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Terbah R, Testro A, Gow P, Majumdar A, Sinclair M. Portal Hypertension in Malnutrition and Sarcopenia in Decompensated Cirrhosis-Pathogenesis, Implications and Therapeutic Opportunities. Nutrients 2023; 16:35. [PMID: 38201864 PMCID: PMC10780673 DOI: 10.3390/nu16010035] [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] [Received: 12/03/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
Malnutrition and sarcopenia are highly prevalent in patients with decompensated cirrhosis and are associated with poorer clinical outcomes. Their pathophysiology is complex and multifactorial, with protein-calorie malnutrition, systemic inflammation, reduced glycogen stores and hormonal imbalances all well reported. The direct contribution of portal hypertension to these driving factors is however not widely documented in the literature. This review details the specific mechanisms by which portal hypertension directly contributes to the development of malnutrition and sarcopenia in cirrhosis. We summarise the existing literature describing treatment strategies that specifically aim to reduce portal pressures and their impact on nutritional and muscle outcomes, which is particularly relevant to those with end-stage disease awaiting liver transplantation.
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Affiliation(s)
- Ryma Terbah
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Adam Testro
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Avik Majumdar
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
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Wielgosz-Grochowska JP, Domanski N, Drywień ME. Influence of Body Composition and Specific Anthropometric Parameters on SIBO Type. Nutrients 2023; 15:4035. [PMID: 37764818 PMCID: PMC10535553 DOI: 10.3390/nu15184035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/04/2023] [Accepted: 09/16/2023] [Indexed: 09/29/2023] Open
Abstract
Recent observations have shown that Small Intestinal Bacterial Overgrowth (SIBO)affects the host through various mechanisms. While both weight loss and obesity have been reported in the SIBO population due to alterations in the gut microbiome, very little is known about the influence of SIBO type on body composition. This study aimed to evaluate whether there is a link between the three types of SIBO: methane dominant (M+), hydrogen dominant (H+), and methane-hydrogen dominant (H+/M+) and specific anthropometric parameters. This observational study included 67 participants (W = 53, M = 14) with gastrointestinal symptoms and SIBO confirmed by lactulose hydrogen-methane breath tests (LHMBTs) using the QuinTron device. Participants underwent a body composition assessment by Bioelectrical Impedance Analysis (BIA) using the InBody Analyzer. In the H+/M+ group, body weight (p = 0.010), BMI (p = 0.001), body fat in kg (p = 0.009), body fat in % (p = 0.040), visceral fat (p = 0.002), and mineral bone content (p = 0.049) showed an inverse correlation with hydrogen (H2) gas production. These findings suggest that body weight, BMI, body fat, and mineral bone content may be inversely linked to the production of hydrogen and the risk of hydrogen-methane SIBO.
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Affiliation(s)
| | - Nicole Domanski
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada;
| | - Małgorzata Ewa Drywień
- Department of Human Nutrition, Institute of Human Nutrition Sciences, Warsaw University of Life Sciences, 02-776 Warsaw, Poland;
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Biomarkers for Bile Acid Malabsorption in Diarrhea-predominant Irritable Bowel Syndrome: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2023; 57:451-458. [PMID: 36867517 DOI: 10.1097/mcg.0000000000001841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND AND AIM A clear relationship of biological indexes between bile acid malabsorption (BAM) and diarrhea-predominant irritable bowel syndrome (IBS-D) has not been well analyzed. This meta-analysis aimed to establish a more convenient method to diagnose BAM in IBS-D patients by comparing the differences in biomarkers between IBS-D patients and healthy people. METHODS Multiple databases were searched for relevant case-control studies. Indicators used to diagnose BAM included 75Se-homocholic acid taurine (SeHCAT), 7α-hydroxy-4-cholesten-3-one(C4), fibroblast growth factor-19 and 48-hour fecal bile acid (48FBA). The rate of BAM (SeHCAT) was calculated by using a random-effect model. The levels of C4, FGF19, and 48FBA were compared, and the overall effect size was combined by a fixed effect model. RESULTS The search strategy identified 10 relevant studies comprising 1034 IBS-D patients and 232 healthy volunteers. The pooled rate of BAM in IBS-D patients was 32% (according to SeHCAT; 95% CI: 24%-40%). The level of C4 in IBS-D patients was significantly higher than that in the control group (2.86 ng/mL; 95% CI: 1.09, 4.63); The level of FGF19 was significantly lower than that in the control group (-33.97 pg/mL; 95% CI: -51.13, -16.82); The level of 48FBA was significantly higher than that in the control group (0.059; 95% CI: 0.41, 0.77). CONCLUSIONS The results mainly concluded serum C4 and FGF19 levels in IBS-D patients. Most of the studies have different normal cutoff points of serum C4 and FGF19 levels; the performance of each test should be further estimated. By comparing the levels of these biomarkers, BAM in patients with IBS-D could be identified more accurately, which would lead to more effective treatment.
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Shah A, Talley NJ, Holtmann G. Current and Future Approaches for Diagnosing Small Intestinal Dysbiosis in Patients With Symptoms of Functional Dyspepsia. Front Neurosci 2022; 16:830356. [PMID: 35600619 PMCID: PMC9121133 DOI: 10.3389/fnins.2022.830356] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/28/2022] [Indexed: 12/12/2022] Open
Abstract
The development and application of next generation sequencing technologies for clinical gastroenterology research has provided evidence that microbial dysbiosis is of relevance for the pathogenesis of gastrointestinal and extra-intestinal diseases. Microbial dysbiosis is characterized as alterations of diversity, function, and density of the intestinal microbes. Emerging evidence suggests that alterations of the gastrointestinal microbiome are important for the pathophysiology of a variety of functional gastrointestinal conditions, e.g., irritable bowel syndrome (IBS) and functional dyspepsia (FD), also known as disorders of brain-gut axis interaction. Clinicians have for many years recognized that small intestinal bacterial overgrowth (SIBO) is typified by a microbial dysbiosis that is underpinned by abnormal bacterial loads in these sites. SIBO presents with symptoms which overlap with symptoms of FD and IBS, point toward the possibility that SIBO is either the cause or the consequence of functional gastrointestinal disorders (FGIDs). More recently, new terms including “intestinal methanogen overgrowth” and “small intestinal fungal overgrowth” have been introduced to emphasize the contribution of methane production by archea and fungi in small intestinal dysbiosis. There is emerging data that targeted antimicrobial treatment of SIBO in patients with FD who simultaneously may or may not have IBS, results in symptom improvement and normalization of positive breath tests. However, the association between SIBO and FGIDs remains controversial, since widely accepted diagnostic tests for SIBO are lacking. Culture of jejunal fluid aspirate has been proposed as the “traditional gold standard” for establishing the diagnosis of SIBO. Utilizing jejunal fluid culture, the results can potentially be affected by cross contamination from oropharyngeal and luminal microbes, and there is controversy regarding the best cut off values for SIBO diagnosis. Thus, it is rarely used in routine clinical settings. These limitations have led to the development of breath tests, which when compared with the “traditional gold standard,” have sub-optimal sensitivity and specificity for SIBO diagnosis. With newer diagnostic approaches–based upon applications of the molecular techniques there is an opportunity to characterize the duodenal and colonic mucosa associated microbiome and associated gut microbiota dysbiosis in patients with various gastrointestinal and extraintestinal diseases. Furthermore, the role of confounders like psychological co-morbidities, medications, dietary practices, and environmental factors on the gastrointestinal microbiome in health and disease also needs to be explored.
