Probiotic treatment with Probioflora in patients with predicted severe acute pancreatitis without organ failure

Gut microbiota in pancreatic diseases: possible new therapeutic strategies

Pancreatic diseases such as pancreatitis, type 1 diabetes and pancreatic cancer impose substantial health-care costs and contribute to marked morbidity and mortality. Recent studies have suggested a link between gut microbiota dysbiosis and pancreatic diseases; however, the potential roles and mechanisms of action of gut microbiota in pancreatic diseases remain to be fully elucidated. In this review, we summarize the evidence that supports relationship between alterations of gut microbiota and development of pancreatic diseases, and discuss the potential molecular mechanisms of gut microbiota dysbiosis in the pathogenesis of pancreatic diseases. We also propose current strategies toward gut microbiota to advance a developing research field that has clinical potential to reduce the cost of pancreatic diseases.

An Updated Systematic Review With Meta-analysis: Efficacy of Prebiotic, Probiotic, and Synbiotic Treatment of Patients With Severe Acute Pancreatitis

OBJECTIVES

The aim of this study was to systematically review the clinical outcomes of all randomized controlled trials of patients with severe acute pancreatitis (SAP) and treated with pre/pro/synbiotics.

METHODS

A systematic literature search of the MEDLINE, Embase, clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials was conducted. Eligible studies were randomized controlled trials that evaluated the clinical outcomes of patients with SAP treated with pre/pro/synbiotics.

RESULTS

Eleven trials comprising 930 patients were included. Patients treated with pre/pro/synbiotics had a significantly shorter hospital stay [weighted mean difference, -4.33 days; 95% confidence interval (CI), -7.71 to -0.95; P = 0.010; I2 = 66.9%] compared with control. In a subgroup analysis where only patients classified as SAP were included, those treated with pre/pro/synbiotics had lower risk of single- or multiple-organ failure (relative risk, 0.62; 95% CI, 0.44-0.88; P = 0.995; I2 = 0.0%) and decreased hospital stay (weighted mean difference, -0.65 days; 95% CI, -0.90 to -0.41; P = 0.121; I2 = 45.3%) compared with control.

CONCLUSIONS

Patients with SAP treated with pre/pro/synbiotics did not have a worse clinical outcome and had lower risk of organ failure and duration of hospital stay. Further studies should examine the optimal timing, type, and dosages of these promising treatments.

Probiotic supplements might not be universally-effective and safe: A review

Last few decades have witnessed the unprecedented growth in the application of probiotics for promoting the general gut health as well as their inception as biotherapeutics to alleviate certain clinical disorders related to dysbiosis. While numerous studies have substantiated the health-restoring potentials for a restricted group of microbial species, the marketed extrapolation of a similar probiotic label to a large number of partially characterized microbial formulations seems biased. In particular, the individuals under neonatal stages and/or those with some clinical conditions including malignancies, leaky gut, diabetes mellitus, and post-organ transplant convalescence likely fail to reap the benefits of probiotics. Further exacerbating the conditions, some probiotic strains might take advantage of the weak immunity in these vulnerable groups and turn into opportunistic pathogens engendering life-threatening pneumonia, endocarditis, and sepsis. Moreover, the unregulated and rampant use of probiotics potentially carry the risk of plasmid-mediated antibiotic resistance transfer to the gut infectious pathogens. In this review, we discuss the safety perspectives of probiotics and their therapeutic interventions in certain at-risk population groups. The embodied arguments and hypotheses certainly will shed light on the fact why probiotic usage should be treated with caution.

Gut Microbiota-Immune System Crosstalk and Pancreatic Disorders

Gut microbiota is key to the development and modulation of the mucosal immune system. It plays a central role in several physiological functions, in the modulation of inflammatory signaling and in the protection against infections. In healthy states, there is a perfect balance between commensal and pathogens, and microbiota and the immune system interact to maintain gut homeostasis. The alteration of such balance, called dysbiosis, determines an intestinal bacterial overgrowth which leads to the disruption of the intestinal barrier with systemic translocation of pathogens. The pancreas does not possess its own microbiota, and it is believed that inflammatory and neoplastic processes affecting the gland may be linked to intestinal dysbiosis. Increasing research evidence testifies a correlation between intestinal dysbiosis and various pancreatic disorders, but it remains unclear whether dysbiosis is the cause or an effect. The analysis of specific alterations in the microbiome profile may permit to develop novel tools for the early detection of several pancreatic disorders, utilizing samples, such as blood, saliva, and stools. Future studies will have to elucidate the mechanisms by which gut microbiota is modulated and how it tunes the immune system, in order to be able to develop innovative treatment strategies for pancreatic disorders.

