Adhesion Ileus after Fecal Microbiota Transplantation in Long-Standing Radiation Colitis

Case Reports in Gastrointestinal Medicine
15 Mar, 2019 ,

A patient with chronic radiation colitis that developed adhesion ileus 2 days after Fecal microbiota transplantation. The adhesions had to be removed surgically. The patient had an uneventful recovery and also mentioned that his gastrointestinal problems had improved for 3-4 weeks.

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A 56-year-old Caucasian female patient underwent Wertheim-Meigs radical hysterectomy as surgical treatment of cervical carcinoma in 1986. Furthermore, radiotherapy of 30 x 8 GY was performed. Her present BMI was 22 kg/m2. She underwent subtotal thyroidectomy because of a cold knot in 2000. Her main medical problem was diarrhea. The patient has been suffering from constant diarrhea for 17 years (stool frequency between 9 and 20 times a day). As part of the diagnostics of the diarrhea H2-breath tests with lactose, fructose and sorbitol were performed. She was diagnosed with a lactose and fructose malabsorption.

Furthermore, a Helicobacter pylorieradication is worth mentioning (2013). Several rectoscopies and colonoscopies (2008, 2013, 2014, and 2016) revealed a radiotherapy-induced stenosis in the area of ​​the sigmoid colon. There were never histologic aspects of inflammatory bowel disease. A computed tomography of the abdomen and pelvis revealed a long-range concentric thickening of the rectal wall with blurred confinement and fluid imbibition of the perirectal fatty tissue (2013). These endoscopic and radiologic findings in combination with the clinical picture confirmed the diagnosis of chronic radiation colitis.

Several conservative therapies were performed, including various probiotics such as E. coli strain Nissle 1917, Bifidobacteria (B. bifidum MIMBb75), loperamide, metoclopramid, mesalazine, intestinal tea, psyllium, rice cures, healing earth, etc. None of these therapeutic approaches led to a significant and sustained improvement of her symptoms.

Due to these complaints, the quality of life of the patient was extremely reduced, the social contacts suffered from it, and the patient could hardly leave home due to the diarrhea. Therefore, she asked to have carried out a fecal microbiota therapy in order to improve the intestinal dysbiosis and thus also to improve the symptoms.

On June 27, 2018, after giving informed consent to this individual therapy trial, and after 5 days of pretreatment with rifaximin, the patient had FMT from an unrelated donor with negative serum tests for hepatitis B and C, HIV, CMV, EBV, Treponema pallidum, and negative stool cultures for costridium difficile toxin, parasites, and worm eggs, as well as noro- and rotaviruses. The colonoscopy was performed until the terminal ileum.

Between 20 and 40 cm ab ano, a mucosal atrophy and narrowing of the intestinal lumen as a result of radiation colitis was visible. FMT was done with 500 ml stool graft in terms of ileum, coecum, and colon ascendens. After the procedure, she received 2 x 2 mg loperamide and 3 x 2 mg the following day and was discharged without any symptoms. On June 28, 2018, she had stool one time and, on the following day, she developed an increasing nausea and a sense of increasing meteorism without defecation and winds.

On June 30, 2018, the patient was sent to the emergency room due to these symptoms. She had no fever and had no colics.

In a CT scan, a complete small intestinal ileus could be detected; the colon was not involved (see Figure 1). Conservative therapeutic attempts were unable to improve the result. That said, the indication for surgery on the following day was made.

A median upper and lower abdominal laparotomy and opening of the abdomen were performed. It came to the protrusion of intestinal loops from the abdominal wall, which were distended. In the distal part of the jejunum there was a strangulation of the intestine with an adhesion.

The adhesion was released and cut. This reversed the strangulation of the bowel. A resection of the small intestine was not required. After surgery, the started diet was well tolerated by the patient. The wounds healedper primam. After discharge from the department of surgery, the gastrointestinal problems had improved for 3-4 weeks, but did then revert to the state before FMT.