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Affiliation(s)
- Ayesha Shah
- Faculty of Medicine and Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Newcastle, NSW, Australia
| | - Nicholas J. Talley
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Newcastle, NSW, Australia
- College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
| | - Gerald Holtmann
- Faculty of Medicine and Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Newcastle, NSW, Australia
- *Correspondence: Gerald Holtmann,
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5
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Ghoshal UC, Sachdeva S, Ghoshal U, Misra A, Puri AS, Pratap N, Shah A, Rahman MM, Gwee KA, Tan VPY, Ahmed T, Lee YY, Ramakrishna BS, Talukdar R, Rana SV, Sinha SK, Chen M, Kim N, Holtmann G. Asian-Pacific consensus on small intestinal bacterial overgrowth in gastrointestinal disorders: An initiative of the Indian Neurogastroenterology and Motility Association. Indian J Gastroenterol 2022; 41:483-507. [PMID: 36214973 PMCID: PMC9549446 DOI: 10.1007/s12664-022-01292-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/02/2022] [Indexed: 02/04/2023]
Abstract
In the clinical setting, small intestinal bacterial overgrowth (SIBO) is a frequent, but under-diagnosed entity. SIBO is linked to various gastrointestinal (GI) and non-GI disorders with potentially significant morbidity. The optimal management of SIBO is undefined while there is a lack of published consensus guidelines. Against this background, under the auspices of the Indian Neurogastroenterology and Motility Association (INMA), formerly known as the Indian Motility and Functional Diseases Association (IMFDA), experts from the Asian-Pacific region with extensive research and clinical experience in the field of gut dysbiosis including SIBO developed this evidence-based practice guideline for the management of SIBO utilizing a modified Delphi process based upon 37 consensus statements, involving an electronic voting process as well as face-to-face meetings and review of relevant supporting literature. These statements include 6 statements on definition and epidemiology; 11 on etiopathogenesis and pathophysiology; 5 on clinical manifestations, differential diagnosis, and predictors; and 15 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservations was 80% or higher, the statement was regarded as accepted. The members of the consensus team consider that this guideline would be valuable to inform clinical practice, teaching, and research on SIBO in the Asian-Pacific region as well as in other countries.
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Affiliation(s)
- Uday C. Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014 India
| | - Sanjeev Sachdeva
- Department of Gastroenterology, G B Pant Hospital, New Delhi, 110 002 India
| | - Ujjala Ghoshal
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014 India
| | - Asha Misra
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014 India
| | | | | | - Ayesha Shah
- University of Queensland, Faculty of Medicine, and Princess Alexandra Hospital, Department of Gastroenterology and Hepatology, Brisbane, Queensland, Australia
| | - M. Masudur Rahman
- Sheikh Russel National Gastroliver Institute and Hospital, Dhaka, Bangladesh
| | - Kok Ann Gwee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ,Stomach, Liver and Bowel Centre, Gleneagles Hospital, Singapore, Singapore
| | - Victoria P Y Tan
- Faculty of Medicine, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia ,GI Function and Motility Unit, Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - B S Ramakrishna
- SIMS Institute of Gastroenterology, Hepatology, and Transplantation, SRM Institutes for Medical Science, Chennai, 600 026 India
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, 500 082 India
| | - S V Rana
- Department of Biochemistry, All India Institute of Medical Sciences, Rishikesh, 249 203 India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012 India
| | - Minhu Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Nayoung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Gerald Holtmann
- University of Queensland, Faculty of Medicine, and Princess Alexandra Hospital, Department of Gastroenterology and Hepatology, Brisbane, Queensland, Australia
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The longitudinal and cross-sectional heterogeneity of the intestinal microbiota. Curr Opin Microbiol 2021; 63:221-230. [PMID: 34428628 DOI: 10.1016/j.mib.2021.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/04/2021] [Indexed: 02/07/2023]
Abstract
A central goal of microbiome research is to understand the factors that balance gut-associated microbial communities, thereby creating longitudinal and cross-sectional heterogeneity in their composition and density. Whereas the diet dictates taxa dominance, microbial communities are linked intimately to host physiology through digestive and absorptive functions that generate longitudinal heterogeneity in nutrient availability. Additionally, the host differentially controls the access to electron acceptors along the longitudinal axis of the intestine to drive the development of microbial communities that are dominated by facultatively anaerobic bacteria in the small intestine or obligately anaerobic bacteria in the large intestine. By secreting mucus and antimicrobials, the host further constructs microhabitats that generate cross-sectional heterogeneity in the colonic microbiota composition. Here we will review how understanding the host factors involved in generating longitudinal and cross-sectional microbiota heterogeneity helps define physiological states that are characteristic of or appropriate to a homeostatic microbiome.
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Kessoku T, Kobayashi T, Imajo K, Tanaka K, Yamamoto A, Takahashi K, Kasai Y, Ozaki A, Iwaki M, Nogami A, Honda Y, Ogawa Y, Kato S, Higurashi T, Hosono K, Yoneda M, Okamoto T, Usuda H, Wada K, Kobayashi N, Saito S, Nakajima A. Endotoxins and Non-Alcoholic Fatty Liver Disease. Front Endocrinol (Lausanne) 2021; 12:770986. [PMID: 34777261 PMCID: PMC8586459 DOI: 10.3389/fendo.2021.770986] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 10/18/2021] [Indexed: 01/18/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide. It occurs with a prevalence of up to 25%, of which 10-20% cases progress to nonalcoholic steatohepatitis (NASH), cirrhosis, and liver cancer. The histopathology of NASH is characterized by neutrophilic infiltration, and endotoxins from gram-negative rods have been postulated as a contributing factor. Elevations in endotoxin levels in the blood can be classified as intestinal and hepatic factors. In recent years, leaky gut syndrome, which is characterized by impaired intestinal barrier function, has become a significant issue. A leaky gut may prompt intestinal bacteria dysbiosis and increase the amount of endotoxin that enters the liver from the portal vein. These contribute to persistent chronic inflammation and progressive liver damage. In addition, hepatic factors suggest that liver damage can be induced by low-dose endotoxins, which does not occur in healthy individuals. In particular, increased expression of CD14, an endotoxin co-receptor in the liver, may result in leptin-induced endotoxin hyper-responsiveness in obese individuals. Thus, elevated blood endotoxin levels contribute to the progression of NASH. The current therapeutic targets for NASH treat steatosis and liver inflammation and fibrosis. While many clinical trials are underway, no studies have been performed on therapeutic agents that target the intestinal barrier. Recently, a randomized placebo-controlled trial examined the role of the intestinal barrier in patients with NAFLD. To our knowledge, this study was the first of its kind and study suggested that the intestinal barrier may be a novel target in the future treatment of NAFLD.
