C Högenauer

Mechanisms and Management of Antibiotic-Associated Diarrhea

Only 10%-20% of all cases of antibiotic-associated diarrhea (AAD) are caused by infection with Clostridium difficile. Other infectious organisms causing AAD include Clostridium perfringens, Staphylococcus aureus, Klebsiella oxytoca, Candida species, and Salmonella species. Most of the clinically mild AAD cases are due to functional disturbances of intestinal carbohydrate or bile acid metabolism, to allergic and toxic effects of antibiotics on intestinal mucosa, or to pharmacological effects on motility. Saccharomyces boulardii and Enterococcus SF68 can reduce the risk of developing AAD. Patients receiving antibiotic treatment should avoid food containing high amounts of poorly absorbable carbohydrates. Mild cases of AAD that may or may not be caused by C. difficile can be resolved by discontinuation of antibiotic therapy and by dietary carbohydrate reduction. Only severe AAD caused by C. difficile requires specific antibiotic treatment.

Effect of oral tacrolimus (FK 506) on steroid‐refractory moderate/severe ulcerative colitis

Background : Steroid refractory ulcerative colitis is most commonly treated with intravenous ciclosporin to avoid colectomy. In search for an alternative drug that can be administered orally we investigated oral tacrolimus (FK 506) for this indication.

Positive effect of abdominal breathing exercise on gastroesophageal reflux disease: a randomized, controlled study.

OBJECTIVES:The lower esophageal sphincter (LES), surrounded by diaphragmatic muscle, prevents gastroesophageal reflux. When these structures become incompetent, gastric contents may cause gastroesophageal reflux disease (GERD). For treatment, lifestyle interventions are always recommended. We hypothesized that by actively training the crura of the diaphragm as part of the LES using breathing training exercises, GERD can be positively influenced.METHODS:A prospective randomized controlled study was performed. Patients with non-erosive GERD or healed esophagitis without large hernia and/or previous surgery were included. Patients were randomized and allocated either to active breathing training program or to a control group. Quality of life (QoL), pH-metry, and on-demand proton pump inhibitor (PPI) usage were assessed at baseline and after 4 weeks of training. For long-term follow-up, all patients were invited to continue active breathing training and were further assessed regarding QoL and PPI usage after 9 months. Paired and unpaired t-test was used for statistical analysis.RESULTS:Nineteen patients with non-erosive GERD or healed esophagitis were randomized into two groups (10 training group and 9 control group). There was no difference in baseline patient characteristics between the groups and all patients finished the study. There was a significant decrease in time with a pH<4.0 in the training group (9.1±1.3 vs. 4.7±0.9%; P<0.05), but there was no change in the control group. QoL scores improved significantly in the training group (13.4±1.98 before and 10.8±1.86 after training; P<0.01), but no changes in QoL were seen in the control group. At long-term follow-up at 9 months, patients who continued breathing exercise (11/19) showed a significant decrease in QoL scores and PPI usage (15.1±2.2 vs. 9.7±1.6; 98±34 vs. 25±12u2009mg/week, respectively; P<0.05), whereas patients who did not train had no long-term effect.CONCLUSIONS:We show that actively training the diaphragm by breathing exercise can improve GERD as assessed by pH-metry, QoL scores and PPI usage. This non-pharmacological lifestyle intervention could help to reduce the disease burden of GERD.

Effects of lactulose and polyethylene glycol on colonic transit.

Background :u2002The effects of lactulose and polyethylene glycol on colonic transit are poorly established.

Empfehlungen zur Anwendung der fäkalen Mikrobiotatransplantation „Stuhltransplantation“: Konsensus der Österreichischen Gesellschaft für Gastroenterologie und Hepatologie (ÖGGH) in Zusammenarbeit mit der Österreichischen Gesellschaft für Infektiologie und Tropenmedizin (OEGIT)

The intestinal microbiota has a pivotal role in the maintenance of health of the human organism, especially in the defense against pathogenic microorganisms. Alterations in the microbiota, also termed dysbiosis, seem to be involved in the pathogenesis of a variety of intestinal and extraintestinal diseases. Fecal microbiota transplantation (FMT), also known as stool transplantation, is a therapeutic procedure aiming at restoring an altered intestinal microbiota by administration of stool microorganisms from a healthy donor into the intestinal tract of a patient. FMT is most commonly used for recurrent forms of Clostridium difficile infections (CDI). There are currently many cohort studies in a large number of patients and a randomized controlled trial showing a dramatic effect of FMT for this indication. Therefore FMT is recommended by international medical societies for the treatment of recurrent CDI with high scientific evidence. Other potential indications are the treatment of fulminant CDI or the treatment of inflammatory bowel diseases. In the practical utilization of FMT there are currently several open questions regarding the screening of stool donors, the processing of stool and the mode of FMT application. Different modes of FMT application have been described, the application into the colon has to be preferred due to less reported side effects than the application into the upper gastrointestinal tract. So far only very few side effects due to FMT have been reported, nevertheless the use and risks of FMT are currently intensely debated in the medical community. This consensus report of the Austrian society of gastroenterology and hepatology (ÖGGH) in cooperation with the Austrian society of infectious diseases and tropical medicine provides instructions for physicians who want to use FMT which are based on the current medical literature.

