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Montrose JA, Kurada S, Fischer M. Current and future microbiome-based therapies in inflammatory bowel disease. Curr Opin Gastroenterol 2024; 40:258-267. [PMID: 38841848 DOI: 10.1097/mog.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW The role of the microbiome and dysbiosis is increasingly recognized in the pathogenesis of inflammatory bowel disease (IBD). Intestinal microbiota transplant (IMT), previously termed fecal microbiota transplant has demonstrated efficacy in restoring a healthy microbiome and promoting gut health in recurrent Clostridioides difficile infection. Several randomized trials (RCTs) highlighted IMT's potential in treating ulcerative colitis, while smaller studies reported on its application in managing Crohn's disease and pouchitis. RECENT FINDINGS This review delves into the current understanding of dysbiosis in IBD, highlighting the distinctions in the microbiota of patients with IBD compared to healthy controls. It explores the mechanisms by which IMT can restore a healthy microbiome and provides a focused analysis of recent RCTs using IMT for inducing and maintaining remission in IBD. Lastly, we discuss the current knowledge gaps that limit its widespread use. SUMMARY The body of evidence supporting the use of IMT in IBD is growing. The lack of a standardized protocol impedes its application beyond clinical trials. Further research is needed to identify patient profile and disease phenotypes that benefit from IMT, to delineate key donor characteristics, optimize the delivery route, dosage, and frequency.
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Affiliation(s)
| | - Satya Kurada
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Monika Fischer
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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2
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Fehily SR, Basnayake C, Wright EK, Yao CK, Godsell J, Gibson PR, Kamm MA. Probiotics: are they beneficial? Intern Med J 2024; 54:861-870. [PMID: 38717051 DOI: 10.1111/imj.16388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/13/2024] [Indexed: 06/18/2024]
Abstract
There are wide-ranging probiotic choices in Australasia. We reviewed the efficacy of probiotics for the management of gastrointestinal (GI) conditions in adults and assessed relevance to clinical practice. The benefits of probiotics were inconsistent, with a strong consensus reached for only a few of the indications. As different species/strains and combinations differ in efficacy, results cannot be extrapolated from one to another. This review endorses specific probiotics for limited indications. Efficacy of most marketed probiotic formulations remains unstudied and unproven, warranting further research.
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Affiliation(s)
- Sasha R Fehily
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Chamara Basnayake
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Emily K Wright
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - C K Yao
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Jack Godsell
- Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Central Clinical School, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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3
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Knowles JP, Church J. Normal Ileal Mucus Is Inadequate for Epithelial Protection in Ileal Pouch Mucosa. Dis Colon Rectum 2024; 67:635-644. [PMID: 38276959 DOI: 10.1097/dcr.0000000000003163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND Clinical, nonspecific pouchitis is common after restorative proctocolectomy for ulcerative colitis, but its cause is unknown. A possible lack of protection for the ileal mucosa in its role as a reservoir for colonic-type bacteria may be the missing piece in defining the causes of pouchitis. OBJECTIVE The study aimed to review the causes of pouchitis and introduce the hypothesis that inadequate mucus protection in the pouch, combined with a predisposition to abnormal inflammation, is the most common cause of nonspecific pouchitis. DATA SOURCES Review of PubMed and MEDLINE for articles discussing pouchitis and intestinal mucus. STUDY SELECTION Studies published from 1960 to 2023. The main search terms were "pouchitis," and "intestinal mucus," whereas Boolean operators were used with multiple other terms to refine the search. Duplicates and case reports were excluded. MAIN OUTCOME MEASURES Current theories about the cause of pouchitis, descriptions of the role of mucus in the physiology of intestinal protection, and evidence of the effects of lack of mucus on mucosal inflammation. RESULTS The crossreference of "intestinal mucus" with "pouchitis" produced 9 references, none of which discussed the role of mucus in the development of pouchitis. Crossing "intestinal mucus" with "pouch" resulted in 32 articles, combining "pouchitis" with "barrier function" yielded 37 articles, and "pouchitis" with "permeability" yielded only 8 articles. No article discussed the mucus coat as a barrier to bacterial invasion of the epithelium or mentioned inadequate mucus as a factor in pouchitis. However, an ileal pouch produces a colonic environment in the small bowel, and the ileum lacks the mucus protection needed for this sort of environment. This predisposes pouch mucosa to bacterial invasion and chronic microscopic inflammation that may promote clinical pouchitis in patients prone to an autoimmune response. LIMITATIONS No prior studies address inadequate mucus protection and the origin of proctitis. There is no objective way of measuring the autoimmune tendency in patients with ulcerative colitis. CONCLUSIONS Studies of intestinal mucus in the ileal pouch and its association with pouchitis are warranted.
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Affiliation(s)
- Jonathan P Knowles
- Division of Colorectal Surgery, Columbia University Medical Center, New York, New York
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4
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Anto VP, Ramos AE, Mollen KP. Ouch, my pouch! a clinician's guide to pouchitis. Semin Pediatr Surg 2024; 33:151406. [PMID: 38636151 DOI: 10.1016/j.sempedsurg.2024.151406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Pouchitis is defined as inflammation of the ileal pouch created during a restorative proctocolectomy with ileal pouch-anal anastomosis. Although the incidence of this inflammatory condition is high, the exact etiology often remains unclear and the management challenging. In this review, we summarize the clinical presentation, pathogenesis, diagnosis, and management of this common complication.
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Affiliation(s)
- Vincent P Anto
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anna E Ramos
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kevin P Mollen
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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5
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Weingarden AR, Ko CW. Non-prescription Therapeutics. Am J Gastroenterol 2024; 119:S7-S15. [PMID: 38153220 DOI: 10.14309/ajg.0000000000002578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/31/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Alexa R Weingarden
- Division of Gastroenterology & Hepatology, Department of Medicine, Stanford University, Redwood City, California, USA
| | - Cynthia W Ko
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington, USA
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6
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Mitra AK, Asala AF, Malone S, Mridha MK. Effects of Probiotics in Adults with Gastroenteritis: A Systematic Review and Meta-Analysis of Clinical Trials. Diseases 2023; 11:138. [PMID: 37873782 PMCID: PMC10594472 DOI: 10.3390/diseases11040138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023] Open
Abstract
Probiotics have been widely used in gastroenteritis due to acute and chronic illnesses. However, evidence supporting the effectiveness of probiotics in different health conditions is inconclusive and conflicting. The aim of this study was to review the existing literature on the effects of probiotics on gastroenteritis among adults. Only original articles on clinical trials that demonstrated the effects of probiotics in adults with gastroenteritis were used for this analysis. Multiple databases, such as PubMed, Google Scholar, MEDLINE and Scopus databases, were searched for the data. The study followed standard procedures for data extraction using a PRISMA flow chart. A quality appraisal of the selected studies was conducted using CADIMA. Finally, a meta-analysis was performed. Thirty-five articles met the selection criteria; of them, probiotics were found effective in the treatment and/or prevention of chronic inflammatory bowel disease (IBD), including ulcerative colitis and Crohn's disease in 17 (49%), and the treatment of pouchitis in 4 (11.4%), antibiotic-induced diarrhea in 3 (8.6%), Helicobacter pylori infection in 2 (5.7%) and diverticulitis in 1 (2.9%), while the remaining 7 (20%) were ineffective, and 1 study's results were inconclusive. The meta-analysis did not demonstrate any significant protective effects of probiotics. Having a τ2 value of zero and I2 of 6%, the studies were homogeneous and had minimum variances. Further studies are suggested to evaluate the beneficial effects of probiotics in IBDs and other chronic bowel diseases.
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Affiliation(s)
- Amal K. Mitra
- Department of Epidemiology and Biostatistics, College of Health Sciences, Jackson State University, Jackson, MS 39213, USA; (A.F.A.); (S.M.)
| | - Adetoun F. Asala
- Department of Epidemiology and Biostatistics, College of Health Sciences, Jackson State University, Jackson, MS 39213, USA; (A.F.A.); (S.M.)
- Office of Preventive Heath, Mississippi State Department of Health, Ridgeland, MS 39157, USA
| | - Shelia Malone
- Department of Epidemiology and Biostatistics, College of Health Sciences, Jackson State University, Jackson, MS 39213, USA; (A.F.A.); (S.M.)
| | - Malay Kanti Mridha
- Brac James P. Grant School of Public Health, Center for Non-Communicable Disease and Nutrition, Brac University, Dhaka 1213, Bangladesh;
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Abstract
BACKGROUND Restorative proctocolectomy with IPAA is the procedure of choice when colectomy is needed for medically refractory ulcerative colitis. Pouchitis is one of the most common complications among patients who have undergone IPAA and represents a spectrum of disease varying in both phenotype and clinical course. OBJECTIVE This study aimed to assist clinicians and surgeons in the treatment of both acute and chronic pouchitis, including newer therapies and future directions. DIAGNOSIS AND MANAGEMENT Diagnosis is made by endoscopy of the pouch with biopsy because other conditions may produce similar symptoms such as increased stool frequency, abdominal cramps, and urgency. Pouchitis is classified by duration (acute versus chronic), disease pattern (infrequent, relapsing, and continuous), and response to antibiotics (responsive, dependent, and refractory). The Pouchitis Disease Activity Index may be used to measure disease activity. The management of pouchitis is guided by the disease phenotype. Acute episodes are treated with an initial 2-week course of antibiotics (typically ciprofloxacin or metronidazole), although patients with relapsing or chronic pouchitis may require long-term antibiotic treatment or the cycling of different antibiotics. Certain probiotics may also be used for maintenance therapy in those with chronic symptoms. For patients with chronic antibiotic refractory pouchitis, oral budesonide, immunosuppressive agents (azathioprine), or biologic therapy (infliximab, adalimumab, vedolizumab, and ustekinumab) may be required for both induction and maintenance with close monitoring for potential side effects. In rare cases, diverting ileostomy or pouch excision may be required. CONCLUSION Pouchitis represents a spectrum of disease phenotypes, ranging from acute antibiotic responsive pouchitis to chronic antibiotic refractory pouchitis. The management of pouchitis is primarily directed by the disease phenotype.