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Affiliation(s)
- Takaomi Kessoku
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Palliative Medicine, Yokohama City University Hospital, Yokohama, Japan
- *Correspondence: Takaomi Kessoku,
| | - Takashi Kobayashi
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kento Imajo
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kosuke Tanaka
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Palliative Medicine, Yokohama City University Hospital, Yokohama, Japan
| | - Atsushi Yamamoto
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kota Takahashi
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuki Kasai
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Anna Ozaki
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Michihiro Iwaki
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Palliative Medicine, Yokohama City University Hospital, Yokohama, Japan
| | - Asako Nogami
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yasushi Honda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuji Ogawa
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shingo Kato
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takuma Higurashi
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kunihiro Hosono
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masato Yoneda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takayuki Okamoto
- Department of Pharmacology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Haruki Usuda
- Department of Pharmacology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Koichiro Wada
- Department of Pharmacology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Noritoshi Kobayashi
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Oncology, Yokohama City University Hospital, Yokohama, Japan
| | - Satoru Saito
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Varjú P, Ystad B, Gede N, Hegyi P, Pécsi D, Czimmer J. The role of small intestinal bacterial overgrowth and false positive diagnosis of lactose intolerance in southwest Hungary-A retrospective observational study. PLoS One 2020; 15:e0230784. [PMID: 32384113 PMCID: PMC7209350 DOI: 10.1371/journal.pone.0230784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 03/09/2020] [Indexed: 12/12/2022] Open
Abstract
Background Lactose intolerance is a frequent gastrointestinal disease affecting 47% of the Eastern European population. Small intestinal bacterial overgrowth (SIBO) leads to carbohydrate malabsorption and therefore to false results during lactose breath and tolerance tests. Objectives We aimed to assess the prevalence of lactose maldigestion and intolerance in Hungary and to investigate the role of combined diagnostic method and testing for SIBO in reducing false results. Methods We retrospectively analyzed data from 264 adult symptomatic patients who underwent 50g lactose breath and tolerance tests in parallel over a one-year period at our center. A ≥20 ppm elevation of H2 or less than 1.1 mmol/l rise of blood glucose was diagnostic for lactose maldigestion. Patients with maldigestion who had symptoms during the test were defined as lactose intolerant. Patients with an early (≤90 min) significant (≥20 ppm) rise of H2 during lactose and/or lactulose breath tests were determined to have SIBO. Patients with slow/rapid oro-cecal transit and inappropriate preparation before the test were excluded. Results 49.6% of the 264 patients had lactose maldigestion, and 29.5% had lactose intolerance. The most frequent symptom was bloating (22.7%), while 34.8% of the study population and 60% of the symptomatic patients had SIBO. In 9.1% and 9.8% of the patients, the lactose breath and tolerance test alone gave false positive result compared with the combined method. SIBO was present in 75% of the false positives diagnosed with breath test only. Conclusions The prevalence of lactose intolerance is lower in Hungary compared to the Eastern European value (29.5% vs 47%), so it is worth performing a population-based prospective analysis in this area. A combination of lactose breath and tolerance tests and the careful monitoring of results (with early H2 rise, lactulose breath test, etc.) can decrease the false cases caused by e.g. SIBO.
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Affiliation(s)
- Péter Varjú
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Birgit Ystad
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Noémi Gede
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
- Hungarian Academy of Sciences-University of Szeged, Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary
| | - Dániel Pécsi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - József Czimmer
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
- * E-mail:
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Sadowski DC, Camilleri M, Chey WD, Leontiadis GI, Marshall JK, Shaffer EA, Tse F, Walters JRF. Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea. Clin Gastroenterol Hepatol 2020; 18:24-41.e1. [PMID: 31526844 DOI: 10.1016/j.cgh.2019.08.062] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause. METHODS We performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator, and outcome questions were developed through an iterative process and were voted on by a group of specialists. RESULTS The certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy, or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea, and Crohn's disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn's disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review, and reinvestigation for patients whose symptoms persist despite BAST. CONCLUSIONS Based on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.
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Affiliation(s)
- Daniel C Sadowski
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada.
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Eldon A Shaffer
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Frances Tse
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Julian R F Walters
- Division of Digestive Diseases, Imperial College London, London, United Kingdom
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10
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Sadowski DC, Camilleri M, Chey WD, Leontiadis GI, Marshall JK, Shaffer EA, Tse F, Walters JRF. Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea. J Can Assoc Gastroenterol 2019; 3:e10-e27. [PMID: 32010878 PMCID: PMC6985689 DOI: 10.1093/jcag/gwz038] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and Aims Chronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause. Methods We performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator and outcome questions were developed through an iterative process and were voted on by a group of specialists. Results The certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea and Crohn's disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn's disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review and reinvestigation for patients whose symptoms persist despite BAST. Conclusions Based on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.
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Affiliation(s)
- Daniel C Sadowski
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Eldon A Shaffer
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Frances Tse
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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11
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Litvak Y, Bäumler AJ. Microbiota-Nourishing Immunity: A Guide to Understanding Our Microbial Self. Immunity 2019; 51:214-224. [DOI: 10.1016/j.immuni.2019.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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12
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Bruno G, Zaccari P, Rocco G, Scalese G, Panetta C, Porowska B, Pontone S, Severi C. Proton pump inhibitors and dysbiosis: Current knowledge and aspects to be clarified. World J Gastroenterol 2019; 25:2706-2719. [PMID: 31235994 PMCID: PMC6580352 DOI: 10.3748/wjg.v25.i22.2706] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/02/2019] [Accepted: 04/19/2019] [Indexed: 02/06/2023] Open
Abstract
Proton pump inhibitors (PPIs) are common medications within the practice of gastroenterology. These drugs, which act through the irreversible inhibition of the hydrogen/potassium pump (H+/K+-ATPase pump) in the gastric parietal cells, are used in the treatment of several acid-related disorders. PPIs are generally well tolerated but, through the long-term reduction of gastric acid secretion, can increase the risk of an imbalance in gut microbiota composition (i.e., dysbiosis). The gut microbiota is a complex ecosystem in which microbes coexist and interact with the human host. Indeed, the resident gut bacteria are needed for multiple vital functions, such as nutrient and drug metabolism, the production of energy, defense against pathogens, the modulation of the immune system and support of the integrity of the gut mucosal barrier. The bacteria are collected in communities that vary in density and composition within each segment of the gastrointestinal (GI) tract. Therefore, every change in the gut ecosystem has been connected to an increased susceptibility or exacerbation of various GI disorders. The aim of this review is to summarize the recently available data on PPI-related microbiota alterations in each segment of the GI tract and to analyze the possible involvement of PPIs in the pathogenesis of several specific GI diseases.