Nutrition in acute pancreatitis: a critical review

Severe acute pancreatitis poses unique nutritional challenges. The optimal nutritional support in patients with severe acute pancreatitis has been a subject of debate for decades. This review provides a critical review of the available literature. According to current literature, enteral nutrition is superior to parenteral nutrition, although several limitations should be taken into account. The optimal route of enteral nutrition remains unclear, but normal or nasogastric tube feeding seems safe when tolerated. In patients with predicted severe acute pancreatitis an on-demand feeding strategy is advised and when patients do not tolerate an oral diet after 72 hours, enteral nutrition can be started. The use of supplements, both parenteral as enteral, are not recommended. Optimal nutritional support in severe cases often requires a tailor-made approach with day-to-day evaluation of its effectiveness.

Dysbiosis of Intestinal Microbiota Associated With Inflammation Involved in the Progression of Acute Pancreatitis

OBJECTIVES

To evaluate alterations of the intestinal bacteria and its associations with the inflammation in acute pancreatitis (AP).

METHODS

A multihospital prospective clinical study was conducted, and a total of 108 participants were enrolled in our study, including 44 with severe AP (SAP), 32 with mild AP (MAP), and 32 healthy volunteers. The structure of intestinal microbiota, 10 predominant bacteria, plasma endotoxin, and serum cytokines were investigated by polymerase chain reaction-denaturing gradient gel electrophoresis, real-time quantitative polymerase chain reaction, Limulus amebocyte lysate tests, and enzyme-linked immunosorbent assays, respectively.

RESULTS

Dramatic alterations in the predominant fecal microbiota were observed in most of both MAP and SAP patients. In addition, the rates of the multiorgan failures and infectious complications in the patients with SAP with altered intestinal microbiota were significantly higher than in those whose intestinal microbiota remained unaltered. Enterococcus increased and Bifidobacterium decreased in the patients with SAP compared to the patients with MAP. Serum IL-6 were positively correlated with Enterobacteriaceae and Enterococcus and negatively correlated with Bifidobacterium, whereas plasma endotoxin positively correlated with Enterococcus (P < 0.05).

CONCLUSIONS

The intestinal bacteria most frequently altered in both the patients with MAP and those with SAP significantly correlated with inflammation, which indicated that the intestinal microbiota may be involved in the progression of AP.

Effect of early enteral nutrition with Bifico on levels of inflammatory mediators in plasma of patients with severe acute pancreatitis

AIM: To explore the effect of early enteral nutrition combined with probiotic treatment (Bifico) on the levels of inflammatory mediators in plasma of patients with severe acute pancreatitis (SAP).

METHODS: Eighty patients diagnosed with SAP between January 2006 and October 2013 at our hospital were included. They were given parenteral nutrition (PN group), enteral nutrition (EN group) or EN and probiotics (P + EN group). Plasma levels of interleukin-8 (IL-8), tumor necrosis factor alpha (TNF-α), C-reactive protein (CRP) and lactate dehydrogenase (LDH), white blood cell count, serum amylase, and plasma lipase were measured 1 d before and 7 d and 14 d after treatment. Hospitalization time and gastrointestinal function score were also recorded and compared.