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Yang J, Qin S, Zhang H. Precise strategies for selecting probiotic bacteria in treatment of intestinal bacterial dysfunctional diseases. Front Immunol 2022; 13:1034727. [PMID: 36341458 PMCID: PMC9632739 DOI: 10.3389/fimmu.2022.1034727] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 10/07/2022] [Indexed: 11/20/2022] Open
Abstract
Abundant microbiota resides in the organs of the body, which utilize the nutrition and form a reciprocal relationship with the host. The composition of these microbiota changes under different pathological conditions, particularly in response to stress and digestive diseases, making the microbial composition and health of the hosts body interdependent. Probiotics are living microorganisms that have demonstrated beneficial effects on physical health and as such are used as supplements to ameliorate symptoms of various digestive diseases by optimizing microbial composition of the gut and restore digestive balance. However, the supplementary effect does not achieve the expected result. Therefore, a targeted screening strategy on probiotic bacteria is crucial, owing to the presence of several bacterial strains. Core bacteria work effectively in maintaining microbiological homeostasis and stabilization in the gastrointestinal tract. Some of the core bacteria can be inherited and acquired from maternal pregnancy and delivery; others can be acquired from contact with the mother, feces, and the environment. Knowing the genera and functions of the core bacteria could be vital in the isolation and selection of probiotic bacteria for supplementation. In addition, other supporting strains of probiotic bacteria are also needed. A comprehensive strategy for mining both core and supporting bacteria before its clinical use is needed. Using metagenomics or other methods of estimation to discern the typically differentiated strains of bacteria is another important strategy to treat dysbiosis. Hence, these two factors are significant to carry out targeted isolation and selection of the functional strains to compose the resulting probiotic preparation for application in both research and clinical use. In conclusion, precise probiotic supplementation, by screening abundant strains of bacteria and isolating specific probiotic strains, could rapidly establish the core microbiota needed to confer resilience, particularly in bacterial dysfunctional diseases. This approach can help identify distinct bacteria which can be used to improve supplementation therapies.
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Affiliation(s)
- Jiajun Yang
- School of Animal Husbandry and Veterinary Medicine, Jiangsu Vocational College of Agriculture and Forestry, Jurong, China
| | - Shunyi Qin
- Key Laboratory of Agricultural Animal Breeding and Healthy Breeding of Tianjin, College of Animal Science and Veterinary Medicine, Tianjin Agricultural University, Tianjin, China
| | - Hao Zhang
- College of Animal Science and Technology, Chinese Agricultural University, Beijing, China
- *Correspondence: Hao Zhang,
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9
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Role of a mixed probiotic product, VSL#3, in the prevention and treatment of colorectal cancer. Eur J Pharmacol 2022; 930:175152. [PMID: 35835181 DOI: 10.1016/j.ejphar.2022.175152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/03/2022] [Accepted: 07/07/2022] [Indexed: 12/09/2022]
Abstract
Colorectal cancer (CRC) is a multifactorial disease. The incidence of this type of cancer in younger patients has increased in recent years, and more strategies are needed to prevent and delay the progression of CRC. Probiotics play an adjunctive role in the prevention and treatment of CRC and can not only prevent the onset and delay the progression of disease but also reduce the side effects after the application of anti-cancer drugs. The anti-cancer effect of individual probiotics has been extensively studied, and the exact curative effect of various probiotics has been found, but the anti-cancer effect of mixed probiotics is still not well summarized. In this review, we discuss the positive effects of mixed probiotics on CRC and the related mechanisms of action, especially VSL#3 (VSL Pharmaceuticals, Inc., Gaithersburg, MD, USA), thus providing new ideas for the treatment of CRC. Moreover, we suggest the need to search for more therapeutic possibilities, especially via the research and application of synbiotics and postbiotics.
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10
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Shen B, Kochhar GS, Rubin DT, Kane SV, Navaneethan U, Bernstein CN, Cross RK, Sugita A, Schairer J, Kiran RP, Fleshner P, McCormick JT, D'Hoore A, Shah SA, Farraye FA, Kariv R, Liu X, Rosh J, Chang S, Scherl E, Schwartz DA, Kotze PG, Bruining DH, Philpott J, Abraham B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P, Picoraro JA, Vermeire S, Sandborn WJ, Silverberg MS, Pardi DS. Treatment of pouchitis, Crohn's disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2022; 7:69-95. [PMID: 34774224 DOI: 10.1016/s2468-1253(21)00214-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/29/2021] [Accepted: 06/01/2021] [Indexed: 02/06/2023]
Abstract
Pouchitis, Crohn's disease of the pouch, cuffitis, polyps, and extraintestinal manifestations of inflammatory bowel disease are common inflammatory disorders of the ileal pouch. Acute pouchitis is treated with oral antibiotics and chronic pouchitis often requires anti-inflammatory therapy, including the use of biologics. Aetiological factors for secondary pouchitis should be evaluated and managed accordingly. Crohn's disease of the pouch is usually treated with biologics and its stricturing and fistulising complications can be treated with endoscopy or surgery. The underlying cause of cuffitis determines treatment strategies. Endoscopic polypectomy is recommended for large, symptomatic inflammatory polyps and polyps in the cuff. The management principles of extraintestinal manifestations of inflammatory bowel disease in patients with pouches are similar to those in patients without pouches.
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Affiliation(s)
- Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA.
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Udayakumar Navaneethan
- Center for IBD and Interventional IBD Unit, Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Raymond K Cross
- Inflammatory Bowel Disease Program, University of Maryland School of Medicine, Maryland, MD, USA
| | - Akira Sugita
- Department of Clinical Research and Department of inflammatory Bowel Disease, Yokohama Municipal Citizens Hospital, Yokohama, Japan
| | - Jason Schairer
- Department of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
| | - Philip Fleshner
- Division of Colorectal Surgery, University of California-Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - James T McCormick
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - Samir A Shah
- Alpert Medical School of Brown University and Miriam Hospital, Gastroenterology Associates, Providence, RI, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Xiuli Liu
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainsville, FL, USA
| | - Joel Rosh
- Department of Pediatric Gastroenterology, Goryeb Children's Hospital/Atlantic Health, Morristown, NJ, USA
| | - Shannon Chang
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Ellen Scherl
- Jill Roberts Center for IBD, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, NewYork Presbytarian Hospital, New York, NY, USA
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bincy Abraham
- Houston Methodist and Weill Cornell Medical College, Houston, TX, USA
| | - Jonathan Segal
- Department of Gastroenterology and Hepatology, Hillingdon Hospital, Uxbridge, UK
| | - Rocio Sedano
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Maia Kayal
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Stuart Bentley-Hibbert
- Department of Radiology, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
| | - Dino Tarabar
- IBD Clinical Center, University Hospital Center Dr Dragiša Mišović, Belgrade, Serbia
| | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Priya Sehgal
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
| | - Joseph A Picoraro
- Department of Pediatrics, Columbia University Irving Medical Center-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - William J Sandborn
- Department of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Mark S Silverberg
- Inflammatory Bowel Disease Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Kayal M, Dubinsky MC. Medical management of chronic pouch inflammation. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2022; 3:100095. [PMID: 35281692 PMCID: PMC8913311 DOI: 10.1016/j.crphar.2022.100095] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 01/03/2022] [Accepted: 02/28/2022] [Indexed: 12/29/2022] Open
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12
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Liu S, Eisenstein S. State-of-the-art surgery for ulcerative colitis. Langenbecks Arch Surg 2021; 406:1751-1761. [PMID: 34453611 PMCID: PMC8481179 DOI: 10.1007/s00423-021-02295-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 12/11/2022]
Abstract
Ulcerative colitis (UC) is an autoimmune-mediated colitis which can present in varying degrees of severity and increases the individual’s risk of developing colon cancer. While first-line treatment for UC is medical management, surgical treatment may be necessary in up to 25–30% of patients. With an increasing armamentarium of biologic therapies, patients are presenting for surgery much later in their course, and careful understanding of the complex interplay of the disease, its management, and the patient’s overall health is necessary when considering he appropriate way in which to address their disease surgically. Surgery is generally a total proctocolectomy either with pelvic pouch reconstruction or permanent ileostomy; however, this may need to be spread across multiple procedures given the complexity of the surgery weighed against the overall state of the patient’s health. Minimally invasive surgery, employing either laparoscopic, robotic, or transanal laparoscopic approaches, is currently the preferred approach in the elective setting. There is also some emerging evidence that appendectomy may delay the progression of UC in some individuals. Those who treat these patients surgically must also be familiar with the numerous potential pitfalls of surgical intervention and have plans in place for managing problems such as pouchitis, cuffitis, and anastomotic complications.
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Affiliation(s)
- Shanglei Liu
- Department of Surgery, UC San Diego Health System, 3855 Health Sciences Dr. #0987, La Jolla, CA, 92093, USA
| | - Samuel Eisenstein
- Department of Surgery, UC San Diego Health System, 3855 Health Sciences Dr. #0987, La Jolla, CA, 92093, USA.
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13
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Rabbenou W, Chang S. Medical treatment of pouchitis: a guide for the clinician. Therap Adv Gastroenterol 2021; 14:17562848211023376. [PMID: 34249146 PMCID: PMC8239975 DOI: 10.1177/17562848211023376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/18/2021] [Indexed: 02/04/2023] Open
Abstract
Pouchitis is the most common complication in patients who have undergone restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Up to 81% of IPAA patients experience pouchitis, with 40% of patients presenting within the first year of surgery. Common risk factors include genetic mutations, extensive colitis, rheumatologic disorders, and primary sclerosing cholangitis. Currently, there are no medications with approved indications for pouchitis. As such, the conventional treatment of pouchitis is entirely off-label. This paper is intended to be a practical and up-to-date review of available therapies used for the management of pouchitis. The mainstay of treatment for acute pouchitis remains antibiotics, but newer therapeutics have also shown promise in the treatment of chronic pouchitis. Common lifestyle considerations that may play a role in pouchitis are also reviewed. PLAIN LANGUAGE SUMMARY Medical treatment of pouchitis: a guide for the clinician The ileal pouch-anal anastomosis ("pouch") is the most common way patients who require surgery to remove their colon are able to avoid a permanent ileostomy ("ostomy"). This pouch, created from the small intestines, serves as a reservoir to hold stool. The most common complication after pouch surgery is pouchitis. Pouchitis symptoms include more frequent bowel movements, urgency to defecate, blood in the stool, incontinence, and abdominal pain. This paper is intended to be a practical review of available therapies including medications and lifestyle changes that can be considered for the management of acute pouchitis, chronic pouchitis, and cuffitis.
