Stimulation of ileal emptying by short-chain fatty acids

Effects of medicines used to treat gastrointestinal diseases on the pharmacokinetics of coadministered drugs: a PEARRL Review

Objectives

Drugs used to treat gastrointestinal diseases (GI drugs) are widely used either as prescription or over-the-counter (OTC) medications and belong to both the 10 most prescribed and 10 most sold OTC medications worldwide. The objective of this review article is to discuss the most frequent interactions between GI and other drugs, including identification of the mechanisms behind these interactions, where possible.

Key findings

Current clinical practice shows that in many cases, these drugs are administered concomitantly with other drug products. Due to their metabolic properties and mechanisms of action, the drugs used to treat gastrointestinal diseases can change the pharmacokinetics of some coadministered drugs. In certain cases, these interactions can lead to failure of treatment or to the occurrence of serious adverse events. The mechanism of interaction depends highly on drug properties and differs among therapeutic categories. Understanding these interactions is essential to providing recommendations for optimal drug therapy.

Summary

Interactions with GI drugs are numerous and can be highly significant clinically in some cases. While alterations in bioavailability due to changes in solubility, dissolution rate, GI transit and metabolic interactions can be (for the most part) easily identified, interactions that are mediated through other mechanisms, such as permeability or microbiota, are less well-understood. Future work should focus on characterising these aspects.

Ileal microbiota of growing pigs fed different dietary calcium phosphate levels and phytase content and subjected to ileal pectin infusion

Two experiments with growing pigs were conducted to determine the effects of dietary P and Ca levels, phytase supplementation, and ileal pectin infusion on changes in bacterial populations in the ileum and on ileal and fecal fermentation patterns. Growing pigs (BW 30.1 +/- 1.3 kg) were fitted with simple T-cannulas at the distal ileum and were fed a low-P corn-soybean meal control diet (3 g of P/kg), or the control diet supplemented with either 15 g of monocalcium phosphate (MCP)/kg (Exp. 1) or 1,000 phytase units of phytase/kg (Exp. 2). Daily infusion treatments consisted of either 60 g of pectin dissolved in 1.8 L of demineralized water or 1.8 L of demineralized water as a control infusion, infused via the ileal cannula. In each experiment, 8 barrows were assigned to 4 dietary treatments according to a double incomplete 4 x 2 Latin square design. The dietary treatments in Exp. 1 were the control diet with water infusion, the control diet with pectin infusion, the MCP diet with water infusion, or the MCP diet with pectin infusion. In Exp. 2, the pigs received the same control treatments as in Exp. 1 and the phytase diet in combination with water or pectin infusion. Gene copy numbers of total bacteria, Lactobacillus spp., Lactobacillus reuteri, Lactobacillus amylovorus/Lactobacillus sobrius, Lactobacillus mucosae, Enterococcus spp., Enterococcus faecium, Enterococcus faecalis, bifidobacteria, the Clostridium coccoides cluster, the Clostridium leptum cluster, the Bacteroides-Prevotella-Porphyrmonas group, and Enterobacteriaceae were determined by quantitative PCR in DNA extracts of ileal digesta. In Exp. 1, addition of MCP reduced ileal gene copy numbers of Enterococcus spp. (P = 0.048), E. faecium (P = 0.015), and the C. leptum cluster (P = 0.028), whereas pectin infusion enhanced (P = 0.008) ileal d-lactate concentration. In Exp. 2, supplemental phytase led to greater ileal gene copy numbers of the C. coccoides (P = 0.041) and C. leptum (P = 0.048) clusters and the Bacteroides-Prevotella-Porphyrmonas group (P = 0.033), whereas it reduced (P = 0.027) fecal n-butyrate concentration. Pectin infusion reduced (P = 0.005) ileal gene copy number of the C. leptum cluster. In conclusion, ileal bacterial populations and fermentation patterns are susceptible to changes in the intestinal availability of Ca and P as well as to the supply of pectin as a fermentable substrate. Greater intestinal Ca availability decreased the numbers of some gram-positive bacteria, whereas greater P availability in the small intestine caused by phytase activity enhanced the growth of strictly anaerobic bacteria.

