He was admitted to the hospital, maintained nothing per os (NPO), and given intravenous fluids. Thoracic Surgery was consulted and performed thoracotomy with Belsey Mark IV fundoplication for gastric outlet obstruction secondary to the large intrathoracic stomach. At one month post-surgery, he was tolerating meals and doing well. Upside down stomach is a rare form of hiatal hernia (<5%) characterized by migration of the gastroesophageal junction and stomach into the mediastinum. It is considered to be a type 3 hiatal hernia with both a sliding and paraesophageal component. A common clinical manifestation is post-prandial distress, however patients may also experience post-prandial fullness, nausea, and vomiting as well as substernal pain, heartburn, and dysphagia. Symptoms are mainly related to impaired gastric emptying due to mechanical obstruction. Complications include incarceration, volvulus development, and severe gastric bleeding. Once diagnosed, upside down stomach should be repaired surgically with relocation of the stomach, excision of the hernia sac, repair of the hiatal defect, and an anti-reflux procedure.Figure 1
Purpose: Fecal occult blood testing (FOBT) is accepted as one method of colon cancer screening, and a positive result is an indication for colonoscopy. However, the utility of FOBT in the inpatient setting is not clear. We sought to describe the yield of colonoscopy in inpatients whose sole pre-op indication was positive FOBT. Methods: This is a retrospective study. Using an electronic GI endoscopy database, we identified all inpatients who underwent colonoscopy from 2008-2013 with a positive FOBT listed as the indication on the order form. Patient charts were reviewed for demographics, clinical presentation, prep quality, and for colonoscopic findings including quality of bowel preparation and adverse events. The type of FOBT, location of testing and presence of iron-deficiency anemia were also recorded. Results: Five hundred twenty-five inpatients undergoing colonoscopy were identified. Of these, 96 (18%) had a positive FOBT as the sole indication for colonoscopy (median age 75; 43% female). Sixty-three patients (66%) had a normal colonoscopy, six were found to harbor colorectal cancer (6%), eight had one or more colonic adenomas ≥ 1cm (6%), 4 had angiodysplasia ≥ 5 in number and ≥ 8 mm in size (4%), five had active colitis (5%), 6 had one/more ulcers ≥ 1cm (6%) and 4 had an incomplete exam (4%). Only one patient experienced a procedural adverse event (sedation-related hypotension). Thirty-one patients (32%) were found to have a poor colonoscopic preparation. After chart review, we identified clinical indications for colonoscopy other than positive FOBT in nearly all patients (98%). These included anemia (65 patients; 68%), history of melena or hematochezia (28 patients; 29%) or concern for carcinoma (1 patient; 1%). Conclusion: Only 44% of inpatients undergoing colonoscopy with positive FOBT as the listed indication had clinically significant findings. However, nearly all patients had at least one other reason to undergo colonoscopy. We believe that FOBT should not be used to decide whether screening colonoscopy should be performed in inpatients.
Abstract BACKGROUND In countries where health coverage is not universal, there is ample evidence of disparities in healthcare, often associated with insurance. Crohn’s disease (CD) is a complex chronic disease with potential for significant morbidity if the content or delivery of healthcare is suboptimal. However, the literature related to primary payers and CD remains lacking. METHODS We queried the National Inpatient Sample (NIS)from 2016-2019 using ICD10-CM/PCS codes to identify hospital discharges with a diagnosis of CD. Patients were subsequently stratified based on insurance (Medicare, Medicaid, Private, and No insurance). Observations were categorized into two groups, private and public (Medicare and Medicaid) insurance. Patients without insurance were excluded from the study. In-hospital mortality, total hospital cost, length of stay, and in-hospital complications were evaluated. Multivariate logistic regression analysis was conducted to adjust for confounders. RESULTS A total of 135,075 discharges with diagnosis of CD were identified with a primary payer insurance, of which 70,275(52.1%) had private insurance and 64,800 (47.9%) public. Patients with private insurance were more likely to be white (68.9% vs 78.4%; P<0.01), have lower Charlson score (46.1% vs 59.1%; P<0.01), belong to the higher income bracket (16.7% vs 29.6%; P<0.01), be admitted to a teaching institution (74.2% vs 79.4%; P<0.01), and be in an urban setting (92.2% vs 95.5%; P<0.01). Patients with private insurance were less likely to require parenteral nutrition (5.9% vs 5.3%; P=0.04), have severe malnutrition (8.8% vs 6.4%; P<0.01), abuse EtOH (1.7% vs 0.8%; P<0.01), use tobacco (1.4% vs 1.1%; P<0.01), use cannabis (4.2% vs 2.3%; P<0.01), have iron deficiency anemia (13.4% vs 11.6%; P<0.01), and die during hospitalization (0.4% vs 0.1%; P<0.01). On multivariate analysis, there was lower mortality in patients with a private primary payer [0.28; (P<0.01)], shorter LOS (5.8 vs 4.9 days mean days; P<0.01), and lower healthcare charges [ -3,903 US$; (P<0.01)]. Overall, those with private insurance had lower in-hospital complications such as respiratory failure [aOR 0.75; (P=0.05)], endotracheal intubation [aOR 0.50; (P<0.01)], prolonged mechanical ventilation [aOR 0.36;(P<0.01)], hemodialysis [aOR 0.34; (P<0.01)], acute kidney injury [aOR 0.72; (P<0.01)], and venous thromboembolism [aOR 0.54; (P<0.01)]. However, they had higher rates of surgical interventions including small bowel resection [aOR 1.57; (P<0.01)], large bowel resection [aOR 1.58; (P<0.01)], laparoscopic surgery [aOR 2.44; (P<0.01)], and to require conversion to open surgery [aOR 1.55; (P<0.01)]. CONCLUSIONS Our findings suggest that primary public payers were independently associated with higher morbidity and mortality in patients admitted with CD.