Inflammatory Bowel Disease Alters Intestinal Bile Acid Transporter Expression

The enterohepatic circulation of bile acids (BAs) critically depends on absorption of BA in the terminal ileum and colon, which can be affected by inflammatory bowel disease (IBD). Diarrhea in IBD is believed to result in part from BA malabsorption (BAM). We explored whether IBD alters mRNA expression of key intestinal BA transporters, BA detoxifying systems, and nuclear receptors that regulate BA transport and detoxification. Using real-time polymerase chain reaction, mucosal biopsy specimens from the terminal ileum in Crohn’s disease (CD) patients and from the descending colon in ulcerative colitis (UC) patients were assessed for mRNA expression. Levels were compared with healthy controls. The main ileal BA uptake transporter, the apical sodium dependent bile acid transporter, was downregulated in active CD and UC and in CD in remission. Other significant changes such as repression of breast cancer–related protein and sulphotransferase 2A1 were seen only during active disease. In UC, pancolitis (but not exclusively left-sided colitis) was associated with altered expression of major BA transporters [multidrug resistance–associated protein 3 (MRP3), MRP4, multidrug resistance gene 1, organic solute transporter α/β] and nuclear receptors (pregnane X receptor, vitamin D receptor) in the descending colon. UC pancolitis leads to broad changes and CD ileitis to selective changes in intestinal BA transporter expression. Early medical manipulation of intestinal BA transporters may help prevent BAM.

Impact of experimental colitis on hepatobiliary transporter expression and bile duct injury in mice

Background and Aims: The pathogenetic link between ulcerative colitis and sclerosing cholangitis (SC) is unclear. We hypothesized that colitis induces changes in bile composition via inflammation‐induced reduction of hepatobiliary transporter gene expression, ultimately resulting in cholestasis and bile duct injury.

Faecal microbiota transplantation--the Austrian approach.

The intestinal microbiome is essential for maintaining human health and defending against intestinal pathogens. Alterations of the intestinal microbiota, also termed dysbiosis, play a pivotal role in the pathogenesis of various human diseases. Faecal microbiota transplantation (FMT) is aimed at correcting these alterations by delivering faecal microorganisms from a healthy person to the intestines of a patient. At present, recurrent Clostridium difficile infection is the only indication supported by solid scientific evidence, but many ongoing studies are investigating FMT in other dysbiosis-related diseases, such as inflammatory bowel disease. As there are no systematic methodological investigations, several questions about techniques, donor screening and safety issues remain. This shortage of evidence, especially on long-term safety concerns, is leading to worldwide controversy regarding the use of FMT. Regulations by healthcare authorities vary among different countries. This review reflects the Austrian situation and its FMT guidelines concerning indications, techniques and donor screening, recently developed by local scientific societies.

Serum macromolecular creatine kinase type 1 as a diagnostic clue in inflammatory bowel disease

In adults, macromolecular creatine kinase (CK) type 1 has been linked to ulcerative colitis (UC), but not to Crohn’s disease (CD). We present two patients with pediatric inflammatory bowel disease (IBD) in which macrocreatine kinase (macro-CK) type 1 led to the final diagnosis of UC. A 13xa0year old with bloody diarrhea and weight loss was diagnosed with CD. CK elevation was interpreted as perimyocarditis attributed to CD. CK elevation persisted; however, cardiac evaluation remained unremarkable. CK gel electrophoresis revealed macro-CK type 1. During a disease flare-up and reevaluation (endoscopy and histology), the diagnosis was changed to UC. A 12-year-old girl with bloody diarrhea, weight loss, and anemia was diagnosed with CD (patchy distal colitis and aphtoid lesions). Repeated CK elevation was observed. Gel electrophoresis confirmed macro-CK type 1. After reevaluation during a flare-up (endoscopy and histology), the diagnosis was changed to UC. Conclusion CK elevation in pediatric IBD could suggest macro-CK type 1 formation, which is possibly linked to UC. In a subset of IBD patients, macro-CK type 1 could help differentiate UC from CD.

Pneumatosis coli – an underrecognized lesion mimicking neoplastic disease

ZusammenfassungDie Pneumatosis (cystoides) intestinalis kann überall im Gastrointestinaltrakt auftreten und ist durch Lufteinschlüsse in der Darmwand definiert. In Abhängigkeit von der Ursache kann die Prognose gut oder lebensbedrohlich sein: die häufigsten Auslöser sind infektiöse und medikamentös-toxische Kolitis, nekrotisierende Enterokolitis, Ischämie sowie vorausgegangene endoskopische Untersuchungen. Wir stellen zwei Fälle von asymptomatischer Pneumatosis coli vor, die in einem Fall primär an ein Polypose-Syndrom, im anderen an ein Malignom denken ließen. Beide Fälle wurden durch Schlingenpolypektomie oder Hemikolektomie histologisch verifiziert. Die Differenzialdiagnose und klinische Signifikanz der Pneumatosis (cystoides) intestinalis werden ausführlich diskutiert. Die Stellung der korrekten Diagnose, basierend auf Endoskopie, Computertomographie und Histologie, ist unabdingbar für die Therapie Betroffener und dient der Vermeidung unnötiger chirurgischer Eingriffe.SummaryPneumatosis (cystoides) intestinalis is defined as the presence of gas in the bowel wall and can be found anywhere in the gastrointestinal tract. It may be harmless or life-threatening, depending on the etiology which includes infectious and drug-induced colitis, bowel ischemia and necrotizing enterocolitis. The lesion has additionally been described following endoscopy. We report two cases of asymptomatic pneumatosis coli mimicking polyposis syndrome or malignancy. Both cases were verified histologically after snare polypectomy or hemicolectomy. The differential diagnosis and the clinical significance of the disease are discussed. Accurate diagnosis, which is mainly based upon endoscopy, computed tomography and histology, is crucial for optimal patient management thus avoiding unnecessary surgical procedures.