Determinants of postprandial flow across the human ileocaecal junction: a combined manometric and scintigraphic study

The relationships between ileocolonic motor patterns and flow have not been defined in humans. Utilizing simultaneous ileocolonic manometry and scintiscanning, we aimed to examine this relationship and test the hypotheses that ileal propagating sequences (PSs) underlie caecal filling, that caecal filling is a stimulus for proximal colonic PSs and that the ileocolonic junction (ICJ) regulates flow between the small and large bowel. In six healthy volunteers, a 5-m-long nasocolonic manometry catheter was positioned such that 16 recording sites, spaced at 7.5-cm intervals, spanned the ileum and proximal colon. Subjects were positioned under a gamma camera 30 MBq of (99m)Tc sulphur colloid was instilled, 22.5 cm proximal to the ICJ. Isotopic images were recorded (10 s per frame) and synchronized with the manometric trace. We identified 171 ileal PSs, 47 caecal PSs and 117 discrete episodes of caecal filling. Of the 117 episodes of caecal filling, 72% were associated temporally with ileal PSs. Conversely, 87% of ileal PSs were associated with caecal filling. Of the PSs originating in the caecum, 90% were temporally associated with caecal filling. We conclude that ileal PSs are highly propulsive and are the major determinant of episodic caecal filling and that caecal filling may be a major stimulus for caecal propagating sequences.

The effects of regular consumption of short-chain fructo-oligosaccharides on digestive comfort of subjects with minor functional bowel disorders

A comparative, randomised, double-blind trial was performed in the medical departments of five hospitals to study the effects of regular consumption of short-chain fructo-oligosaccharides (sc-FOS) on the digestive comfort of subjects with minor functional bowel disorders (FBD). In step 1, 2235 subjects were questioned to assess the incidence and intensity of digestive disorders. In step 2, 105 of these patients diagnosed with minor FBD were randomised into two groups to receive either 5 g sc-FOS or 5 g placebo (sucrose and maltodextrins) per d over a 6-week period. The incidence and intensity of digestive disorders were assessed at the end of the treatment period (day 43) using the step 1 questionnaires. A quality-of-life questionnaire was also completed at the start and end of the treatment period to assess potential effects on well-being and social performance. In step 1, 44 % of the subjects questioned presented FBD, of whom 57.1 % suffered from minor FBD. In step 2, on day 43, the intensity of digestive disorders decreased by 43.6 % in the sc-FOS group v. a 13.8 % increase in the placebo group (P = 0.026). Symptoms were experienced less frequently by 75.0 % of subjects in the sc-FOS group, while 53.8 % of controls experienced no change (P = 0.064). Using the functional digestive disorders quality of life questionnaire, the discomfort item scores increased in the sc-FOS group (P = 0.031). However, expressed as change in quality of life (improvement, worsening or unchanged), daily activities were significantly improved in the sc-FOS group (P = 0.022). Regular consumption of sc-FOS may improve digestive comfort in a working population not undergoing medical treatment.

The ileocolonic sphincter

The human ileocolonic sphincter (ICS) develops a sustained tone mainly due to propagated and not propagated phasic motor activity. The ileocaecocolonic segment is also able to behave, yet uncommonly, as a synchronized segment involving propagated contractions originating from the ileum and migrating to the proximal colon. The ICS motor activity alone has a limited role towards forward flow. On the contrary, the functional entity corresponding to the distal ileum and the ICS provides a clearance mechanism for reflux of colonic contents into the small intestine. The presence of short chain fatty acids (SCFA) in the distal ileum, sensed either by endocrine cells or chemo-sensitive vagal afferents, is an important actor in triggering this clearance mechanism. The ICS tone is in part myogenic but a neuronal nitrergic component is also involved. Reflex excitatory and inhibitory responses of the ICS originating from ileal or colonic distension involve primarily spinal nitrergic and adrenergic pathways.

Effect of short-chain fatty acids on contraction of smooth muscle in the canine colon

OBJECTIVE

To determine effects of short-chain fatty acids (SCFA) on canine colonic smooth muscle.

SAMPLE POPULATION

Colonic tissue obtained from 14 healthy dogs.

PROCEDURE

Short-chain fatty acid (SCFA; acetate, propionate, and butyrate; 1 to 100 mmol/L)-induced contractions were compared with responses obtained with acetylmethylcholine (AMCh; 10(-4) mol/L). Roles of enteric neurons, cholinergic receptors, calcium stores in the sarcoplasmic reticulum, and extracellular calcium in the SCFA-induced responses were investigated by incubating muscle strips with tetrodotoxin (1 micromol/L), atropine (1 micromol/L), ryanodine (10 micromol/L), nifedipine (1 micromol/L), ethylene glycol-bis (beta-aminoethylether)-N,N,N',N'-tetra-acetate (EGTA; 0.1 mmol/L), or an extracellular calcium-depleted (zero extracellular calcium) solution prior to the addition of propionate or butyrate.