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Affiliation(s)
- Wendy Rabbenou
- Division of Gastroenterology and Hepatology, New York University Langone Medical Center, New York, NY, USA
| | - Shannon Chang
- Division of Gastroenterology and Hepatology, New York University Langone Medical Center, 305 E 33rd Street, New York, NY 10016, USA
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14
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Li H, Christman LM, Li R, Gu L. Synergic interactions between polyphenols and gut microbiota in mitigating inflammatory bowel diseases. Food Funct 2021; 11:4878-4891. [PMID: 32490857 DOI: 10.1039/d0fo00713g] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Inflammatory bowel diseases (IBD) are a group of chronic and recurring inflammatory conditions in the colon and intestine. Their etiology is not fully understood but involves the combination of gut dysbiosis, genetics, immune functions, and environmental factors including diet. Polyphenols from plant-based food synergistically interact with gut microbiota to suppress inflammation and alleviate symptoms of IBD. Polyphenols increase the diversity of gut microbiota, improve the relative abundance of beneficial bacteria, and inhibit the pathogenic species. Polyphenols not absorbed in the small intestine are catabolized in the colon by microbiota into microbial metabolites, many of which have higher anti-inflammatory activity and bioavailability than their precursors. The polyphenols and their microbial metabolites alleviate IBD through reduction of oxidative stress, inhibition of inflammatory cytokines secretion (TNF-α, IL-6, IL-8, and IL-1β), suppression of NF-κB, upregulation of Nrf2, gut barrier protection, and modulation of immune function. Future studies are needed to discover unknown microbial metabolites of polyphenols and correlate specific gut microbes with microbial metabolites and IBD mitigating activity. A better knowledge of the synergistic interactions between polyphenols and gut microbiota will help to devise more effective prevention strategies for IBD. This review focuses on the role of polyphenols, gut microbiota and their synergistic interactions on the alleviation of IBD as well as current trends and future directions of IBD management.
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Affiliation(s)
- Hao Li
- Food Science and Human Nutrition Department, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, Florida 32611, USA.
| | - Lindsey M Christman
- Food Science and Human Nutrition Department, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, Florida 32611, USA.
| | - Ruiqi Li
- Food Science and Human Nutrition Department, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, Florida 32611, USA.
| | - Liwei Gu
- Food Science and Human Nutrition Department, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, Florida 32611, USA.
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15
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Darb Emamie A, Rajabpour M, Ghanavati R, Asadolahi P, Farzi S, Sobouti B, Darbandi A. The effects of probiotics, prebiotics and synbiotics on the reduction of IBD complications, a periodic review during 2009-2020. J Appl Microbiol 2020; 130:1823-1838. [PMID: 33098703 DOI: 10.1111/jam.14907] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 12/16/2022]
Abstract
AIMS To perform a systematic review on randomized controlled trials to examine the efficacy of probiotics, prebiotics and synbiotics in the treatment of IBD. METHODS AND RESULTS PubMed, Web of science, Scopus and Google Scholar were systematically searched from January 2009 to January 2020 using the following keywords: 'Inflammatory Bowel Disease', 'Probiotics' and 'Clinical trial'. The statistical analysis was performed using SPSS software version 24.0. A total of 1832 articles were found during the initial search and 21 clinical trials were eligible. Studies comparing the effects of probiotics and placebo among patients with active ulcerative colitis (UC) showed a significant difference in clinical outcomes. Moreover, probiotics improved the overall induction of remission rates among patients with Crohn's disease (CD). Probiotics significantly decreased the IL-1β, TNF-α and IL-8 levels. Also, the need for systemic steroids, hospitalization, surgery, as well as histological score and disease activity index significantly decreased in patients who used probiotic or pro-/synbiotics. CONCLUSIONS The use of probiotics, as food supplements, can induce anti-inflammatory reactions, balance the intestinal homeostasis and induce remission in IBD. The efficacy of probiotics on remission induction is more reported in UC rather than CD. Larger well-designed clinical trials are needed to further determine whether probiotics are of clear benefits for remission in IBD.
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Affiliation(s)
- A Darb Emamie
- Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - M Rajabpour
- Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - R Ghanavati
- Behbahan Faculty of Medical Sciences, Behbahan, Iran
| | - P Asadolahi
- Microbiology Department, Faculty of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - S Farzi
- Department of Microbiology, Faculty of Medicine, Shahed University, Tehran, Iran
| | - B Sobouti
- Burn Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - A Darbandi
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.,Microbial Biotechnology Research Centre, Iran University of Medical Sciences, Tehran, Iran
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16
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Nyabanga CT, Axelrad JE, Zhang X, Barnes EL, Chang S. Adjunctive Pharmacotherapy Use in Patients With Ileal Pouch-Anal Anastomosis (IPAA). CROHN'S & COLITIS 360 2020; 2:otaa091. [PMID: 36777759 PMCID: PMC9802495 DOI: 10.1093/crocol/otaa091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Indexed: 01/07/2023] Open
Abstract
Background This study evaluated the prevalence of adjunctive pharmacotherapies use among ileal pouch-anal anastomosis (IPAA) patients. Methods The IBD Partners database was queried to compare IPAA patients with and without pouch-related symptoms (PRS). Within the cohort of patients with PRS, patient reported outcomes were compared among opioid, nonsteroidal anti-inflammatory drug (NSAID), and probiotic users. Results There were no differences in patient reported outcomes based on NSAID or probiotic usage. Opioid users reported increased bowel frequency, urgency, poor general well-being, abdominal pain, and depression (P < 0.05 for all variables). Conclusions In IPAA patients with PRS, opioid use, but not NSAIDs or probiotics, was associated with a higher burden of PRS.
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Affiliation(s)
- Custon T Nyabanga
- Department of Internal Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Jordan E Axelrad
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, New York, USA
| | - Xian Zhang
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shannon Chang
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, New York, USA,Address correspondence to: Shannon Chang, MD, Division of Gastroenterology, NYU Langone Medical Center, 240 East 38th Street, 23rd Floor, New York, NY 10016 ()
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17
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Abstract
Total proctocolectomy with ileal pouch-anal anastomosis is the surgical procedure of choice for patients with medically-refractory ulcerative colitis or ulcerative colitis with associated dysplasia. Although most patients after ileal pouch-anal anastomosis experience good functional outcomes, a number of complications may develop. Of the long-term complications, pouchitis is most common. Although most respond to antibiotic treatment, some patients develop chronic pouchitis, leading to substantial morbidity and occasionally pouch failure. In patients with pouchitis who are not responsive to conventional antimicrobial therapy, secondary causes of chronic pouchitis need to be considered, including Crohn's disease of the pouch. In recent years, more literature has become available regarding the medical management of chronic pouchitis and Crohn's disease of the pouch, including the use of newer biologic agents. We herein provide a concise review on inflammatory complications involving the ileal pouch, including a focused approach to diagnosis and medical management.
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18
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Benlice C, Shen B, Steele SR. Prevention and Medical Treatment of Pouchitis In Ulcerative Colitis. Curr Drug Targets 2020; 20:1399-1408. [PMID: 31333137 DOI: 10.2174/1389450120666190723130137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/04/2019] [Accepted: 06/12/2019] [Indexed: 01/10/2023]
Abstract
Approximately 50% of patients who have undergone IPAA surgery for Ulcerative Colitis (UC) develop at least 1 episode of pouchitis. Patients with pouchitis have a wide range of symptoms, endoscopic and histologic features, disease course, and prognosis. To date, there are no universally accepted diagnostic criteria in terms of endoscopy and histology; though, semi-objective assessments to diagnose pouchitis in patients with ileal pouch- anal anastomosis (IPAA) have been proposed using composite scores such as the Pouchitis Triad, Heidelberg Pouchitis Activity Score and Pouchitis Disease Activity Index (PDAI). In a systematic review that included four randomized trials evaluating five agents for the treatment of acute pouchitis, ciprofloxacin was more effective at inducing remission as compared with metronidazole. Rifaximin was not more effective than placebo, while budesonide enemas and metronidazole were similarly effective for inducing remission of acute pouchitis. Patients with pouchitis relapsing more than three times per year are advised maintenance therapy, and guidelines recommend ciprofloxacin or the probiotic VSL#3. In patients with antibiotic-refractory pouchitis, secondary factors associated with an antibiotic-refractory course should be sought and treated. In this review, we will discuss the prevention and management of pouchitis in Ulcerative Colitis patients.
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Affiliation(s)
- Cigdem Benlice
- Desk A-30, Department of Colorectal Surgery, Digestive Disease Institute Cleveland Clinic, 9500 Euclid Ave. Cleveland, OH 44195, USA
| | - Bo Shen
- Desk A-30, Department of Colorectal Surgery, Digestive Disease Institute Cleveland Clinic, 9500 Euclid Ave. Cleveland, OH 44195, USA
| | - Scott R Steele
- Desk A-30, Department of Colorectal Surgery, Digestive Disease Institute Cleveland Clinic, 9500 Euclid Ave. Cleveland, OH 44195, USA
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19
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Picardo S, Altuwaijri M, Devlin SM, Seow CH. Complementary and alternative medications in the management of inflammatory bowel disease. Therap Adv Gastroenterol 2020; 13:1756284820927550. [PMID: 32523629 PMCID: PMC7257842 DOI: 10.1177/1756284820927550] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 04/23/2020] [Indexed: 02/04/2023] Open
Abstract
The use of complementary and alternative medications (CAM), products, and therapies not considered to be part of conventional medicine is common among patients with inflammatory bowel disease (IBD). Patients often turn to these therapies as they are considered natural and safe, with significant benefit reported beyond disease control. There is emerging evidence that some of these therapies may have anti-inflammatory activity; however, robust evidence for their efficacy in modulating disease activity is currently lacking. Patients often avoid discussing the use of CAM with their physicians, which may lead to drug interactions and/or reduced adherence with conventional therapy. It is important for physicians to be aware of the commonly used CAM and current evidence behind these therapies in order to better counsel their patients about their use in the management of IBD. This narrative review provides an overview of the evidence of the more commonly used CAM in patients with IBD.