A 29-year-old female with past medical history of gastroesophageal reflux disease and obesity came to the emergency department with a chief complaint of left upper quadrant abdominal pain. Her symptoms started three days prior after eating a meal. She described the pain as 10/10 intermittent pain that radiated to the back associated with nausea, vomiting, and diaphoresis. She denied alcohol abuse, trauma, or prior abdominal surgeries or procedures. She did not take any medications. Her vital signs were within normal limits. On physical exam, the only notable finding was left upper quadrant tenderness upon palpation. Laboratory studies showed leukocytosis of 14.8 × 103 cells/mm3 (normal: 3.6–10.2 × 103 cells/mm3), hematocrit 41.9% (normal: 36.7–47.1%), blood urine nitrogen of 11 mg/dL (normal: 8–21 mg/dL), creatinine of 0.83 mg/dL (normal: 0.57–1.11 mg/dL), and calcium level of 9.3 mg/dL (normal: 8.6–10.2 mg/dL). Total bilirubin and alkaline phosphatase were within normal limits. Alanine aminotransferase and aspartate aminotransferase were slightly elevated at 52 U/L (normal 10–36 U/L) and 37 U/L (normal: 10–30 U/L), respectively. Lipid panel was unremarkable. Lipase was elevated at 265 U/L (lipase laboratory upper limit of normal is 69 U/L). Abdominal ultrasound showed fatty liver but no evidence of cholelithiasis or common bile duct dilatation. Computed tomography (CT) abdomen and pelvis with intravenous (IV) contrast showed a hiatal hernia with an inflamed pancreatic tail herniated above the left hemidiaphragm (Figure 1, Figure 2, Figure 3). Thus, the patient was diagnosed with acute pancreatitis due to pancreatic tail herniation. She was managed conservatively with fluids and analgesia. Her diet was advanced as tolerated (i.e., initially a liquid diet then advanced to a low fat, normal consistency diet which was well tolerated prior to discharge). She improved clinically and was discharged with outpatient follow-up with surgery for hiatal hernia repair.
Introduction: Fecal microbiota transplantation (FMT) is an effective treatment for Clostridioides difficile infection. There is evidence to suggest that the human metabolic profile may be influenced by FMT. Furthermore, recent data indicate that the body mass index (BMI) of donors can influence the BMI of recipients, where FMT from an obese donor may lead to obesity in the recipient. To better understand the role of FMT and its effect on weight, we sought to determine if there was a change in recipient BMI after FMT corresponding to donor BMI. Methods: Patients who underwent FMT at Mayo Clinic from August 2012 to August 2019 were identified from a maintained database. Demographics of recipients and corresponding donors were recorded from this database. Recipient BMI 1 year before and after FMT, and donor pre-FMT BMI measurements were extracted from a query of electronic medical records. Body mass index between 18.5-24.9 kg/m2 was defined as normal and ≥25 kg/m2 was defined as overweight. Trends in BMI changes of recipients were analyzed using mixed linear regression models. Results: We identified 403 patients with pre- and post-FMT BMI recordings. Median age of recipients was 59.1 years (interquartile range [IQR] 40.6 – 70.2) at the time of FMT; 61.8% were female and 38.2% were male. Median pre-FMT recipient BMI was 26.7 kg/m2 (IQR 22.7 – 31.6). Median donor BMI was 24.5 kg/m2 (IQR 23.9 – 27.5). Stool from a donor with a normal BMI was transplanted in 58.2% of recipients and 41.8% of recipients received stool from overweight donors. Donor BMI information was missing for 3.2% of recipients. Recipient BMI increased by 0.05/month after FMT within the 1-year follow-up period (95% CI 0.01-0.09, P=0.020). Donor BMI had no significant effect on recipient BMI change over time (P=0.24) or the BMI level (-0.18 per donor BMI point, 95% CI -0.48-0.12, P=0.233). Conclusion: Recipient BMI increases post-FMT. However, donor BMI did not correlate with recipient BMI changes post procedure. Recipient weight gain after FMT might be reflective of recovery towards baseline weight. In our study, data on pre-CDI weight loss are not available, but it is possible that increase in BMI after FMT represents the regain of weight that was lost during the period of diarrheal illness. Large, prospective, controlled trials examining weight in the context of FMT are needed before definitive conclusions can be drawn.