RESULTS

Incubation with SCFA elicited isometric stress responses (0.25 to 2.15 x 10(4) N/m2) in colonic longitudinal smooth muscle. Maximal responses to butyrate and propionate (50 mmol/L) were 37 and 23%, respectively, of the maximal AMCh response. Acetate was least effective in stimulating contractile responses. Tetrodotoxin and atropine did not affect SCFA-induced contractions. Nifedipine and zero extracellular calcium solution abolished responses to butyrate and propionate, whereas EGTA attenuated (> 60%) but did not abolish those responses. Ryanodine did not affect SCFA-induced contractile responses. The SCFA did not affect colonic circular smooth muscle. CONCLUSIONS AND CLINICAL RESPONSE: The SCFA stimulate longitudinal but not circular colonic smooth muscle contractions via a direct effect on smooth muscle. The mechanism of the SCFA effect appears to involve the influx of extracellular calcium. These findings may account for some of the effects of fiber on canine colonic motility [corrected].

Desensitization of ileal vagal receptors by short-chain fatty acids in pigs

Coloileal reflux episodes trigger specialized ileal motor activities and inhibit gastric motility in pigs. The initiation of these events requires the detection by the distal ileum of the invading colonic contents that differ from the ileal chyme primarily in short-chain fatty acid (SCFA) concentrations. In addition to the already described humoral pathway, this detection might also involve ileal vagal afferents. Sensitivity to SCFA of 12 ileal vagal units was investigated in anesthetized pigs with single-unit recording at the left cervical vagus. SCFA mixtures (0.35, 0.7, and 1.4 mol/l) containing acetic, propionic, and butyric acids in proportions identical to that in the porcine cecocolon were compared with isotonic and hypertonic saline. All units behaved as slowly adapting mechanoreceptors (half-adaptation time = 35.4 +/- 15.89 s), and their sensitivity to local mechanical probing was suppressed by local anesthesia; 7 units significantly decreased their spontaneous firing with 0.7 and 1.4 but not 0.35 mol/l SCFA infusion compared with hypertonic or isotonic saline. Similarly, the response induced by distension in the same seven units was reduced (5 neurons) or abolished (2 neurons) after infusion of 0.7 (22.8 +/- 2.39 impulses/s) and 1.4 (30.3 +/- 2.12 impulses/s) mol/l SCFA solutions compared with isotonic saline (38.6 +/- 4.09 impulses/s). These differences in discharge were not the result of changes in ileal compliance, which remained constant after SCFA. In conclusion, SCFA, at concentrations near those found during coloileal reflux episodes, reduced or abolished mechanical sensitivity of ileal vagal afferents.

Short-chain fatty acids present in the ileum inhibit fasting gastrointestinal motility in conscious pigs

Colonic compounds, primarily short-chain fatty acids (SCFAs), inhibit gastric tone in humans. However, since colonic compounds reflux into the ileum, SCFAs might act also at the ileal level. This study evaluates the effects of the contact of SCFAs with the ileum alone towards gastrointestinal motility in fasted conscious pigs. Gastrointestinal motility was recorded during ileal infusion of a mixture containing acetate, propionate and butyrate in intact vs ileostomized animals (n = 10). Ileal infusions of isomolar (500 mmol L-1) vs isocaloric (600 kJ L-1) SCFAs were also performed. SCFA mixture reduced significantly the amplitude and increased the frequency of antral contractions in intact (motility index: 2624 +/- 503.4 vs 4077 +/- 388.2) and ileostomized pigs (motility index: 2428 +/- 678.1 vs 4709 +/- 773.4) compared with iso-osmotic saline. SCFAs at isomolar concentrations inhibited equally gastric motor pattern irrespective of their chemical structure. On the contrary, isocaloric concentrations of SCFAs induced graded effects: acetic acid being the most potent to reduce gastric motility. In conclusion, SCFAs inhibit gastrointestinal motility by a direct contact with the ileum. This inhibition was concentration dependent.