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Affiliation(s)
| | | | - Shane M. Devlin
- Inflammatory Bowel Disease Unit, Department of
Gastroenterology, Cumming School of Medicine, University of Calgary, AB,
Canada
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20
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Adamina M, Gerasimidis K, Sigall-Boneh R, Zmora O, de Buck van Overstraeten A, Campmans-Kuijpers M, Ellul P, Katsanos K, Kotze PG, Noor N, Schäfli-Thurnherr J, Vavricka S, Wall C, Wierdsma N, Yassin N, Lomer M. Perioperative Dietary Therapy in Inflammatory Bowel Disease. J Crohns Colitis 2020; 14:431-444. [PMID: 31550347 DOI: 10.1093/ecco-jcc/jjz160] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The incidence of inflammatory bowel disease [IBD] is rising worldwide and no cure is available. Many patients require surgery and they often present with nutritional deficiencies. Although randomised controlled trials of dietary therapy are lacking, expert IBD centres have long-established interdisciplinary care, including tailored nutritional therapy, to optimise clinical outcomes and resource utilisation. This topical review aims to share expertise and offers current practice recommendations to optimise outcomes of IBD patients who undergo surgery. METHODS A consensus expert panel consisting of dietitians, surgeons, and gastroenterologists, convened by the European Crohn's and Colitis Organisation, performed a systematic literature review. Nutritional evaluation and dietary needs, perioperative optimis ation, surgical complications, long-term needs, and special situations were critically appraised. Statements were developed using a Delphi methodology incorporating three successive rounds. Current practice positions were set when ≥80% of participants agreed on a recommendation. RESULTS A total of 26 current practice positions were formulated which address the needs of IBD patients perioperatively and in the long term following surgery. Routine screening, perioperative optimisation by oral, enteral, or parenteral nutrition, dietary fibre, and supplements were reviewed. IBD-specific situations, including management of patients with a restorative proctocolectomy, an ostomy, strictures, or short-bowel syndrome, were addressed. CONCLUSIONS Perioperative dietary therapy improves the outcomes of IBD patients who undergo a surgical procedure. This topical review shares interdisciplinary expertise and provides guidance to optimise the outcomes of patients with Crohn's disease and ulcerative colitis. taking advantage of contemporary nutrition science.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,University of Basel, Basel, Switzerland
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, Dentistry and Nursing, Glasgow Royal Infirmary, Glasgow, UK
| | - Rotem Sigall-Boneh
- PIBD Research Center, Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Zmora
- Department of Surgery, Assaf Harofeh Medical Center, Tel Aviv, Israel
| | | | - Marjo Campmans-Kuijpers
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Catholic University of Paraná [PUCPR], Curitiba, Brazil
| | - Nurulamin Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | | | - Stephan Vavricka
- Department of Surgery, Kantonsspital Winterthur, Winerthur, Switzerland
| | - Catherine Wall
- Department of Nutritional Sciences, King's College London, London, UK
| | - Nicolette Wierdsma
- Department of Nutrition and Dietetics, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands
| | - Nuha Yassin
- Department of Colorectal Surgery, Wolverhampton Hospital, Wolverhampton, UK
| | - Miranda Lomer
- Department of Nutritional Sciences, King's College London, London, UK.,Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
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21
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Barnes EL, Lightner AL, Regueiro M. Perioperative and Postoperative Management of Patients With Crohn's Disease and Ulcerative Colitis. Clin Gastroenterol Hepatol 2020; 18:1356-1366. [PMID: 31589972 DOI: 10.1016/j.cgh.2019.09.040] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/18/2019] [Accepted: 09/28/2019] [Indexed: 02/07/2023]
Abstract
Although the number of available therapies for the treatment of ulcerative colitis and Crohn's disease (CD) continues to expand, a significant portion of patients with inflammatory bowel disease will require surgical intervention. Surgery remains an integral part of the treatment algorithm for patients with ulcerative colitis and CD, and thus multidisciplinary approaches to the perioperative and postoperative management of patients with inflammatory bowel disease are critical to improving outcomes during these periods. New mechanisms of biologic therapies are emerging and new treatment strategies focused on earlier and potentially more aggressive use of immunosuppressive therapies are advocated in the current treatment era. In this review, we outline multidisciplinary strategies for the preoperative management of immunosuppressive therapies, including a discussion of the most recent evidence regarding the safety of biologic therapy in the preoperative period. We also discuss the postoperative medical management of patients undergoing intestinal resection for CD, with a particular focus on risk stratification and appropriate therapy selection in the immediate postoperative setting. Finally, we review potential postoperative complications after restorative proctocolectomy with ileal pouch-anal anastomosis and their management.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, The Pier C. and Renee A. Borra Family Endowed Chair in Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio; Digestive Disease and Surgery Institute, Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
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22
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Cheng FS, Pan D, Chang B, Jiang M, Sang LX. Probiotic mixture VSL#3: An overview of basic and clinical studies in chronic diseases. World J Clin Cases 2020; 8:1361-1384. [PMID: 32368530 PMCID: PMC7190945 DOI: 10.12998/wjcc.v8.i8.1361] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/27/2020] [Accepted: 04/08/2020] [Indexed: 02/05/2023] Open
Abstract
Probiotics are known as “live microorganisms” and have been proven to have a health effect on hosts at the proper dose. Recently, a kind of probiotic mixture including eight live bacterial strains, VSL#3, has attracted considerable attention for its combined effect. VSL#3 is the only probiotic considered as a kind of medical food; it mainly participates in the regulation of the intestinal barrier function, including improving tight junction protein function, balancing intestinal microbial composition, regulating immune-related cytokine expression and so on. The objective of this review is to discuss the treatment action and mechanism for the administration of VSL#3 in chronic diseases of animals and humans (including children). We found that VSL#3 has a therapeutic or preventive effect in various systemic diseases per a large number of studies, including digestive systemic diseases (gastrointestinal diseases and hepatic diseases), obesity and diabetes, allergic diseases, nervous systemic diseases, atherosclerosis, bone diseases, and female reproductive systemic diseases.
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Affiliation(s)
- Fang-Shu Cheng
- Department of Dermatology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
- Class 85 of 101k, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Dan Pan
- Department of Geriatrics, the First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning Province, China
| | - Bing Chang
- Department of Gastroenterology, the First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning Province, China
| | - Min Jiang
- Department of Gastroenterology, the First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning Province, China
| | - Li-Xuan Sang
- Department of Geriatrics, the First Affiliated Hospital, China Medical University, Shenyang 110001, Liaoning Province, China
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23
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Barreiro-de Acosta M, Bastón-Rey I, Calviño-Suárez C, Enrique Domínguez-Muñoz J. Pouchitis: Treatment dilemmas at different stages of the disease. United European Gastroenterol J 2020; 8:256-262. [PMID: 32213019 DOI: 10.1177/2050640619900571] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Pouchitis is a frequent complication in ulcerative colitis patients after proctocolectomy with ileal pouch-anal anastomosis. It is an unspecific inflammation of the pouch with unknown aetiology. First-line treatment for acute and chronic pouchitis is antibiotics. Some cases of severe chronic refractory pouchitis may benefit from biological treatment. Anti-tumour necrosis factor should be recommended as the first option, leaving the new biologicals for multirefractory patients. Permanent ileostomy may be an option in severe cases, after failure of medical treatment. Prophylaxis therapy with a probiotic mixture is recommended after the first episode of pouchitis, whereas it is not clear whether probiotics are useful for all patients after surgery. Here, we present a case report and review the treatment options in different forms of pouchitis.
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Affiliation(s)
| | - Iria Bastón-Rey
- Gastroenterology Department, University Hospital of Santiago de Compostela, A Coruña, Spain
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24
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Abstract
Inflammatory bowel diseases (IBD), including Crohn's disease, ulcerative colitis, and pouchitis, are chronic, relapsing intestinal inflammatory disorders mediated by dysregulated immune responses to resident microbiota. Current standard therapies that block immune activation with oral immunosuppressives or biologic agents are generally effective, but each therapy induces a sustained remission in only a minority of patients. Furthermore, these approaches can have severe adverse events. Recent compelling evidence of a role of unbalanced microbiota (dysbiosis) driving immune dysfunction and inflammation in IBD supports the therapeutic rationale for manipulating the dysbiotic microbiota. Traditional approaches using currently available antibiotics, probiotics, prebiotics, and synbiotics have not produced optimal results, but promising outcomes with fecal microbiota transplant provide a proof of principle for targeting the resident microbiota. Rationally designed oral biotherapeutic products (LBPs) composed of mixtures of protective commensal bacterial strains demonstrate impressive preclinical results. Resident microbial-based and microbial-targeted therapies are currently being studied with increasing intensity for IBD primary therapy with favorable early results. This review presents current evidence and therapeutic mechanisms of microbiota modulation, emphasizing clinical studies, and outlines prospects for future IBD treatment using new approaches, such as LBPs, bacteriophages, bacterial function-editing substrates, and engineered bacteria. We believe that the optimal clinical use of microbial manipulation may be as adjuvants to immunosuppressive for accelerated and improved induction of deep remission and as potential safer solo approaches to sustained remission using personalized regimens based on an individual patient's microbial profile.
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Affiliation(s)
- Akihiko Oka
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, 111 Mason Farm Road, Chapel Hill, NC, 27599, USA
| | - R Balfour Sartor
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, 111 Mason Farm Road, Chapel Hill, NC, 27599, USA.
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, 125 Mason Farm Road, Chapel Hill, NC, 27599, USA.
- National Gnotobiotic Rodent Resource Center, University of North Carolina at Chapel Hill, 120 Mason Farm Road, Chapel Hill, NC, 27514, USA.
