Journal des maladies et troubles inflammatoires de l'intestin

Dieulafoy's lesion is an aberrant submucosal arteriole that erodes through the overlying mucosa in the absence of an ulcer. They are a rare cause of gastrointestinal (GI) hemorrhage and can cause rapid blood loss. Dieulafoy's lesions are usually located in the upper GI tract along the lesser curvature of the stomach or duodenum. However, lesions in other areas of the GI tract including post-surgical bowel, have also been found. Angiogenesis at the anastomotic junctions can sometimes lead to the formation of Dieulafoy's -like lesions. A very high index of suspicion is needed to establish the diagnosis of such lesions.

Background: Fecal microbiota transplant for refractory C. difficile infection in a patient with recent trans-catheter aortic valve replacement.
Case: A 69 year-old female patient who underwent a trans-catheter aortic valve replacement (TAVR) and previous stent placement one month prior to her presentation with refractory Clostridium difficile infection (CDI) who was planned for Fecal Microbiota Transplant (FMT) via colonoscopy. The patient had initially presented with seven days of diarrhea and tested positive for C. Difficile toxin via EIA.
Conclusion: There is limited data regarding the safety and efficacy of FMT in patients with prosthetic valves. While not a contraindication to FMT, there exists concern for bacterial translocation and subsequent endocarditis. This case illustrates the importance of FMT as a therapeutic modality for severe refractory C. Difficile colitis, particularly in patients with valve replacements.

Objective: In Crohn's disease (CD) major therapeutic decisions are triggered by failure of medical therapy or by a flare and are based on various diagnostic modalities, the prior clinical course and the patient’s perception. We analyzed, whether under real world conditions a therapeutic decision can be maintained over 12 months or needs to be adjusted in this time.
Methods: In 50 patients diffusion-weighted magnetic resonance imaging (DW MRI) studies were used as an indicator for the need to make a therapeutic decision. Decisions were based on the prior clinical course, endoscopy, ultrasound, DW MRI and the patient’s perception of the situation and were categorized as surgery (A), no change (B) or intensification of medical therapy (C). The clinical course was analyzed using CDAI and CRP at 3, 6 and 12 months follow up.
Results: 33 of 50 patients had a failure of medical therapy and 17 of 50 had a flare in absence of medical therapy. The median disease duration was 8 years. Group A: In 13 patients surgery for fibro-stenosis or a penetrating complication induced remission lasting for 12 months. Group B: In 17 cases medical therapy initially was kept unchanged. As a group they had a wide range of CDAI values. During 1 year 3 of 17 went on to intensified medication, and 5 of 17 were operated, eventually leading to clinical response or remission. Group C: 20 patients changed to intensified medication, 3 of these 20 were later operated. In group C CDAI improvement lasted longer in those with a disease duration ≤ 5 years.
Conclusion: In CD therapeutic decisions often cannot be maintained but need to be adjusted even during 1 year. The likelihood to err is highest if the initial decision is to leave the existing medical therapy unchanged.