The physiology of ileo-anal pouch function

Even excellent clinical function after ileo-anal pouch construction is associated with a variety of physiological abnormalities. Small bowel intestinal motility is essentially normal but the ileal reservoir serves to markedly suppress the ileal motor response both to progressive distension by intestinal contents and to transmitted myoelectrical complexes. As a result, the healthy pouch can accommodate a large volume of intestinal content before the rising baseline pressure and the appearance of large isolated contraction waves produce an urge to defecate. Evacuation in the normal pouch patient is rapid and highly efficient and is achieved by means of the Valsalva maneuver without any evidence of significant intestinal propulsion. External anal sphincter function is fully preserved but internal anal sphincter function is significantly impaired in the immediate postoperative period. Recovery occurs over the next 6 to 12 months but is often incomplete. Bacterial overgrowth in the pouch and prepouch ileum is almost universal and results in the premature deconjugation of primary bile salts and accumulation of secondary bile salts within the pouch. These produce morphologic changes in the ileal mucosa, and their excretion in pouch effluent gradually depletes the bile salt pool. Anerobic organisms also bind with vitamin B12 and the vitamin B12-intrinsic factor complex, resulting in subtle but measurable reductions in vitamin B12 levels in pouch patients. Finally, anerobic fermentation of mucus and undigested carbohydrate results in excessive quantities of short chain fatty acids within the pouch lumen. The clinical significance of these substances is unclear, but they may have an adverse action on both ileal mucosal and smooth muscle function. In essence, however, the pouch surgeon can maximize the likelihood of good clinical function by constructing a large capacity pouch, by avoiding surgery in patients with clearly deficient anal sphincter mechanisms, and by careful attention to pouch-anal anastomotic technique.

Relationships between cecoileal reflux and ileal motor patterns in conscious pigs

Ileal infusion of cecocolonic contents, used to mimick reflux, enhanced terminal ileal motility, increasing the frequencies of prolonged propagated contractions (PPC) and discrete clustered contractions (DCC). Because the reflux rate in dogs and humans is marginal, the relationship of these motor patterns to reflux remained putative. In six conscious pigs, the ileal pH, used to indicate reflux event, was measured 10 and 5 cm proximal to the ileocecal sphincter (ICS). Ileal motility was evaluated with three strain gauges 15, 10, and 5 cm proximal to the ICS. Ileal pH dips were observed about eight times per hour in the fasting or fed state, and 46% of the pH dips were preceded by a retrograde contraction. During pH dips, frequency of ileal contractions not classified as PPC or DCC was significantly increased. Of the PPC 52% occurred immediately after the start of the dip and might act as a clearance mechanism because dips associated with PPC were of smaller amplitude and duration than those not associated with PPC. Most DCC also occurred during pH dips but their delay to the onset of the dip was longer. The pig presents frequent cecoileal reflux events associated with ileal motor patterns, some of them might facilitate reflux, whereas others act as a clearance mechanism.

Effects of short-chain fatty acids on gastrointestinal motility

Besides their action on gut morphology and function, short-chain fatty acids (SCFAs), produced by bacterial fermentation of carbohydrates in the colon, influence gastrointestinal motility. As they are not present in the stomach and proximal small intestine, SCFAs do not directly affect motility of these segments. However, caecal infusion of SCFAs as well as colonic fermentation of lactulose induce a relaxation of the proximal stomach in humans, indicating that SCFAs can affect motility at a distance from their site of production. Moreover, this suggests that SCFAs may be involved in the so-called "ileocolonic brake', i.e. the inhibition of gastric emptying by nutrients reaching the ileo-colonic junction. In the terminal ileum, where their concentration may increase following a colo-ileal reflux, SCFAs stimulate contractions and shorten ileal emptying, which may protect ileal mucosa against the potentially harmful effects of the reflux of colonic contents. Although SCFAs are produced and concentrated in the colon, their action on motility of this organ is not clearly understood and may depend on concentration, molecular structure of the acids, responsiveness of the colonic segments and animal species. The mechanisms of action of SCFAs on gastrointestinal motility are not completely elucidated. They may involve systemic humoral and neural pathways as well as local reflexes and myogenic responses.