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Affiliation(s)
- Giovanni Bruno
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, Rome 00161, Italy
| | - Piera Zaccari
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, Rome 00161, Italy
| | - Giulia Rocco
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, Rome 00161, Italy
| | - Giulia Scalese
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, Rome 00161, Italy
| | - Cristina Panetta
- Department of Surgical Sciences, Sapienza University of Rome, Rome 00161, Italy
| | - Barbara Porowska
- Department of Cardio-Thoracic, Vascular Surgery and Transplants, Sapienza University of Rome, Rome 00161, Italy
| | - Stefano Pontone
- Department of Surgical Sciences, Sapienza University of Rome, Rome 00161, Italy
| | - Carola Severi
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, Rome 00161, Italy
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Small intestinal bacterial overgrowth and nonalcoholic fatty liver disease. Clin Exp Hepatol 2019; 5:1-10. [PMID: 30915401 PMCID: PMC6431096 DOI: 10.5114/ceh.2019.83151] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 05/22/2018] [Indexed: 02/07/2023] Open
Abstract
The gut microbiota has recently been recognized as a major environmental factor in the pathophysiology of several human diseases. The anatomical and functional association existing between the gut and the liver provides the theoretical basis to assume that the liver is a major target for gut microbes. In the last decades, many studies have reported an altered composition of gut microbiota in patients with chronic liver diseases and liver cirrhosis, suggesting a progressively marked dysbiosis to be related to worsening of the liver disease. Modifications of microbiota result in alteration in providing signals through the intestine and bacterial products, as well as hormones produced in the bowel that affect metabolism at different levels including the liver. There is increasing evidence for a correlation between intestinal microbiota, bacterial translocation and hepatic steatosis. Intestinal microbiota affects nutrient absorption and energy homeostasis. Altered intestinal permeability may favor the passage of bacteria derived compounds into the systemic circulation, causing a systemic inflammatory state, characteristic of the metabolic syndrome. At present, an increasing number of studies indicate a close relationship between dysbiosis, defined as abnormal composition and the amount of intestinal bacteria (gut microbiota), intestinal permeability and some metabolic, inflammatory, degenerative and even psychiatric diseases. Microbiota pharmacological modulation seems to be a promising tool for a new therapeutic approach to non-alcoholic fatty liver disease and in prevention of cirrhosis. The following study aims to briefly discuss the role of microbiota disorder (dysbiosis), and in particular small intestinal bacterial overgrowth (SIBO), in the pathogenesis of nonalcoholic fatty liver disease (NAFLD).
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Thomsen M, Vitetta L. Adjunctive Treatments for the Prevention of Chemotherapy- and Radiotherapy-Induced Mucositis. Integr Cancer Ther 2018; 17:1027-1047. [PMID: 30136590 PMCID: PMC6247548 DOI: 10.1177/1534735418794885] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Chemoradiotherapy-associated mucositis can manifest as
pain, inflammation, dysphagia, diarrhea, weight loss, rectal bleeding, and
infection. Mucositis is a major dose-limiting side effect of chemotherapy,
affecting nutritional intake and oral and intestinal function. Despite several
interventions being available, there is a need for safe and effective
preventative and treatment options for treatment-induced mucositis. The goals of
this review are to discuss interventions based on foods and natural products and
present the research to date. Methods: A narrative literature
review identified 60 clinical studies examining various nutritional compounds
and 20 examining probiotics. 9 studies on probiotics for the prevention of
diarrhea were also assessed on methodological quality and limitations
identified. Results: Several compounds have been posited as useful
adjuvants for cancer treatment–related mucositis. Probiotics demonstrate
efficacy for the prevention and treatment of chemoradiotherapy-induced
gastrointestinal toxicity without significant side effects. Glutamine and
activated charcoal were reported to reduce chemotherapy-induced diarrhea but not
radiation-induced intestinal mucositis. Honey has been reported to decrease
treatment interruptions, weight loss, and delays the onset of oral mucositis.
Zinc, glutamine, and topical vitamin E were demonstrated efficacy for oral
mucositis. Conclusion: There is plausible clinical evidence for the
administration of several adjunctive treatments for the prevention and treatment
of mucositis. Probiotics were reported to reduce the burden of intestinal
mucositis and treatment-induced diarrhea. Activated charcoal and glutamine are
beneficial for chemotherapy-induced diarrhea, whereas the administration of
honey, zinc, and glutamine reduce the risk of developing oral mucositis during
chemotherapy or radiotherapy.
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Affiliation(s)
| | - Luis Vitetta
- 1 University of Sydney, Sydney, New South Wales, Australia.,2 Medlab Clinical Ltd, Sydney, New South Wales, Australia
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15
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Akashi T, Hashimoto R, Ohno A, Matsumoto K, Nakamura Y. Enteral Nutrition With an Enteral Formula Containing Egg Yolk Lecithin After Percutaneous Endoscopic Gastrostomy: A Case Series. Gastroenterology Res 2018; 11:157-160. [PMID: 29707085 PMCID: PMC5916642 DOI: 10.14740/gr995w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 03/19/2019] [Indexed: 11/11/2022] Open
Abstract
The occurrence of diarrhea at the beginning of enteral nutrition complicates the continuation of enteral nutrition. Recently, studies in Japan indicated that diarrhea could be improved by changing the enteral formula to one that is emulsified with egg yolk lecithin. In this study, we administered the enteral formula K-2S plus, which is emulsified with egg yolk lecithin, to 15 patients (four men and 11 women; mean age, 79.9 ± 2.0 years) after they had undergone a percutaneous endoscopic gastrostomy (PEG) to prevent the occurrence of diarrhea related to enteral nutrition. Two days after the PEG, the patients would receive 200 mL K-2S plus intermittently three times daily; thereafter, the amount of K-2S plus was increased according to the patient’s condition. The administration rate was scheduled as 200 mL/h when 200 mL were administered at one time. For ≥ 300 mL, the scheduled administration rate was 300 mL/h. When we administered K-2S plus at the beginning of enteral nutrition after the PEG, the dose of the enteral formula could be increased without any occurrence of diarrhea or vomiting. Five patients had received intravenous nutrition before the PEG; thus, we were concerned about diarrhea in these patients. In conclusion, an enteral formula emulsified with egg yolk lecithin may be safely used at the time of enteral nutrition initiation without causing diarrhea.
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Affiliation(s)
- Tetsuro Akashi
- Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Risa Hashimoto
- Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Akihisa Ohno
- Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Kazuhide Matsumoto
- Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Yukari Nakamura
- Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
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16
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Ma K, Xiong N, Shen Y, Han C, Liu L, Zhang G, Wang L, Guo S, Guo X, Xia Y, Wan F, Huang J, Lin Z, Wang T. Weight Loss and Malnutrition in Patients with Parkinson's Disease: Current Knowledge and Future Prospects. Front Aging Neurosci 2018; 10:1. [PMID: 29403371 PMCID: PMC5780404 DOI: 10.3389/fnagi.2018.00001] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/04/2018] [Indexed: 12/28/2022] Open
Abstract
Parkinson's Disease (PD) is currently considered a systemic neurodegenerative disease manifested with not only motor but also non-motor symptoms. In particular, weight loss and malnutrition, a set of frequently neglected non-motor symptoms, are indeed negatively associated with the life quality of PD patients. Moreover, comorbidity of weight loss and malnutrition may impact disease progression, giving rise to dyskinesia, cognitive decline and orthostatic hypotension, and even resulting in disability and mortality. Nevertheless, the underlying mechanism of weight loss and malnutrition in PD remains obscure and possibly involving multitudinous, exogenous or endogenous, factors. What is more, there still does not exist any weight loss and malnutrition appraision standards and management strategies. Given this, here in this review, we elaborate the weight loss and malnutrition study status in PD and summarize potential determinants and mechanisms as well. In conclusion, we present current knowledge and future prospects of weight loss and malnutrition in the context of PD, aiming to appeal clinicians and researchers to pay a closer attention to this phenomena and enable better management and therapeutic strategies in future clinical practice.