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25
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26
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Ardalan ZS, Sparrow MP. A Personalized Approach to Managing Patients With an Ileal Pouch-Anal Anastomosis. Front Med (Lausanne) 2019; 6:337. [PMID: 32064264 PMCID: PMC7000529 DOI: 10.3389/fmed.2019.00337] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/23/2019] [Indexed: 12/11/2022] Open
Abstract
Quality of life after ileal pouch-anal anastomosis (IPAA) surgery is generally good. However, patients can be troubled by pouch-related symptoms and pouch disorders that can be inflammatory, mechanical/surgical, and functional. Management of patients with IPAA begins with measures to maintain a healthy pouch such as optimizing pouch function, providing tailored advice on a healthy diet and lifestyle, screening for and addressing metabolic complications of IPAA, pouch surveillance, and risk stratification for risk of pouchitis and pouch failure. Pouchitis is the most common inflammatory disorder. Primary pouchitis is a spectrum currently classified into three progressive phases-an antibiotic-responsive, an antibiotic-dependent, and an antibiotic-refractory phase. It is predominately microbially mediated in acute antibiotic-responsive pouchitis and predominately immune mediated in chronic antibiotic-refractory pouchitis (CARP). Secondary prophylaxis is recommended for recurrent antibiotic-responsive and for antibiotic-dependent pouchitis. Secondary causes of antibiotic-refractory pouchitis should be ruled out before a diagnosis of CARP is made. CARP is best classified as primary sclerosing cholangitis associated, immunoglobulin G4-associated, and autoimmune. Primary sclerosing cholangitis-associated CARP can be treated with budesonide or oral vancomycin. Early recognition of immunoglobulin G4-associated pouchitis minimizes ineffective antibiotic use. Autoimmune CARP can be managed in a manner similar to UC. The current place of immunosuppressives in the treatment algorithm depends on availability and early access to biological agents. Vedolizumab and ustekinumab are the preferred first- and second-line biologics for autoimmune CARP owing to their efficacy, better side effect profile, and low immunogenicity and need for concomitant immunomodulatory therapy. Antitumor necrosis factor should be reserved for autoimmune CARP failing the above and for CD of the pouch. There are no guidelines for the surveillance of pouches for dysplasia. Incidence varies based on a patient's risk. Since incidence is low, a risk-stratified approach is recommended.
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27
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A Synbiotic with Tumor Necrosis Factor- α Inhibitory Activity Ameliorates Experimental Jejunoileal Mucosal Injury. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9184093. [PMID: 29862296 PMCID: PMC5971273 DOI: 10.1155/2018/9184093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 03/31/2018] [Indexed: 02/06/2023]
Abstract
Despite the recent development of biological modifiers for inflammatory bowel diseases (IBD), there continues to be considerable interest in fermented medicines because of its negligible adverse effects. We previously showed that the synbiotic Gut Working Tablet (GWT) alleviates experimental colitis. Here we show that GWT is capable of ameliorating jejunoileal mucosal injury, which is frequently seen with IBD. We created experimental jejunoileal mucositis in rats by injection of methotrexate (MTX) which increases intestinal permeability, a hallmark finding of IBD. Administering GWT to MTX-injected rats restored intestinal integrity by reversing villi shortening, crypt loss, and goblet cell depletion in the mucosa. Also GWT reduced activities of myeloperoxidase and lipid peroxidase and increased superoxide dismutase activity, which is critical for maintaining intestinal function. We further found that GWT suppressed mRNA expression of tumor necrosis factor-α (TNF-α) and interleukin-12 (IL-12) in macrophage and reduced TNF-α mRNA expression in specimens with experimental colitis, which is in contrast to VSL#3 that enhanced TNF-α production. Together, the current and previous animal studies clearly demonstrate the protective role of GWT in chemically induced enterocolitis. Crohn's disease, a well-known IBD, can affect any portion of the intestine, and these results suggest that GWT may be useful as a novel therapeutic or maintenance therapy for IBD.
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28
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Limketkai BN, Wolf A, Parian AM. Nutritional Interventions in the Patient with Inflammatory Bowel Disease. Gastroenterol Clin North Am 2018; 47:155-177. [PMID: 29413010 DOI: 10.1016/j.gtc.2017.09.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nutritional strategies have been explored as primary or adjunct therapies for inflammatory bowel disease (IBD). Exclusive enteral nutrition is effective for the induction of remission in Crohn disease and is recommended as a first-line therapy for children. Dietary strategies focus on adjusting the ratio of consumed nutrients that are proinflammatory or antiinflammatory. Treatments with dietary supplements focus on the antiinflammatory effects of the individual supplements (eg, curcumin, omega-3 fatty acids, vitamin D) or their positive effects on the intestinal microbiome (eg, prebiotics, probiotics). This article discusses the role of diets and dietary supplements in the treatment of IBD.
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Affiliation(s)
- Berkeley N Limketkai
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway M211, Stanford, CA 94305, USA.
| | - Andrea Wolf
- Department of Clinical Nutrition, Stanford Health Care, Stanford, 300 Pasteur Drive, Palo Alto, CA 94305, USA
| | - Alyssa M Parian
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
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29
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Slingerland AE, Schwabkey Z, Wiesnoski DH, Jenq RR. Clinical Evidence for the Microbiome in Inflammatory Diseases. Front Immunol 2017; 8:400. [PMID: 28446909 PMCID: PMC5388779 DOI: 10.3389/fimmu.2017.00400] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/21/2017] [Indexed: 12/11/2022] Open
Abstract
Clinical evidence is accumulating for a role of the microbiome in contributing to or modulating severity of inflammatory diseases. These studies can be organized by various organ systems involved, as well as type of study approach utilized, whether investigators compared the microbiome of cases versus controls, followed patients longitudinally, or intervened with antibiotics, prebiotics, or bacterial introduction. In this review, we summarize the clinical evidence supporting the microbiome as an important mechanism in the onset and maintenance of inflammation.
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Affiliation(s)
- Ann E Slingerland
- Immunology Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zaker Schwabkey
- Department of Genomic Medicine, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diana H Wiesnoski
- Department of Genomic Medicine, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert R Jenq
- Department of Genomic Medicine, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Stem Cell Transplantation Cellular Therapy, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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30
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Cheifetz AS, Gianotti R, Luber R, Gibson PR. Complementary and Alternative Medicines Used by Patients With Inflammatory Bowel Diseases. Gastroenterology 2017; 152:415-429.e15. [PMID: 27743873 DOI: 10.1053/j.gastro.2016.10.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/03/2016] [Accepted: 10/06/2016] [Indexed: 02/06/2023]
Abstract
Patients and physicians often have many questions regarding the role of complementary and alternative medicines (CAMs), or nonallopathic therapies, for inflammatory bowel diseases (IBDs). CAMs of various forms are used by more than half of patients with IBD during some point in their disease course. We summarize the available evidence for the most commonly used and discussed CAMs. We discuss evidence for the effects of herbs (such as cannabis and curcumin), probiotics, acupuncture, exercise, and mind-body therapy. There have been few controlled studies of these therapies, which have been limited by their small sample sizes; most studies have been uncontrolled. In addition, there has been a lack of quality control for herbal preparations. It has been a challenge to design rigorous, randomized, placebo-controlled trials, in part owing to problems of adequate blinding for psychological interventions, acupuncture, and exercise. These barriers have limited the acceptance of CAMs by physicians. However, such therapies might be used to supplement conventional therapies and help ease patient symptoms. We conclude that physicians should understand the nature of and evidence for CAMs for IBD so that rational advice can be offered to patients who inquire about their use. CAMs have the potential to aid in the treatment of IBD, but further research is needed to validate these approaches.
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Affiliation(s)
- Adam S Cheifetz
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Robert Gianotti
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Raphael Luber
- Department of Gastroenterology, Alfred Hospital and Monash University, Melbourne, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Hospital and Monash University, Melbourne, Australia.
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Machiels K, Sabino J, Vandermosten L, Joossens M, Arijs I, de Bruyn M, Eeckhaut V, Van Assche G, Ferrante M, Verhaegen J, Van Steen K, Van Immerseel F, Huys G, Verbeke K, Wolthuis A, de Buck Van Overstraeten A, D'Hoore A, Rutgeerts P, Vermeire S. Specific members of the predominant gut microbiota predict pouchitis following colectomy and IPAA in UC. Gut 2017; 66:79-88. [PMID: 26423113 DOI: 10.1136/gutjnl-2015-309398] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 09/10/2015] [Accepted: 09/11/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Pouchitis is the most common complication after colectomy with ileal pouch-anal anastomosis (IPAA) for UC and the risk is the highest within the 1st year after surgery. The pathogenesis is not completely understood but clinical response to antibiotics suggests a role for gut microbiota. We hypothesised that the risk for pouchitis can be predicted based on the faecal microbial composition before colectomy. DESIGN Faecal samples from 21 patients with UC undergoing IPAA were prospectively collected before colectomy and at predefined clinical visits at 1 month, 3 months, 6 months and 12 months after IPAA. The predominant microbiota was analysed using community profiling with denaturing gradient gel electrophoresis followed by quantitative real-time PCR validation. RESULTS Cluster analysis before colectomy distinguished patients with pouchitis from those with normal pouch during the 1st year of follow-up. In patients developing pouchitis, an increase of Ruminococcus gnavus (p<0.001), Bacteroides vulgatus (p=0.043), Clostridium perfringens (p=0.011) and a reduction of two Lachnospiraceae genera (Blautia (p=0.04), Roseburia (p=0.008)) was observed. A score combining these five bacterial risk factors was calculated and presence of at least two risk factors showed a sensitivity and specificity of 100% and 63.6%, respectively. CONCLUSIONS Presence of R. gnavus, B. vulgatus and C. perfringens and absence of Blautia and Roseburia in faecal samples of patients with UC before surgery is associated with a higher risk of pouchitis after IPAA. Our findings suggest new predictive and therapeutic strategies in patients undergoing colectomy with IPAA.