In vitro contractile effects of short chain fatty acids in the rat terminal ileum

Short chain fatty acids (SCFAs), produced in the gut by bacterial fermentation of carbohydrates, change intestinal motility by mechanisms as yet unknown. This study examined the mechanism(s) of action of SCFAs on contractility using isolated rat terminal ileum segments and isolated ileal smooth muscle cells. Strip contractions were recorded under isometric conditions. Intracellular calcium concentration ([Ca2+]i) was measured in single cells loaded with indo-1 penta-acetoxymethyl ester (indo-1 AM). SCFAs (10(-9) to 10(-2) mol/l) induced concentration dependent contractions. The effect was not different among the individual SCFAs. Exogenous acids (namely tartaric and citric acids) caused similar responses as SCFAs, whereas sodium acetate had no effect. The contraction was not blocked by tetrodotoxin, atropine or hexamethonium, showing that it was not mediated through a cholinergic pathway. Moreover, removal of the mucosa or addition of procaine (a local anaesthetic) to the bath did not change the SCFA induced contraction, while verapamil (a calcium-channel antagonist) completely suppressed it. In addition, application of SCFAs to isolated ileal myocytes evoked peaks in [Ca2+]i inhibited by D 600 (a blocker of voltage dependent calcium channels). Taken together, these results suggest that the contractile response stimulated by SCFAs in the rat terminal ileum could result from an acid sensitive calcium dependent myogenic mechanism.

Effects of artificial ileocolonic sphincter on motility in intestinal remnant following subtotal small intestinal resection in the dog

We studied the effects of a sphincter substitute on motility in the intestinal remnant following an extensive distal intestinal resection. Two groups of adult dogs were studied; each underwent a 75% resection of the distal small intestine, and in one group a nipple valve was fashioned at the distal end of the remnant. Nutritional status, absorptive function, motility, and transit were studied over a three-month period. While the nipple valve animals had less diarrhea, steatorrhea, and hypoalbuminemia, motor activity and transit were similar in both groups. Thus, in both groups, fasting motor activity was dominated by clusters of phasic pressure activity. (Cluster frequency, per hour, mean +/- SE, resection vs resection with nipple valve: 4.8 +/- 1.05 vs 3.58 +/- 0.54, NS). We conclude that the beneficial effects of a sphincter substitute in ameliorating the short bowel syndrome in this dog model are not related to any modification of the motor response to resection but may simply reflect those of a low-grade mechanical obstruction.

Short-chain fatty acids do not alter jejunal motility in man

Short-chain fatty acids (SCFAs) alter ileal and colonic motility, but their effects on duodenojejunal motility are unknown. Simultaneous jejunal manometric recordings and hydrogen breath tests after lactulose were performed in eight healthy subjects during continuous duodenal infusion of either saline or SCFAs. These experiments were conducted in the fasting state and postprandially. The effects of various boluses of SCFAs on duodenojejunal motility were also determined in six subjects. During the fasting period, the number and characteristics of migrating motor complex, prolonged propagated contractions, discrete clustered contractions, motility index, and orocecal transit time were similar during saline and SCFAs. Similarly, the motility index and the duration of the postprandial period were not different between SCFAs and saline after the meal. The motility index was significantly increased after each of the 100-ml boluses (saline or SCFAs), but was not altered after the 12.5-ml boluses, suggesting a volume-related effect. Thus, SCFAs do not seem to affect proximal small bowel motility in healthy humans.

Response of canine ileocolonic sphincter to intraluminal acetic acid and colonic distension

The aim was to determine the effect of intraluminal acetic acid and proximal colonic distension on canine ileocolonic sphincter pressure, ileal motility, and coloileal reflux. In six conscious dogs with an isolated ileocolonic loop, basal pressure of the ileocolonic sphincter was similar during ileal perfusion with 100 mM acetic acid at 1 ml/min (mean +/- SEM = 18 +/- 0.4 mm Hg) and with saline (18 +/- 0.5 mm Hg; P = 0.81). Discrete clustered ileal contractions were more frequent with acetic acid, however, and when they propagated across the sphincter, sphincter pressure increased from 18 +/- 0.4 mm Hg to 36 +/- 1.3 mm Hg (P = 0.002). Sphincter pressure was also greater during colonic perfusion with acetic acid (32 +/- 0.7 mm Hg) than during ileal perfusion with acetic acid or saline (P less than 0.017). Moreover, sphincter pressure gradually increased as the colon was distended with saline (slope = 0.8 mm Hg/cm H2O, P less than 0.017) or acetic acid (slope = 0.5 mm Hg/cm H2O, P less than 0.017), but the increase did not prevent coloileal reflux. In conclusion, ileal clustered contractions, colonic perfusion of acetic acid, and colonic distension all increased canine ileocolonic sphincter pressure.