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Affiliation(s)
- Kai Ma
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nian Xiong
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Shen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chao Han
- Department of Neurology, Anhui Provincial Hospital, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Ling Liu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guoxin Zhang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Luxi Wang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiyi Guo
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xingfang Guo
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Xia
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fang Wan
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinsha Huang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhicheng Lin
- Department of Psychiatry, Harvard Medical School, Division of Basic Neuroscience, and Mailman Neuroscience Research Center, McLean Hospital, Belmont, MA, United States
| | - Tao Wang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Ghoshal UC, Shukla R, Ghoshal U. Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge between Functional Organic Dichotomy. Gut Liver 2017; 11:196-208. [PMID: 28274108 PMCID: PMC5347643 DOI: 10.5009/gnl16126] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 07/07/2016] [Accepted: 07/11/2016] [Indexed: 12/13/2022] Open
Abstract
The pathogenesis of irritable bowel syndrome (IBS), once thought to be largely psychogenic in origin, is now understood to be multifactorial. One of the reasons for this paradigm shift is the realization that gut dysbiosis, including small intestinal bacterial overgrowth (SIBO), causes IBS symptoms. Between 4% and 78% of patients with IBS and 1% and 40% of controls have SIBO; such wide variations in prevalence might result from population differences, IBS diagnostic criteria, and, most importantly, methods to diagnose SIBO. Although quantitative jejunal aspirate culture is considered the gold standard for the diagnosis of SIBO, noninvasive hydrogen breath tests have been popular. Although the glucose hydrogen breath test is highly specific, its sensitivity is low; in contrast, the early-peak criteria in the lactulose hydrogen breath test are highly nonspecific. Female gender, older age, diarrhea-predominant IBS, bloating and flatulence, proton pump inhibitor and narcotic intake, and low hemoglobin are associated with SIBO among IBS patients. Several therapeutic trials targeting gut microbes using antibiotics and probiotics have further demonstrated that not all symptoms in patients with IBS originate in the brain but rather in the gut, providing support for the micro-organic basis of IBS. A recent proof-of-concept study showing the high frequency of symptom improvement in patients with IBS with SIBO further supports this hypothesis.
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Affiliation(s)
- Uday C Ghoshal
- Department of Gastroenterology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ratnakar Shukla
- Department of Gastroenterology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ujjala Ghoshal
- Department of Gastroenterology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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18
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Akashi T, Muto A, Takahashi Y, Nishiyama H. Enteral Formula Containing Egg Yolk Lecithin Improves Diarrhea. J Oleo Sci 2017; 66:1017-1027. [PMID: 28794309 DOI: 10.5650/jos.ess17007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Diarrhea often occurs during enteral nutrition. Recently, several reports showed that diarrhea improves by adding egg yolk lecithin, an emulsifier, in an enteral formula. Therefore, we evaluated if this combination could improve diarrhea outcomes. We retrospectively investigated the inhibitory effects on watery stools by replacing a polymeric fomula with that containing egg yolk lecithin. Then, we investigated the emulsion stability in vitro. Next, we examined the lipid absorption using different emulsifiers among bile duct-ligated rats and assessed whether egg yolk lecithin, medium-chain triglyceride, and dietary fiber can improve diarrhea outcomes in a rat model of short bowel syndrome. Stool consistency or frequency improved on the day after using the aforementioned combination in 13/14 patients. Average particle size of the egg yolk lecithin emulsifier did not change by adding artificial gastric juice, whereas that of soy lecithin and synthetic emulsifiers increased. Serum triglyceride concentrations were significantly higher in the egg yolk lecithin group compared with the soybean lecithin and synthetic emulsifier groups in bile duct-ligated rats. In rats with short bowels, the fecal consistency was a significant looser the dietary fiber (+) group than the egg yolk lecithin (+) groups from day 6 of test meal feedings. The fecal consistency was also a significant looser the egg yolk lecithin (-) group than the egg yolk lecithin (+) groups from day 4 of test meal feeding. The fecal consistency was no significant difference between the medium-chain triglycerides (-) and egg yolk lecithin (+) groups. Enteral formula emulsified with egg yolk lecithin promotes lipid absorption by preventing the destruction of emulsified substances by gastric acid. This enteral formula improved diarrhea and should reduce the burden on patients and healthcare workers.
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Affiliation(s)
- Tetsuro Akashi
- Department of Internal medicine, Saiseikai Fukuoka General Hospital
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19
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Jung SE, Joo NS, Han KS, Kim KN. Obesity Is Inversely Related to Hydrogen-Producing Small Intestinal Bacterial Overgrowth in Non-Constipation Irritable Bowel Syndrome. J Korean Med Sci 2017; 32:948-953. [PMID: 28480652 PMCID: PMC5426230 DOI: 10.3346/jkms.2017.32.6.948] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/19/2017] [Indexed: 12/13/2022] Open
Abstract
There have been inconsistent findings on the association of obesity and non-constipation irritable bowel syndrome (IBS). Small intestinal bacterial overgrowth (SIBO) with hydrogen (H₂) gas forming-microflora causes non-constipation IBS. But, the effect of H₂ producing SIBO on obesity in non-constipation IBS patients has not been studied yet. The aim of this study was to investigate the association between obesity and SIBO in non-constipation IBS patients. We reviewed the charts of patients who showed IBS symptoms along with the documented results of their lactulose hydrogen breath test (LHBT) for SIBO. Multivariate models were used to assess the association between obesity and SIBO. Four-hundred fifty-eight patients were retrospectively included in the study. Of the 485 IBS patients, 158 (30.7%) subjects had positive results for LHBT. Subjects without SIBO showed significantly higher levels of body mass index (24.8 vs. 23.3; P < 0.001) and waist circumference (86.5 vs. 82.7; P < 0.001) as compared to subjects with SIBO. In multivariate analysis, the odds ratios of SIBO were 0.396 (P = 0.018) for obesity and 0.482 (P = 0.021) for abdominal obesity. This is the first human study to demonstrate that obesity is inversely related to SIBO with H₂ gas production in non-constipation IBS patients.
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Affiliation(s)
- Seung Eun Jung
- Department of Family Practice and Community Health, Ajou University School of Medicine, Suwon, Korea
| | - Nam Seok Joo
- Department of Family Practice and Community Health, Ajou University School of Medicine, Suwon, Korea
| | - Kyung Sun Han
- Department of Family Practice and Community Health, Ajou University School of Medicine, Suwon, Korea
| | - Kyu Nam Kim
- Department of Family Practice and Community Health, Ajou University School of Medicine, Suwon, Korea.
