Hematochezia

The study design is illustrated in Fig. 1a and consisted of two parts. Firstly, thirty-four 10-week-old male C57BL/6J mice were housed under specific pathogen-free conditions in Shanghai SLAC Laboratory Animal Co. Ltd, Shanghai, China, and were divided into three groups: KD (n = 10, KD contains 10% kcal protein, <1% kcal carbohydrate, and 89% kcal fat, FBSH Biotechnology Co. Ltd, Shanghai, China), LCD (n = 10, LCD contains 20% kcal protein, 10% kcal carbohydrate, and 70% kcal fat, FBSH Biotechnology Co. Ltd), and ND (n = 14, 18% kcal protein, 65% kcal carbohydrate, and 17% kcal fat). Mice were co-housed prior to starting the test diets to control for cage effects.^{45 (link)} Food intake was set at 11.9 kcal/day and decreased to 11.2 kcal/day after weight gain was observed during the first weeks of the study. Cross-sectional mice were always maintained on 11.2 kcal/day. A detailed description of diet composition is provided in Supplementary Table 4. After 16 weeks of dietary intervention, the mice were treated with or without 3% DSS for 1.5 weeks and defined as KD colitis (KD-C, n = 10), LCD colitis (LCD-C, n = 10), ND colitis (ND-C, n = 10), and ND (n = 4) groups.
Secondly, 34 germ-free C57BL/6J mice were bred at the Shanghai SLAC Laboratory Animal Co. Ltd, China. GF mice received FMT using feces from the dietary-treated mice and were treated with a normal diet for 2 weeks before being administered with 3% DSS for 1 week (normal diet) and divided into four groups: KD + FMT colitis (FKD + C, n = 10), LCD + FMT colitis (FLCD + C, n = 10), ND + FMT colitis (FND + C, n = 10), and ND + FMT (FND, n = 4). Body weight was measured weekly, while fecal and blood samples were collected from each cage before and after DSS treatment. The blood collection was performed using cardiac puncture. Epididymal white adipose, MLNs, liver tissue, and colon tissue were collected after sacrifice. Body mass index was calculated using Lee’s index [body weight (g) × 1000/body length (cm)]^1/3. Colitis was assessed using the DAI and calculated based on weight loss percentage, diarrhea, and haematochezia. All procedures were carried out according to protocols approved by the Animal Care and Use Committee of Shanghai Tenth People’s Hospital affiliated to Tongji University.
See Supplementary Materials for details on fecal transplantation, serum metabolic measurement, 16S rDNA microbiota profiling, bioinformatics analysis, metabolomics analysis by gas chromatography–mass spectrometry (GC-MS), metabolomics analysis by ultra-high-performance liquid chromatography-high resolution mass spectrometry (UHPLC-HRMS/MS), metabolomics data analysis, hematoxylin and eosin (H&E) staining and histopathological evaluation, measurement of hepatocyte fat deposition, immunofluorescence staining, RNA extraction and quantitative RT-PCR, RT2 profiler PCR array gene expression, transcriptome sequencing, and statistical analysis.

This study was designed as a prospective, double‐blinded, randomized, placebo‐controlled, trial. The study design was approved by the ethical committee of the Centre for Clinical Veterinary Medicine Ludwig‐Maximilians‐University, Munich (reference 68‐19‐05‐2016). An informed client consent form was signed by all owners. The dogs were recruited between July 2016 and January 2018 by the same veterinarian (MW) across 4 small animal clinics in Munich, Germany. The randomization list was formed before start of the study through a third person using a research randomizer available on the following website: https://www.graphpad.com/quickcalcs/randomize1.cfm. Dogs of either sex with acute nonhemorrhagic diarrhea between 5 and 40 kg bodyweight, and of at least 9 months of age were enrolled into this study. Only dogs with a fecal consistency score of at least 2 on the CADS‐Index (Table 1) and a duration of gastrointestinal symptoms of <3 days were enrolled. Exclusion criteria were the following: treatment with an antimicrobial within 30 days or treatment with an anti‐inflammatory drug within 7 days before presentation, blood in feces, any signs of systemic inflammation (eg, rectal temperature > 39.0°C [102.2 °F]), severe illness (eg, lethargic mental status, moderate to severe abdominal pain), or significant dehydration prompting hospitalization. These exclusion criteria were chosen to define the disease as “uncomplicated,” thus only dogs that could be treated as outpatients, were included.
The histories of all dogs were recorded in a standardized method with specific questions regarding stress‐related factors, diet, dietary changes, feeding of treats, chronic illnesses, other diseases in the last months before presentation, drug administration and timing of any past diarrheic episode.
Diagnostic work‐up in all dogs before inclusion consisted of a blood count, serum chemistry profile (urea nitrogen, creatinine, SDMA, sodium, chloride, potassium, phosphate, total bilirubin, ALT, ALP, gamma‐GT, AST, GLDH, total protein, albumin, globulin, glucose, alpha‐amylase, lipase, cholesterol, fructosamine, creatine kinase, LDH, calcium, magnesium, triglycerides), and a fecal flotation.