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Affiliation(s)
- Kathleen Machiels
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - João Sabino
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - Leen Vandermosten
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - Marie Joossens
- Department Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Center for the Biology of Disease, VIB, Leuven, Belgium.,Faculty of Sciences and Bioengineering Sciences, Microbiology Unit, Vrije Universiteit Brussel, Brussels, Belgium
| | - Ingrid Arijs
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - Magali de Bruyn
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - Venessa Eeckhaut
- Department of Pathology, Bacteriology and Avian Diseases, Ghent University, Merelbeke, Belgium
| | - Gert Van Assche
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - Jan Verhaegen
- Department of Microbiology and Immunology, University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - Kristel Van Steen
- Department of Electrical Engineering and Computer Science, Montefiore Institute, Liège, Belgium
| | - Filip Van Immerseel
- Department of Pathology, Bacteriology and Avian Diseases, Ghent University, Merelbeke, Belgium
| | - Geert Huys
- Laboratory of Microbiology & BCCM/LMG Bacteria Collection, Faculty of Sciences, Ghent University, Ghent, Belgium
| | - Kristin Verbeke
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - Albert Wolthuis
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
| | | | - Andre D'Hoore
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - Paul Rutgeerts
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
| | - Séverine Vermeire
- Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, KU Leuven, Leuven, Belgium
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Kedia S, Rampal R, Paul J, Ahuja V. Gut microbiome diversity in acute infective and chronic inflammatory gastrointestinal diseases in North India. J Gastroenterol 2016; 51:660-71. [PMID: 26994772 DOI: 10.1007/s00535-016-1193-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/23/2016] [Indexed: 02/04/2023]
Abstract
The disease profile in the Indian population provides a unique opportunity for studying the host microbiome interaction in both infectious (amebiasis) and autoimmune diseases like inflammatory bowel disease (IBD) from a similar environment and genetic background. Analysis of fecal samples from untreated amebic liver abscess (ALA) patients, Entamoeba histolytica (Eh)-negative and -positive asymptomatic individuals, and pus samples from naive ALA patients revealed a significant reduction in Lactobacillus in asymptomatic individuals (Eh +ve) and ALA patients. Two anaerobic genera, namely Bacteroides and Peptostreptococcus, were detected in naive ALA pus samples. Analysis of fecal samples from amoebic colitis patients showed a significant decline in population of Bacteroides, Clostridium coccoides and leptum subgroup, Lactobacillus, Campylobacter, and Eubacterium, whereas a significant increase in Bifidobacterium was observed. Mucosa-associated bacterial flora analysis from IBD patients and healthy controls revealed a significant difference in concentration of bacteria among predominating and subdominating genera between ulcerative colitis (UC), Crohn's disease (CD) patients, and controls. In contrast to the mucosal studies, we found a significant increase in lactobacilli population in fecal samples of active UC patients. Another study revealed a significant decrease of Clostridium coccoides and leptum clusters in fecal samples of active UC patients along with decreased concentrations of fecal SCFAs, especially of n-butyrate, iso-butyrate, and acetate. We therefore found similar perturbations in gut microbiome in both infectious and autoimmune diseases, indicating inflammation to be the major driver for changes in gut microbiome.
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Affiliation(s)
- Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Ritika Rampal
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Jaishree Paul
- School of Life Sciences, Jawaharlal Nehru University, New Delhi, India
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
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Gionchetti P, Calabrese C, Lauri A, Rizzello F. The therapeutic potential of antibiotics and probiotics in the treatment of pouchitis. Expert Rev Gastroenterol Hepatol 2016. [PMID: 26202437 DOI: 10.1586/17474124.2015.1072046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pouchitis is the most frequent long-term complication of pouch surgery for ulcerative colitis. There is consistent evidence on the implication of bacterial flora in the pathogenesis of pouchitis, and there is evidence for a therapeutic role of antibiotics and probiotics in therapy of this disease. Antibiotics, particularly ciprofloxacin and metronidazole, are the mainstay of treatment for acute pouchitis. In chronic refractory pouchitis, after having excluded other diagnoses (infections, Crohn's disease of the pouch, ischemia and irritable pouch), antibiotic combination therapy is the treatment of choice. The highly concentrated probiotic mixture VSL#3 has been shown to be effective in prevention of pouchitis onset and in maintaining antibiotic-induced remission.
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Affiliation(s)
- Paolo Gionchetti
- a Department of Medical and Surgical Sciences (DIMEC), University of Bologna-Italy, Bologna, Italy
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Durchschein F, Petritsch W, Hammer HF. Diet therapy for inflammatory bowel diseases: The established and the new. World J Gastroenterol 2016; 22:2179-2194. [PMID: 26900283 PMCID: PMC4734995 DOI: 10.3748/wjg.v22.i7.2179] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 11/10/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
Although patients with inflammatory bowel diseases (IBD) have a strong interest in dietary modifications as part of their therapeutic management, dietary advice plays only a minor part in published guidelines. The scientific literature shows that dietary factors might influence the risk of developing IBD, that dysbiosis induced by nutrition contributes to the pathogenesis of IBD, and that diet may serve as a symptomatic treatment for irritable bowel syndrome-like symptoms in IBD. The role of nutrition in IBD is underscored by the effect of various dietary therapies. In paediatric patients with Crohn’s disease (CD) enteral nutrition (EN) reaches remission rates similar to steroids. In adult patients, however, EN is inferior to corticosteroids. EN is not effective in ulcerative colitis (UC). Total parenteral nutrition in IBD is not superior to steroids or EN. The use of specific probiotics in patients with IBD can be recommended only in special clinical situations. There is no evidence for efficacy of probiotics in CD. By contrast, studies in UC have shown a beneficial effect in selected patients. For patients with pouchitis, antibiotic treatment followed by probiotics, like VSL#3 or Lactobacillus GG, is effective. When probiotics are used, the risk of bacterial translocation and subsequent bacteremia has to be considered. More understanding of the normal intestinal microflora, and better characterization of probiotic strains at the phenotypic and genomic levels is needed as well as clarification of the mechanisms of action in different clinical settings. A FODMAP reduced diet may improve symptoms in IBD.
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35
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Lichtenstein L, Avni-Biron I, Ben-Bassat O. The current place of probiotics and prebiotics in the treatment of pouchitis. Best Pract Res Clin Gastroenterol 2016; 30:73-80. [PMID: 27048898 DOI: 10.1016/j.bpg.2016.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 01/28/2016] [Accepted: 02/02/2016] [Indexed: 01/31/2023]
Abstract
Pouchitis is a common complication in patients undergoing restorative proctocolectomy for ulcerative colitis. Therapeutic attempts include manipulations of pouch flora composition. In this review, we bring together the evidence supporting the use of probiotics and prebiotics in pouchitis patients, to clarify the place of these treatments in current therapeutic regimens.
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Affiliation(s)
- Lev Lichtenstein
- Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, University of Tel Aviv, Israel.
| | - Irit Avni-Biron
- Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, University of Tel Aviv, Israel
| | - Ofer Ben-Bassat
- Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, University of Tel Aviv, Israel
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Abstract
The alterations in the gut microbiota observed in patients with inflammatory bowel disease and in particular in Crohn's disease and in ulcerative colitis patients with pouchitis, provide the rationale for administering probiotic agents in the medical treatment of those conditions. In the maintenance treatment of inactive Crohn's disease probiotics, when administered alone, were found ineffective in preventing clinical and/or endoscopic recurrence. By contrast, a combination of a probiotic agent (eg, Saccharomyces boulardii) with standard pharmacological therapy can promote clinical benefit. In patients with pouchitis, so far only the probiotic mixture VSL #3 proved to effectively prevent relapses after successful antibiotic treatment of active inflammation. Further controlled studies, enrolling higher numbers of patients, are needed to better identify the exact role of probiotics in this area.
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Abstract
Data about the effectiveness of biologics, including anti-tumor necrosis factor (TNF) therapy and anti-integrin strategies, in antibiotic refractory pouchitis or Crohn's disease-associated pouch complications are sparse. We performed a systematic review of the literature in Medline and Web of Science. All English language publications and meeting abstracts describing patients with pouchitis treated with anti-TNF or anti-integrin therapies were included. We identified a total of 17 papers and 2 abstracts, most of these retrospective case series, including a total of 192 patients treated either with infliximab (n=140) or adalimumab (n=52). No reports were found for anti-integrin therapies or other anti-TNF agents such as certolizumab pegol or golimumab. Because of the heterogeneity of the studies, small numbers of patients, differing cotreatments, and subjective outcome definitions, the exact efficacy of these biological therapies cannot be assessed in a combined fashion. Overall infliximab appears to have good clinical effectiveness in selected patients achieving up to 80% short-term and around 50% long-term response, whereas the few data available for adalimumab are not sufficient to draw valid conclusions. Larger prospectively collected multicenter data with clearly defined inclusion criteria and outcomes are necessary to better define the clinical value of anti-TNF therapy in patients with antibiotic refractory pouchitis or Crohn's-like complications of the pouch.
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38
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Th17 Cells as Potential Probiotic Therapeutic Targets in Inflammatory Bowel Diseases. Int J Mol Sci 2015; 16:20841-58. [PMID: 26340622 PMCID: PMC4613231 DOI: 10.3390/ijms160920841] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/19/2015] [Accepted: 08/25/2015] [Indexed: 12/19/2022] Open
Abstract
Inflammatory bowel diseases (IBD) are characterized by wasting and chronic intestinal inflammation triggered by various cytokine-mediated pathways. In recent years, it was shown that T helper 17 (Th17) cells are involved in the pathogenesis of IBD, which makes them an attractive therapeutic target. Th17 cells preferentially produce interleukin (IL)-17A–F as signature cytokines. The role of the interplay between host genetics and intestinal microbiota in the pathogenesis of IBD was demonstrated. Probiotics are live microorganisms that when orally ingested in adequate amounts, confer a health benefit to the host by modulating the enteric flora or by stimulating the local immune system. Several studies indicated the effectiveness of probiotics in preventing and treating IBD (ulcerative colitis, and Crohn’s disease). Furthermore, there is mounting evidence of probiotics selectively targeting the Th17 lineage in the prevention and management of inflammatory and autoimmune diseases such as IBD. This review highlights critical roles of Th17 cells in the pathogenesis of IBD and the rationale for using probiotics as a novel therapeutic approach for IBD through manipulation of Th17 cells. The potential molecular mechanisms by which probiotics modulate Th17 cells differentiation and production are also discussed.
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Landy J, Walker AW, Li JV, Al-Hassi HO, Ronde E, English NR, Mann ER, Bernardo D, McLaughlin SD, Parkhill J, Ciclitira PJ, Clark SK, Knight SC, Hart AL. Variable alterations of the microbiota, without metabolic or immunological change, following faecal microbiota transplantation in patients with chronic pouchitis. Sci Rep 2015; 5:12955. [PMID: 26264409 PMCID: PMC4532993 DOI: 10.1038/srep12955] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 07/06/2015] [Indexed: 12/17/2022] Open
Abstract
Faecal microbiota transplantation (FMT) is effective in the treatment of Clostridium difficile infection, where efficacy correlates with changes in microbiota diversity and composition. The effects of FMT on recipient microbiota in inflammatory bowel diseases (IBD) remain unclear. We assessed the effects of FMT on microbiota composition and function, mucosal immune response, and clinical outcome in patients with chronic pouchitis. Eight patients with chronic pouchitis (current PDAI ≥7) were treated with FMT via nasogastric administration. Clinical activity was assessed before and four weeks following FMT. Faecal coliform antibiotic sensitivities were analysed, and changes in pouch faecal and mucosal microbiota assessed by 16S rRNA gene pyrosequencing and (1)H NMR spectroscopy. Lamina propria dendritic cell phenotype and cytokine profiles were assessed by flow cytometric analysis and multiplex assay. Following FMT, there were variable shifts in faecal and mucosal microbiota composition and, in some patients, changes in proportional abundance of species suggestive of a "healthier" pouch microbiota. However, there were no significant FMT-induced metabolic or immunological changes, or beneficial clinical response. Given the lack of clinical response following FMT via a single nasogastric administration our results suggest that FMT/bacteriotherapy for pouchitis patients requires further optimisation.