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Chronic Diarrhea: Diagnosis and Management. Clin Gastroenterol Hepatol 2017; 15:182-193.e3. [PMID: 27496381 DOI: 10.1016/j.cgh.2016.07.028] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 07/27/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
Chronic diarrhea is a common problem affecting up to 5% of the population at a given time. Patients vary in their definition of diarrhea, citing loose stool consistency, increased frequency, urgency of bowel movements, or incontinence as key symptoms. Physicians have used increased frequency of defecation or increased stool weight as major criteria and distinguish acute diarrhea, often due to self-limited, acute infections, from chronic diarrhea, which has a broader differential diagnosis, by duration of symptoms; 4 weeks is a frequently used cutoff. Symptom clusters and settings can be used to assess the likelihood of particular causes of diarrhea. Irritable bowel syndrome can be distinguished from some other causes of chronic diarrhea by the presence of pain that peaks before defecation, is relieved by defecation, and is associated with changes in stool form or frequency (Rome criteria). Patients with chronic diarrhea usually need some evaluation, but history and physical examination may be sufficient to direct therapy in some. For example, diet, medications, and surgery or radiation therapy can be important causes of chronic diarrhea that can be suspected on the basis of history alone. Testing is indicated when alarm features are present, when there is no obvious cause evident, or the differential diagnosis needs further delineation. Testing of blood and stool, endoscopy, imaging studies, histology, and physiological testing all have roles to play but are not all needed in every patient. Categorizing patients after limited testing may allow more directed testing and more rapid diagnosis. Empiric antidiarrheal therapy can be used to mitigate symptoms in most patients for whom a specific treatment is not available.
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Abstract
PURPOSE OF REVIEW A new syndrome responding to gluten-free diet and defined non-celiac gluten sensitivity entered the spectrum of gluten-related disorders, together with celiac disease and wheat allergy. However, its definition, prevalence, diagnosis, pathogenesis, treatment, and follow up are still controversial. The purpose of the review is to summarize the evidence and problems emerging from the current literature. RECENT FINDINGS Direct implication of gluten in the onset of symptoms is often unproved as a low fermentable oligo-, di- and mono-saccharides and polyols diet or other components of cereals as wheat amylase trypsin inhibitor could be similarly involved. To date, no specific biomarkers or histological abnormalities confirm diagnosis, and only the self-reported response to gluten-free diet as well as a positive double blind placebo-gluten challenge characterizes these non-celiac, non-wheat allergic patients. Critical revision of published studies can offer practical indications in approaching this clinical topic and useful suggestions to standardize scientific researches.
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Affiliation(s)
- Maria Teresa Bardella
- Center for the Prevention and Diagnosis of Celiac Disease, Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122, Milan, Italy.
- , Via Giambologna, 1 - 20136, Milan, Italy.
| | - Luca Elli
- Center for the Prevention and Diagnosis of Celiac Disease, Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122, Milan, Italy
| | - Francesca Ferretti
- Center for the Prevention and Diagnosis of Celiac Disease, Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122, Milan, Italy
- Department of Medical, Surgical and Transplant Physiopathology, University of Milan, via Francesco Sforza 35, 20122, Milan, Italy
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Fernández-Bañares F, Accarino A, Balboa A, Domènech E, Esteve M, Garcia-Planella E, Guardiola J, Molero X, Rodríguez-Luna A, Ruiz-Cerulla A, Santos J, Vaquero E. Diarrea crónica: definición, clasificación y diagnóstico. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:535-59. [DOI: 10.1016/j.gastrohep.2015.09.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 09/21/2015] [Accepted: 09/30/2015] [Indexed: 12/16/2022]
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Khalifeh-Soltani A, Ha A, Podolsky MJ, McCarthy DA, McKleroy W, Azary S, Sakuma S, Tharp KM, Wu N, Yokosaki Y, Hart D, Stahl A, Atabai K. α8β1 integrin regulates nutrient absorption through an Mfge8-PTEN dependent mechanism. eLife 2016; 5. [PMID: 27092791 PMCID: PMC4868538 DOI: 10.7554/elife.13063] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 04/18/2016] [Indexed: 12/25/2022] Open
Abstract
Coordinated gastrointestinal smooth muscle contraction is critical for proper nutrient absorption and is altered in a number of medical disorders. In this work, we demonstrate a critical role for the RGD-binding integrin α8β1 in promoting nutrient absorption through regulation of gastrointestinal motility. Smooth muscle-specific deletion and antibody blockade of α8 in mice result in enhanced gastric antral smooth muscle contraction, more rapid gastric emptying, and more rapid transit of food through the small intestine leading to malabsorption of dietary fats and carbohydrates as well as protection from weight gain in a diet-induced model of obesity. Mechanistically, ligation of α8β1 by the milk protein Mfge8 reduces antral smooth muscle contractile force by preventing RhoA activation through a PTEN-dependent mechanism. Collectively, our results identify a role for α8β1 in regulating gastrointestinal motility and identify α8 as a potential target for disorders characterized by hypo- or hyper-motility. DOI:http://dx.doi.org/10.7554/eLife.13063.001 Animals absorb nutrients from the food they eat in a complicated process that involves multiple steps. In the mouth, teeth break down the food into smaller chunks. Then the food passes through the stomach and small intestine, where enzymes break it down into individual molecules that are small enough to be absorbed by cells that line the small intestine. These cells then package the molecules and release them into the bloodstream so that they can be distributed to the rest of the body. Muscles in the wall of the small intestine control how quickly food travels through this part of the gut. If food moves too quickly, the cells that line the intestine have less time to absorb the food molecules and may fail to absorb enough nutrients. If the food moves too slowly, an individual may experience nausea or vomiting, or the contents of their stomach may spill into their lungs. In 2014, researchers reported that a protein in breast milk called Mfge8 helps to boost the number of fat molecules absorbed from food. Now, Khalifeh-Soltani et al. – including some of the same researchers involved in the earlier work – show that Mfge8 also slows the rate at which food travels through the small intestine in mice. Mfge8 binds to another protein called integrin α8β1 to control how often the intestine muscles contract. Genetically engineered mice that lacked integrin α8β1 developed diarrhea and food passed through their intestines more quickly than in normal mice. Furthermore, these mice did not gain as much weight as normal mice when they were fed a high-fat diet. Khalifeh-Soltani et al.’s findings show that Mfge8 has a dual role in controlling the absorption of food molecules in the small intestine. The next challenge is to find out whether drugs that alter the activity of integrin α8β1 could be used to help treat patients with diseases in which food moves too quickly, or too slowly, through the gut. DOI:http://dx.doi.org/10.7554/eLife.13063.002
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Affiliation(s)
- Amin Khalifeh-Soltani
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, United States.,Department of Medicine, University of California, San Francisco, San Francisco, United States
| | - Arnold Ha
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, United States
| | - Michael J Podolsky
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, United States.,Department of Medicine, University of California, San Francisco, San Francisco, United States
| | - Donald A McCarthy
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, United States
| | - William McKleroy
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, United States
| | - Saeedeh Azary
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, United States
| | - Stephen Sakuma
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, United States
| | - Kevin M Tharp
- Metabolic Biology, University of California, Berkeley, Berkeley, United States.,Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, United States
| | - Nanyan Wu
- Lung Biology Center, University of California, San Francisco, San Francisco, United States
| | - Yasuyuki Yokosaki
- Cell-Matrix Frontier Laboratory, Biomedical Research Unit, Health Administration Center, Hiroshima University, Hiroshima, Japan
| | - Daniel Hart
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, United States
| | - Andreas Stahl
- Metabolic Biology, University of California, Berkeley, Berkeley, United States.,Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, United States
| | - Kamran Atabai
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, United States.,Department of Medicine, University of California, San Francisco, San Francisco, United States.,Lung Biology Center, University of California, San Francisco, San Francisco, United States
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Kent ACC, Cross G, Taylor DR, Sherwood RA, Watson PJ. Measurement of serum 7α-hydroxy-4-cholesten-3-one as a marker of bile acid malabsorption in dogs with chronic diarrhoea: a pilot study. Vet Rec Open 2016; 3:e000163. [PMID: 27110372 PMCID: PMC4838766 DOI: 10.1136/vetreco-2015-000163] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/04/2016] [Accepted: 01/07/2016] [Indexed: 01/29/2023] Open
Abstract
Bile acid malabsorption is a common cause of chronic diarrhoea in people, however it has never previously been investigated in dogs, despite clinical suspicion of its existence. The goal of this study was to assess the feasibility of measuring serum 7α-hydroxy-4-cholesten-3-one (C4) in dogs, as a potential marker of bile acid malabsorption, and to see whether this is related to clinical disease severity or the presence of hypocobalaminaemia. Serum C4 concentration was measured in 20 clinically healthy control dogs and 17 dogs with chronic diarrhoea. Three of the 17 affected dogs (17.6 per cent) had a C4 concentration significantly above the range of clinically healthy dogs; these dogs were all poorly responsive to conventional therapy. These results suggest that bile acid malabsorption may be a clinically relevant disorder in dogs with chronic diarrhoea and serum C4 may be a useful tool to investigate this further.