A 35-year-old incarcerated AA male was admitted to the hospital several times for hematochezia with multiple unrevealing endoscopic evaluations. He was readmitted for a gastroenterology (GI) bleed, and magnetic resonance enterography (MRE) and fecal calprotectin were again unremarkable. Repeat colonoscopy showed severe inflammation of the terminal ileum (TI) with patchy mild–moderate inflammation of colon and pathology consistent with idiopathic IBD. He was started on IV steroids and discharged on an oral prednisone taper for 9 weeks. Initial planned outpatient therapy was 5 mg/kg infliximab, but he experienced a delayed start requiring an additional steroid taper. Infliximab was started 4 months later at standard dosing. He unfortunately was late for his second dose and missed his third dose due to hospitalization for ongoing symptoms. During that admission, his anemia was so severe that a blood transfusion was required. At that time, the decision was made to reinduce with an increased dose at 10 mg/kg every 4 weeks with the first dose on the day of discharge. Since that time, he has been late for multiple infusions due to prison-related scheduling issues. After requiring his fifth prolonged prednisone taper in 1 year, he underwent infliximab reload at 10 mg/kg. He again was late for his every 4-week maintenance infusions. Since being released from prison, he has been on time for infliximab infusions 10 mg/kg every 8 weeks with reported improvement in his diarrhea and hematochezia. Subsequent endoscopy revealed resolution of the TI disease with patchy mild colitis in only 1 region of the colon. His dosing regimen was optimized to 10 mg/kg every 4 weeks and clinically he has been doing well.

A 31-year-old incarcerated AA male complained of hematochezia and fever requiring admission to the hospital and was diagnosed with Clostridium difficile colitis. CT scan and colonoscopy showed left-sided colitis. Following treatment with oral vancomycin, outpatient colonoscopy was consistent with residual proctosigmoiditis. Through SDM, he was started on mesalamine enemas but had difficulty retaining them and decision was made to start on UST for ease of dosing and avoidance of per-rectum therapies per patient preference. The UST was infused at the clinic during a scheduled visit. He missed multiple doses due to inconsistent transport to clinic for nurse-led administration of medication. He was then released from custody and off all therapy until developing C. difficile infection requiring hospitalization. He was treated with vancomycin and then resumed on PO and PR mesalamine as an outpatient. However, upon reincarceration with questionable access to medication, he developed worsening symptoms and was started on sulfasalazine. Repeat colonoscopy showed Mayo 3 pancolitis with pathology confirming moderate inflammation. He resumed UST therapy with a standard loading dose given at a clinic appointment and 90 mg SC every 8 weeks consistently while incarcerated. The patient has since been released from the detention center and has a steady job. He has been in frequent contact with the PCMH and the behavioral health social worker who assists him in coming to appointments and receiving his medication in a timely fashion from the specialty pharmacy. Clinically, he is doing well and is planned for endoscopic evaluation shortly once his insurance is valid. Additional biochemical evaluation is pending given the cost associated with self-pay laboratory studies.

Azoxymethane (AOM, 10mg/kg, Sigma-Aldrich- A5486-25MG) in saline was injected intraperitoneally (IP) 2 days in advance of three cycles of 3.5% dextran sodium sulfate (DSS, MP Biomedicals- 160110, molecular weight: 36,000–50,000). Each cycle consisted of 5 days of 3.5% DSS in the drinking water, followed by 16 days of regular water. Mice were euthanized at various time points (“baseline”; at the end of each DSS treatment, designated as “colitis”; one week after each DSS cycle, designated as “recovery”, with the end of the 3^rd cycle being designated as “cancer”). This AOM-DSS colitis model leads to predictable and reproducible colitis and cancer [15 ]. Disease activity index (DAI) was recorded, a colonoscopy was performed 1 week after each DSS treatment, and mice were euthanized at various time points (colitis, recovery, cancer) with colon tissue either stored in liquid nitrogen or placed in formalin. Disease activity index was calculated based on weight loss (1 = 0–10%, 2 = 10–15%, 3 = 15–20%, 4 = >20%), stool consistency (1 = solid, 2 = loose, 3 = wet, 4 = diarrhea), and hematochezia (1 = no blood, 2 = slight blood, 3 = blood, 4 = significant hematochezia).