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Affiliation(s)
- J Landy
- 1] IBD Unit, Gastroenterology Dept. St Mark's Hospital, Harrow, London, UK [2] Antigen Presentation Research Group, Faculty of Medicine, Imperial College London, Northwick Park and St Mark's Campus, Harrow, UK
| | - A W Walker
- 1] Pathogen Genomics Group, Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, UK [2] Microbiology Group, Rowett Institute of Nutrition and Health, University of Aberdeen, Greenburn Road, Aberdeen, UK
| | - J V Li
- Centre for Digestive and Gut Health &Division of Computational and Systems Medicine, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - H O Al-Hassi
- Antigen Presentation Research Group, Faculty of Medicine, Imperial College London, Northwick Park and St Mark's Campus, Harrow, UK
| | - E Ronde
- Antigen Presentation Research Group, Faculty of Medicine, Imperial College London, Northwick Park and St Mark's Campus, Harrow, UK
| | - N R English
- Antigen Presentation Research Group, Faculty of Medicine, Imperial College London, Northwick Park and St Mark's Campus, Harrow, UK
| | - E R Mann
- Antigen Presentation Research Group, Faculty of Medicine, Imperial College London, Northwick Park and St Mark's Campus, Harrow, UK
| | - D Bernardo
- Antigen Presentation Research Group, Faculty of Medicine, Imperial College London, Northwick Park and St Mark's Campus, Harrow, UK
| | - S D McLaughlin
- School of Health and Social Care, Bournemouth University, Bournemouth, UK
| | - J Parkhill
- Pathogen Genomics Group, Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, UK
| | - P J Ciclitira
- Department of Gastroenterology, The Rayne Institute, St Thomas' Hospital, London, UK
| | - S K Clark
- Department of Surgery, St Mark's Hospital, Harrow, London, UK
| | - S C Knight
- Antigen Presentation Research Group, Faculty of Medicine, Imperial College London, Northwick Park and St Mark's Campus, Harrow, UK
| | - A L Hart
- 1] IBD Unit, Gastroenterology Dept. St Mark's Hospital, Harrow, London, UK [2] Antigen Presentation Research Group, Faculty of Medicine, Imperial College London, Northwick Park and St Mark's Campus, Harrow, UK
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Hansen JJ, Sartor RB. Therapeutic Manipulation of the Microbiome in IBD: Current Results and Future Approaches. ACTA ACUST UNITED AC 2015; 13:105-20. [PMID: 25595930 DOI: 10.1007/s11938-014-0042-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OPINION STATEMENT Despite recent major strides in our understanding of the genetic and microbial influences that contribute to the development of the inflammatory bowel diseases (IBDs), their etiology continues to be enigmatic. Results from experiments in animal models of IBDs overwhelmingly support a causal role of the microbiota in these diseases, though whether such a cause-effect relationship exists in human IBDs is still uncertain. Therefore, virtually all currently approved and most often prescribed treatments for IBDs are directed toward the over-active immune response in these diseases rather than the intestinal bacteria. Nevertheless, there is an important need for non-immunosuppressive therapies that may present a more favorable risk-benefit profile such as those that selectively target the disruptions in gut microbiota that accompany IBDs. This need has led to clinical trials of various microbial-directed therapies including fecal microbial transplant, antibiotics, probiotics, and prebiotics. Unfortunately, these published studies, many of which are small, have generally failed to demonstrate a consistent benefit of these agents in IBDs, thus leading to slow acceptance of microbe-focused treatments for these conditions. In this article, we review and summarize the microbial basis for IBDs and the results of the most recent trials of fecal microbial transplant, antibiotics, probiotics, and prebiotics in IBDs. We also comment on possible safety concerns with these agents, speculate on why they have failed to show efficacy in certain clinical settings, and propose strategies to improve their usefulness.
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Affiliation(s)
- Jonathan J Hansen
- Department of Medicine, University of North Carolina at Chapel Hill, CB 7032, Chapel Hill, NC, 27599, USA,
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Orel R, Kamhi Trop T. Intestinal microbiota, probiotics and prebiotics in inflammatory bowel disease. World J Gastroenterol 2014; 20:11505-11524. [PMID: 25206258 PMCID: PMC4155344 DOI: 10.3748/wjg.v20.i33.11505] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 01/06/2014] [Accepted: 06/13/2014] [Indexed: 02/06/2023] Open
Abstract
It has been presumed that aberrant immune response to intestinal microorganisms in genetically predisposed individuals may play a major role in the pathogenesis of the inflammatory bowel disease, and there is a good deal of evidence supporting this hypothesis. Commensal enteric bacteria probably play a central role in pathogenesis, providing continuous antigenic stimulation that causes chronic intestinal injury. A strong biologic rationale supports the use of probiotics and prebiotics for inflammatory bowel disease therapy. Many probiotic strains exhibit anti-inflammatory properties through their effects on different immune cells, pro-inflammatory cytokine secretion depression, and the induction of anti-inflammatory cytokines. There is very strong evidence supporting the use of multispecies probiotic VSL#3 for the prevention or recurrence of postoperative pouchitis in patients. For treatment of active ulcerative colitis, as well as for maintenance therapy, the clinical evidence of efficacy is strongest for VSL#3 and Escherichia coli Nissle 1917. Moreover, some prebiotics, such as germinated barley foodstuff, Psyllium or oligofructose-enriched inulin, might provide some benefit in patients with active ulcerative colitis or ulcerative colitis in remission. The results of clinical trials in the treatment of active Crohn’s disease or the maintenance of its remission with probiotics and prebiotics are disappointing and do not support their use in this disease. The only exception is weak evidence of advantageous use of Saccharomyces boulardii concomitantly with medical therapy in maintenance treatment.
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Abstract
PURPOSE OF REVIEW Pouchitis, representing a spectrum of disease phenotypes, is the most common long-term complication in patients who have undergone restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Its management and prevention are challenging. RECENT FINDINGS Treatment modalities vary according to phenotypes of pouchitis. The medical therapy of pouchitis remains largely empiric and antibiotic-based. However, patients may develop de-novo chronic antibiotic-refractory pouchitis (CARP) or progress from acute antibiotic-responsive phenotype. Patients with CARP often require alternative medical approaches to routine antibiotics, including the use of oral or topical mesalazine, corticosteroids, and sometimes immunomodulators or biological agents against tumour necrosis factor. There are two strategies to prevent pouchitis, the primary (i.e., the prevention of the initial episode) and secondary (i.e., the prevention of recurrent episodes) prophylaxis. There are scant data in the literature on nutritional aspects. SUMMARY We evaluated the efficacy of current strategies of prevention and treatments of pouchitis and propose algorithms, including attention to nutrition wherein data exist.
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Affiliation(s)
- Zhaoxiu Liu
- aDepartment of Gastroenterology, Affiliated Hospital of Nantong University, Jiangsu, China bDepartment of Gastroenterology/Hepatology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA cDepartment of General Surgery, Qidong City Hospital, Jiangsu, China
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Modulating the microbiota in inflammatory bowel diseases: prebiotics, probiotics or faecal transplantation? Proc Nutr Soc 2014; 73:490-7. [PMID: 24969143 DOI: 10.1017/s0029665114000639] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Crohn's disease (CD) and ulcerative colitis (UC) are the two major phenotypes of inflammatory bowel diseases (IBD) which constitute a spectrum of chronic, debilitating diseases characterised by a relapsing inflammation of the intestinal mucosal lining. Evidence from a variety of disciplines implicates the intestinal microbiota in the pathogenesis of idiopathic IBD and their complications, including pouchitis. Many studies have reported a dysbiosis in IBD, characterised by a decrease in diversity, a decreased abundance of some dominant commensal members (such as Clostridium IV and XIVa) and an increase in detrimental bacteria (such as sulphate reducing bacteria and Escherichia coli). Therapies such as prebiotics and probiotics aim to selectively manipulate the intestinal microbiota and have been evaluated as an attractive therapeutic option with few side effects. The multispecies product VSL#3 was found effective in preventing and maintaining remission in pouchitis, whereas both VSL#3 and E. coli Nissle were effective in maintaining remission in UC. A more drastic approach to restore the composition of the microbiota and correct the underlying imbalance is a faecal microbiota transplantation (FMT). FMT has been successfully applied to treat patients with even recalcitrant Clostridium difficile infection. Particularly in UC, the majority of studies suggest that FMT may be an effective treatment option although the evidence is still limited. It is anticipated that our increasing knowledge on the composition and function of the intestinal microbiota components will allow in the future for a better selection of highly performing bacteria with specific functions required for specific benefits.
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Abstract
Proctitis accounts for a significant proportion of cases of ulcerative colitis (UC), and some patients subsequently develop more extensive disease. However, most patients continue to have limited inflammation, although the changes in the distal colon and rectum can occasionally be severe, and symptoms of increased frequency, rectal bleeding and urgency can be as disabling as they are for patients with more extensive colitis. Furthermore, although symptoms are typically well controlled with standard medications, medically refractory proctitis poses particular problems. Patients generally are not systemically unwell, and there is no added fear of cancer. Therefore, the prospect of colectomy for such limited disease is resisted by patients, physicians and surgeons alike. Unusual therapies, often delivered locally by enema or suppository, have been tested in small case series without definitive outcomes. The pathogenesis of such limited, yet intractable inflammation remains unclear, and the differential diagnosis should be carefully reviewed to ensure that local disease, whether it is infectious, vascular, or a result of injury or degeneration, is not overlooked. Ileo-anal pouch formation is the surgery of choice for about 20% of patients with UC who undergo colectomy. In the majority of cases, this surgery results in an acceptable quality of life and freedom from a stoma. However, in a sizeable minority of cases, pouch dysfunction can cause intractable problems. The causes of pouch dysfunction are varied and must all be considered carefully, particularly in refractory cases. Pouchitis is a common issue and is usually transient and easily treated. However, refractory and chronic pouchitis can be challenging. Ischaemia, injury, infection and Crohn's disease can all cause refractory pouch dysfunction. In a minority of cases, there appears to be no apparent organic pathology, and the presumptive diagnosis is that of a functional pouch disorder. Although it is much rarer, neoplastic changes in the pouch must also be considered, and the risk managed appropriately. The management of both intractable proctitis and the problematic pouch is made more challenging by the wide differential diagnosis that must be considered and by the paucity of high-quality clinical trials to support any one therapy. Key strategies to overcoming these limitations include methodical and systematic investigation and review, and a willingness to tailor therapy to the individual patient. Clinical trials of new treatments should be supported, and data from the experience with small cohorts of patients should be meticulously collected, critically analysed and widely disseminated.