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Affiliation(s)
- A C C Kent
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK; Willows Referral Service, Highlands Road, Shirley, Solihull, UK
| | - G Cross
- Clinical Biochemistry Department , King's College Hospital , London , UK
| | - D R Taylor
- Clinical Biochemistry Department , King's College Hospital , London , UK
| | - R A Sherwood
- Clinical Biochemistry Department , King's College Hospital , London , UK
| | - P J Watson
- Department of Veterinary Medicine , University of Cambridge , Cambridge , UK
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25
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Deng L, Liu Y, Zhang D, Li Y, Xu L. Prevalence and treatment of small intestinal bacterial overgrowth in postoperative patients with colorectal cancer. Mol Clin Oncol 2016; 4:883-887. [PMID: 27123301 DOI: 10.3892/mco.2016.807] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 02/25/2016] [Indexed: 02/06/2023] Open
Abstract
To investigate the prevalence of small intestinal bacterial overgrowth (SIBO) in patients with colorectal cancer (CRC) after surgical treatment and observe whether gastrointestinal symptoms may improve with rifaximin, 43 postoperative CRC patients (CRC group) and 30 healthy individuals (normal group) were subjected to the glucose hydrogen breath test (GHBT). All the patients were asked to evaluate the gastrointestinal symptoms using the visual analogue scale (VAS). SIBO-positive patients were administered rifaximin for 10 days on the basis of the original treatment. After the treatment, the patients were asked to undergo GHBT and re-evaluate the gastrointestinal symptoms score (GISS). The results demonstrated that 18 of the 43 postoperative patients with CRC were SIBO-positive (41.86%), which was significantly higher compared with the incidence in normal controls (6.67%) (P<0.05). GISS was higher in SIBO-positive patients (P<0.05). Following rifaximin treatment, 6 of the 18 (33.33%) SIBO-positive patients had improved, as evaluated by GHBT and VAS. Additionally, the GISS in the SIBO-turned-negative group had improved significantly compared with that in the non-turned-negative group (P<0.05). The symptoms of all 18 SIBO-positive patients following rifaximin treatment improved notably, particularly diarrhea (P<0.05). In conclusion, postoperative CRC patients are more likely to develop SIBO compared with healthy individuals, and SIBO may aggravate digestive symptoms. The administration of rifaximin improved the overall gastrointestinal symptoms, particularly diarrhea, in SIBO-positive patients.
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Affiliation(s)
- Lihua Deng
- Department of Gastroenterology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, Shandong 266071, P.R. China
| | - Yang Liu
- Department of Gastroenterology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, Shandong 266071, P.R. China
| | - Dongsheng Zhang
- Department of Hepatobiliary Surgery, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, Shandong 266071, P.R. China
| | - Yuan Li
- Department of Gastroenterology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, Shandong 266071, P.R. China
| | - Lin Xu
- Department of Gastroenterology, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao, Shandong 266071, P.R. China
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26
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Clarke JO. SIBO in gastroparesis: sci-fi or science fact? Dig Dis Sci 2014; 59:510-2. [PMID: 24435184 DOI: 10.1007/s10620-013-3011-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 12/20/2013] [Indexed: 01/14/2023]
Affiliation(s)
- John O Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University, 1830 East Monument Street, Room 425, Baltimore, MD, 21205, USA,
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27
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Pan D, Yu Z. Intestinal microbiome of poultry and its interaction with host and diet. Gut Microbes 2014; 5:108-19. [PMID: 24256702 PMCID: PMC4049927 DOI: 10.4161/gmic.26945] [Citation(s) in RCA: 483] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 10/23/2013] [Accepted: 10/24/2013] [Indexed: 02/03/2023] Open
Abstract
The gastrointestinal (GI) tract of poultry is densely populated with microorganisms which closely and intensively interact with the host and ingested feed. The gut microbiome benefits the host by providing nutrients from otherwise poorly utilized dietary substrates and modulating the development and function of the digestive and immune system. In return, the host provides a permissive habitat and nutrients for bacterial colonization and growth. Gut microbiome can be affected by diet, and different dietary interventions are used by poultry producers to enhance bird growth and reduce risk of enteric infection by pathogens. There also exist extensive interactions among members of the gut microbiome. A comprehensive understanding of these interactions will help develop new dietary or managerial interventions that can enhance bird growth, maximize host feed utilization, and protect birds from enteric diseases caused by pathogenic bacteria.
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Affiliation(s)
- Deng Pan
- Department of Animal Sciences; The Ohio State University; Columbus, OH USA
| | - Zhongtang Yu
- Department of Animal Sciences; The Ohio State University; Columbus, OH USA
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28
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Sachdev AH, Pimentel M. Gastrointestinal bacterial overgrowth: pathogenesis and clinical significance. Ther Adv Chronic Dis 2013; 4:223-31. [PMID: 23997926 DOI: 10.1177/2040622313496126] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Small intestinal bacterial overgrowth (SIBO) is defined as the presence of an abnormally high number of coliform bacteria in the small bowel. It is associated with a broad range of predisposing small intestinal motility disorders and with surgical procedures that result in bowel stasis. The most common symptoms associated with SIBO include diarrhea, flatulence, abdominal pain and bloating. Quantitative culture of small bowel contents and a variety of indirect tests have been used over the years in an attempt to facilitate the diagnosis of SIBO. The indirect tests include breath tests and biochemical tests based on bacterial metabolism of a variety of substrates. Unfortunately, there is no single valid test for SIBO, and the accuracy of all current tests remains limited due to the failure of culture to be a gold standard and the lack of standardization of the normal bowel flora in the small intestine. Currently, the ideal approach to treat SIBO is to treat the underlying disease, eradicate overgrowth, and address nutritional deficiencies that may be associated with the development of SIBO.