RESULTS: After treatment, white blood cell count, serum amylase, plasma lipase and IL-8, CRP and LDH, and gastrointestinal function score were decreased in all the three groups (P < 0.05), while TNF-α in the PN group had no significant change between before and after treatment (F = 0.793, 0.745; P = 0.854, 0.772). White blood cell count, amylase and lipase levels after treatment in the P + EN group were significantly lower than those in the PN group and EN group (4.9 × 10⁹/L ± 2.4 × 10⁹/L vs 9.6 × 10⁹/L ± 3.0 × 10⁹/L vs 5.3 × 10⁹/L ± 2.7 × 10⁹/L; 197 U/L ± 50 U/L vs 297 U/L ± 77 U/L vs 253 U/L ± 63 U/L; 297 U/L ± 72 U/L vs 724 U/L ± 103 U/L vs 323 U/L ± 74 U/L; F = 5.346, 5.753; P = 0.023, 6.556, 0.022, 0.029). IL-8 and TNF-α levels were also significantly lower than those in the PN group and EN group (27.0 pg/mL ± 7.9 pg/mL vs 47.6 pg/mL ± 8.4 pg/mL vs 31.0 pg/mL ± 8.0 pg/mL; 43.5 pg/mL ± 22.7 pg/mL vs 132.5 pg/mL ± 32.6 pg/mL vs 67.5 pg/mL ± 21.4 pg/mL; F = 8.375, 7.278; P = 0.017, 0.012). Plasma CRP and LDH levels were significantly lower in the P + EN group after treatment than in the PN group and EN group (39.4 mg/L ± 19.7 mg/L vs 102.5 mg/L ± 41.9 mg/L vs 68.3 mg/L ± 32.9 mg/L; 20.3 U/L ± 12.3 U/L vs 79.3 U/L ± 34.4 U/L vs 35.3 U/L ± 10.4 U/L; F = 8.353, 10.354; P = 0.032, 0.013). Gastrointestinal function scores in the PN group, EN group and P + EN group on 14 d were significantly decreased, and the decrease was more significant in the P + EN group than in the PN group and EN group (0.25 ± 0.02 vs 0.71 ± 0.08 vs 0.40 ± 0.04; F = 12.456; P = 0.000). The mortality and incidence of complications were significantly lower and duration of hospitalization was significantly shorter in the combination group than in the EN group (χ² = 4.428, 28.986; P = 0.019, 0.000).

CONCLUSION: Early application of EN combined with Bifico can reduce the levels of enzymes and mediators of inflammation, pancreatic secretion, complications, hospitalization time, and mortality in SAP patients.

Enteral nutrition in acute pancreatitis: A review of the current evidence

The use of enteral feeding as part of the management of acute pancreatitis dates back almost two decades. This review describes the indications for and limitations of enteral feeding for the treatment of acute pancreatitis using up-to-date evidence-based data. A systematic review was carried out to analyse current data on the use of enteral nutrition in the management of acute pancreatitis. Relevant literature was analysed from the viewpoints of enteral vs parenteral feeding, early vs delayed enteral nutrition, nasogastric vs nasojejunal feeding, and early oral diet and immunonutrition, particularly glutamine and probiotic supplementation. Finally, current applicable guidelines and the effects of these guidelines on clinical practice are discussed. The latest meta-analyses suggest that enteral nutrition significantly reduces the mortality rate of severe acute pancreatitis compared to parenteral feeding. To maintain gut barrier function and prevent early bacterial translocation, enteral feeding should be commenced within the first 24 h of hospital admission. Also, the safety of nasogastric feeding, which eases the administration of enteral nutrients in the clinical setting, is likely equal to nasojejunal feeding. Furthermore, an early low-fat oral diet is potentially beneficial in patients with mild pancreatitis. Despite the initial encouraging results, the current evidence does not support the use of immunoenhanced nutrients or probiotics in patients with acute pancreatitis.

Probiotics in treatment of severe acute pancreatitis

Severe acute pancreatitis (SAP) is a life-threatening condition characterized by high mortality, with infection and bacteremia being major causes of death. Prophylactic antibiotic administration failed to show any favorable effect on the incidence of infectious complications in SAP patients. Consequently, microorganism intervention is recommend by World Health Organization (WHO). Probiotics improve the prognosis of SAP patients by promoting gastrointestinal peristalsis, modulating the content of gut microbiota, maintaining the integrity of the gut barrier, modulating the immune response by the gut-associated immune system and reducing the damage to the pancreas, lung and liver. It has been demonstrated that probiotics in combination with immunonutrition could improve the prognosis of SAP patients. However, the use of probiotics in SAP remains controversial currently.