dClostridium difficile infection (CDI) causes nearly half a million cases of diarrhea and colitis in the United States each year. Although the importance of the gut microbiota in C. difficile pathogenesis is well recognized, components of the human gut flora critical for colonization resistance are not known. Culture-independent high-density Roche 454 pyrosequencing was used to survey the distal gut microbiota for 39 individuals with CDI, 36 subjects with C. difficile-negative nosocomial diarrhea (CDN), and 40 healthy control subjects. A total of 526,071 partial 16S rRNA sequence reads of the V1 to V3 regions were aligned with 16S databases, identifying 3,531 bacterial phylotypes from 115 fecal samples. Genomic analysis revealed significant alterations of organism lineages in both the CDI and CDN groups, which were accompanied by marked decreases in microbial diversity and species richness driven primarily by a paucity of phylotypes within the Firmicutes phylum. Normally abundant gut commensal organisms, including the Ruminococcaceae and Lachnospiraceae families and butyrate-producing C2 to C4 anaerobic fermenters, were significantly depleted in the CDI and CDN groups. These data demonstrate associations between the depletion of Ruminococcaceae, Lachnospiraceae, and butyrogenic bacteria in the gut microbiota and nosocomial diarrhea, including C. difficile infection. Mechanistic studies focusing on the functional roles of these organisms in diarrheal diseases and resistance against C. difficile colonization are warranted.

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Endoscopic hemostasis of diverticular hemorrhage in a colonic conduit by use of an over-the-scope clip A 64-year-old woman with a history of esophageal adenocarcinoma underwent Ivor Lewis esophagectomy. Twelve years later, she was found to have gastric adenocarcinoma, for which she underwent total gastrectomy with colonic interposition. The patient subsequently underwent Roux-en-Y surgical revision because of frequent reflux and bilious emesis. She presented with a 1-day history of hematemesis and melena and was found to be hypotensive, with acute anemia. She was not taking any antithrombotic medications. EGD revealed the esophagocolonic anastomosis to be 23 cm from the incisors. Fresh blood was seen within the colonic conduit. A diverticulum with an adherent clot was seen within the proximal colonic conduit, just distal to the anastomosis. Removal of the clot by suction and lavage resulted in brisk bleeding. Using an over-the-scope clip, we suctioned the bleeding diverticulum, and the clip was deployed with hemostasis (Fig.

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