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Affiliation(s)
- Alex Kent
- Translational Gastroenterology Unit, John Radcliffe Hospital and the University of Oxford, Oxford, UK
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46
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Mosli M, Al Beshir M, Al-Judaibi B, Al-Ameel T, Saleem A, Bessissow T, Ghosh S, Almadi M. Advances in the diagnosis and management of inflammatory bowel disease: challenges and uncertainties. Saudi J Gastroenterol 2014; 20:81-101. [PMID: 24705146 PMCID: PMC3987157 DOI: 10.4103/1319-3767.129473] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 12/30/2013] [Indexed: 12/14/2022] Open
Abstract
Over the past two decades, several advances have been made in the management of patients with inflammatory bowel disease (IBD) from both evaluative and therapeutic perspectives. This review discusses the medical advancements that have recently been made as the standard of care for managing patients with ulcerative colitis (UC) and Crohn's Disease (CD) and to identify the challenges associated with implementing their use in clinical practice. A comprehensive literature search of the major databases (PubMed and Embase) was conducted for all recent scientific papers (1990-2013) giving the recent updates on the management of IBD and the data were extracted. The reported advancements in managing IBD range from diagnostic and evaluative tools, such as genetic tests, biochemical surrogate markers of activity, endoscopic techniques, and radiological modalities, to therapeutic advances, which encompass medical, endoscopic, and surgical interventions. There are limited studies addressing the cost-effectiveness and the impact that these advances have had on medical practice. The majority of the advances developed for managing IBD, while considered instrumental by some IBD experts in improving patient care, have questionable applications due to constraints of cost, lack of availability, and most importantly, insufficient evidence that supports their role in improving important long-term health-related outcomes.
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Affiliation(s)
- Mahmoud Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Mohammad Al Beshir
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, King Fahd Specialist Hospital, Dammam, Saudi Arabia
| | - Bandar Al-Judaibi
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Turki Al-Ameel
- Department of Medicine, King Fahd Specialist Hospital, Dammam, Saudi Arabia
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Abdulaziz Saleem
- Department of Surgery, McGill University and McGill University Health Centre, Montreal, Canada
- Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Talat Bessissow
- Department of Medicine, McGill University and McGill University Health Centre, Montreal, Canada
| | - Subrata Ghosh
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Majid Almadi
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
- Department of Medicine, McGill University and McGill University Health Centre, Montreal, Canada
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47
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Abstract
: Restorative proctocolectomy with ileal pouch-anal anastomosis is commonly used in the management of ulcerative colitis. Inflammation of the ileal pouch reservoir, or pouchitis, is a common complication of ileal pouch-anal anastomosis that is incompletely understood. Risk factors including nonsmoker status and primary sclerosing cholangitis have been linked with pouchitis development, but the etiopathogenesis of pouchitis remains poorly defined. Pouchitis is more commonly a complication of ileal pouch-anal anastomosis performed in patients with ulcerative colitis, and similar to ulcerative colitis, chronic pouchitis is associated with extraintestinal manifestations and other diseases of immune origin, suggesting overlap in the disease pathogenesis. It is becoming apparent that pouchitis encompasses clinically distinct subtypes based on the response or lack of response to antibiotic therapy. There is also emerging evidence of the role of autoimmunity in a subgroup of patients with pouchitis, including patients with concurrent primary sclerosing cholangitis, seropositivity for immunoglobulin G4, or infiltration of immunoglobulin G4-expressing plasma cells in the pouch mucosa. The identification of underlying autoimmunity may have important clinical implications in the diagnosis, subclassification, and management of pouchitis.
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48
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Pouchitis: what every gastroenterologist needs to know. Clin Gastroenterol Hepatol 2013; 11:1538-49. [PMID: 23602818 DOI: 10.1016/j.cgh.2013.03.033] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/12/2013] [Accepted: 03/28/2013] [Indexed: 02/07/2023]
Abstract
Pouchitis is the most common complication among patients with ulcerative colitis who have undergone restorative proctocolectomy with ileal pouch-anal anastomosis. Pouchitis is actually a spectrum of diseases that vary in etiology, pathogenesis, phenotype, and clinical course. Although initial acute episodes typically respond to antibiotic therapy, patients can become dependent on antibiotics or develop refractory disease. Many factors contribute to the course of refractory pouchitis, such as the use of nonsteroidal anti-inflammatory drugs, infection with Clostridium difficile, pouch ischemia, or concurrent immune-mediated disorders. Identification of these secondary factors can help direct therapy.
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49
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Arthur JC, Gharaibeh RZ, Uronis JM, Perez-Chanona E, Sha W, Tomkovich S, Mühlbauer M, Fodor AA, Jobin C. VSL#3 probiotic modifies mucosal microbial composition but does not reduce colitis-associated colorectal cancer. Sci Rep 2013; 3:2868. [PMID: 24100376 PMCID: PMC3792409 DOI: 10.1038/srep02868] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 09/18/2013] [Indexed: 02/07/2023] Open
Abstract
Although probiotics have shown success in preventing the development of experimental colitis-associated colorectal cancer (CRC), beneficial effects of interventional treatment are relatively unknown. Here we show that interventional treatment with VSL#3 probiotic alters the luminal and mucosally-adherent microbiota, but does not protect against inflammation or tumorigenesis in the azoxymethane (AOM)/Il10⁻/⁻ mouse model of colitis-associated CRC. VSL#3 (10⁹ CFU/animal/day) significantly enhanced tumor penetrance, multiplicity, histologic dysplasia scores, and adenocarcinoma invasion relative to VSL#3-untreated mice. Illumina 16S sequencing demonstrated that VSL#3 significantly decreased (16-fold) the abundance of a bacterial taxon assigned to genus Clostridium in the mucosally-adherent microbiota. Mediation analysis by linear models suggested that this taxon was a contributing factor to increased tumorigenesis in VSL#3-fed mice. We conclude that VSL#3 interventional therapy can alter microbial community composition and enhance tumorigenesis in the AOM/Il10⁻/⁻ model.
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Affiliation(s)
| | - Raad Z. Gharaibeh
- Bioinformatics Services Division, Department of Bioinformatics and Genomics, University of North Carolina at Charlotte, Kannapolis, NC 28081, USA
| | | | | | - Wei Sha
- Bioinformatics Services Division, Department of Bioinformatics and Genomics, University of North Carolina at Charlotte, Kannapolis, NC 28081, USA
| | - Sarah Tomkovich
- Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | | | - Anthony A. Fodor
- Department of Bioinformatics and Genomics, University of North Carolina at Charlotte, Charlotte, NC 28223, USA
| | - Christian Jobin
- Department of Medicine, Chapel Hill, NC 27599, USA
- Pharmacology, Chapel Hill, NC 27599, USA
- Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Medicine, University of Florida at Gainesville, Gainesville, FL32611, USA
- Department of Infectious Diseases and Pathology, University of Florida at Gainesville, Gainesville, FL32611, USA
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50
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Persborn M, Gerritsen J, Wallon C, Carlsson A, Akkermans LMA, Söderholm JD. The effects of probiotics on barrier function and mucosal pouch microbiota during maintenance treatment for severe pouchitis in patients with ulcerative colitis. Aliment Pharmacol Ther 2013; 38:772-83. [PMID: 23957603 DOI: 10.1111/apt.12451] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Revised: 05/14/2013] [Accepted: 07/23/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND A total of 10-15% of patients with an ileoanal pouch develop severe pouchitis necessitating long-term use of antibiotics or pouch excision. Probiotics reduce the risk of recurrence of pouchitis, but mechanisms behind these effects are not fully understood. AIM To examine mucosal barrier function in pouchitis, before and after probiotic supplementation and to assess composition of mucosal pouch microbiota. METHODS Sixteen patients with severe pouchitis underwent endoscopy with biopsies of the pouch on three occasions: during active pouchitis; clinical remission by 4 weeks of antibiotics; after 8 weeks of subsequent probiotic supplementation (Ecologic 825, Winclove, Amsterdam, the Netherlands). Thirteen individuals with a healthy ileoanal pouch were sampled once as controls. Ussing chambers were used to assess transmucosal passage of Escherichia coli K12, permeability to horseradish peroxidase (HRP) and ⁵¹Cr-EDTA. Composition and diversity of the microbiota was analysed using Human Intestinal Tract Chip. RESULTS Pouchitis Disease Activity Index (PDAI) was significantly improved after antibiotic and probiotic supplementation. Escherichia coli K12 passage during active pouchitis [3.7 (3.4-8.5); median (IQR)] was significantly higher than in controls [1.7 (1.0-2.4); P < 0.01], did not change after antibiotic treatment [5.0 (3.3-7.1); P = ns], but was significantly reduced after subsequent probiotic supplementation [2.2 (1.7-3.3); P < 0.05]. No significant effects of antibiotics or probiotics were observed on composition of mucosal pouch microbiota; however, E. coli passage correlated with bacterial diversity (r = -0.40; P = 0.018). Microbial groups belonging to Bacteroidetes and Clostridium clusters IX, XI and XIVa were associated with healthy pouches. CONCLUSIONS Probiotics restored the mucosal barrier to E. coli and HRP in patients with pouchitis, a feasible factor in prevention of recurrence during maintenance treatment. Restored barrier function did not translate into significant changes in mucosal microbiota composition, but bacterial diversity correlated with barrier function.
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Affiliation(s)
- M Persborn
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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