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29
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Bohm M, Siwiec RM, Wo JM. Diagnosis and management of small intestinal bacterial overgrowth. Nutr Clin Pract 2013; 28:289-99. [PMID: 23614961 DOI: 10.1177/0884533613485882] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Small intestinal bacterial overgrowth (SIBO) can result from failure of the gastric acid barrier, failure of small intestinal motility, anatomic alterations, or impairment of systemic and local immunity. The current accepted criteria for the diagnosis of SIBO is the presence of coliform bacteria isolated from the proximal jejunum with >10(5) colony-forming units/mL. A major concern with luminal aspiration is that it is only one random sampling of the small intestine and may not always be representative of the underlying microbiota. A new approach to examine the underlying microbiota uses rapid molecular sequencing, but its clinical utilization is still under active investigation. Clinical manifestations of SIBO are variable and include bloating, flatulence, abdominal distention, abdominal pain, and diarrhea. Severe cases may present with nutrition deficiencies due to malabsorption of micro- and macronutrients. The current management strategies for SIBO center on identifying and correcting underlying causes, addressing nutrition deficiencies, and judicious utilization of antibiotics to treat symptomatic SIBO.
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Affiliation(s)
- Matthew Bohm
- Department of Medicine, Division of Gastroenterology/Hepatology, Indiana University, Indianapolis, Indiana, USA.
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30
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Sung YK, Gwak GY, Choi MS, Koh KC, Paik SW, Yoo BC, Lee JH. A case of nonalcoholic steatohepatitis and small intestinal bacterial overgrowth with peripheral edema caused by intestinal bypass surgery and relieved by repair. Gut Liver 2012; 6:520-3. [PMID: 23170161 PMCID: PMC3493737 DOI: 10.5009/gnl.2012.6.4.520] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Revised: 12/22/2010] [Accepted: 02/18/2011] [Indexed: 12/16/2022] Open
Abstract
Intestinal bypass surgery, particularly jejuno-ileal bypass surgery, performed for the purpose of weight reduction may cause an unexpected exacerbation of nonalcoholic steatohepatitis (NASH). Here, we report a case of NASH caused by small intestinal bacterial overgrowth, which developed after jejuno-colic bypass surgery and resolved dramatically after surgical correction.
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Affiliation(s)
- Young Kyung Sung
- Department of Medicine, Samsung Medical Center, Sunkyunkwan University School of Medicine, Seoul, Korea
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31
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The bowel and migraine: update on celiac disease and irritable bowel syndrome. Curr Pain Headache Rep 2012; 16:278-86. [PMID: 22447132 DOI: 10.1007/s11916-012-0258-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This article explores possible relationships between migraine, irritable bowel syndrome (IBS), celiac disease (CD), and gluten sensitivity. These seemingly distinct medical entities curiously share many common epidemiological, psychosocial, and pathophysiological similarities. Considerable evidence is emerging to support a concept that experiencing significant threatening adverse events creates a state of hypervigilance in the nervous system, which associates with exaggerated response to future threats and episodic attacks of migraine and IBS. While this sensitizing response is generally considered to reside in the central nervous system, it may be possible that the initiation resides in the enteric nervous system as well. What appears to link migraine, IBS, and CD is a disease model of a genetically sensitive nervous system transformed into one that is hypervigilant, and that over time can often develop disabling and pervasive disease.
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33
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The gut microbiota and irritable bowel syndrome: friend or foe? Int J Inflam 2012; 2012:151085. [PMID: 22577594 PMCID: PMC3346986 DOI: 10.1155/2012/151085] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 01/07/2012] [Indexed: 12/20/2022] Open
Abstract
Progress in the understanding of the pathophysiology of irritable bowel syndrome (IBS), once thought to be a purely psychosomatic disease, has advanced considerably and low-grade inflammation and changes in the gut microbiota now feature as potentially important. The human gut harbours a huge microbial ecosystem, which is equipped to perform a variety of functions such as digestion of food, metabolism of drugs, detoxification of toxic compounds, production of essential vitamins, prevention of attachment of pathogenic bacteria to the gut wall, and maintenance of homeostasis in the gastrointestinal tract. A subset of patients with IBS may have a quantitative increase in bacteria in the small bowel (small intestinal bacterial overgrowth). Qualitative changes in gut microbiota have also been associated with IBS. Targeting the gut microbiota using probiotics and antibiotics has emerged as a potentially effective approach to the treatment of this, hitherto enigmatic, functional bowel disorder. The gut microbiota in health, quantitative and qualitative microbiota changes, and therapeutic manipulations targeting the microbiota in patients with IBS are reviewed in this paper.
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36
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Chang MS, Green PHR. A review of rifaximin and bacterial overgrowth in poorly responsive celiac disease. Therap Adv Gastroenterol 2012; 5:31-6. [PMID: 22282706 PMCID: PMC3263982 DOI: 10.1177/1756283x11422264] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A proportion of patients with celiac disease have a poor response to a gluten-free diet, which may be due to small-intestinal bacterial overgrowth (SIBO). Treatment with rifaximin is often used in the clinical setting, but there is limited literature to support this practice. In addition, challenges in the diagnosis of SIBO confound response interpretation. Our recent placebo-controlled trial did not demonstrate any improvement in gastrointestinal symptoms after treatment with rifaximin and casts doubt on the utility of lactulose-hydrogen breath testing for SIBO in this population.
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Affiliation(s)
- Matthew S. Chang
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Peter H. R. Green
- Department of Medicine, Columbia University College of Physicians and Surgeons, 180 Fort Washington Avenue, New York, NY 10032, USA
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37
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Kurien M, Evans KE, Leeds JS, Hopper AD, Harris A, Sanders DS. Bile acid malabsorption: an under-investigated differential diagnosis in patients presenting with diarrhea predominant irritable bowel syndrome type symptoms. Scand J Gastroenterol 2011; 46:818-22. [PMID: 21492055 DOI: 10.3109/00365521.2011.574728] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Bile acid malabsorption (BAM) has been reported as a possible cause of diarrhea predominant irritable bowel syndrome (D-IBS) type symptoms. We aimed to determine how commonly patients with D-IBS type symptoms had a diagnosis of BAM as demonstrated by a positive SeHCAT (75 Selenium-homocholic acid taurine) test (retention <10% at seven days). MATERIALS AND METHODS A retrospective analysis was undertaken of patient's records for all patients who underwent a SeHCAT test between 2001 and 2009 in a tertiary hospital (Group A). Concurrently, a cohort of patients with Rome II D-IBS type symptoms was examined to determine the potential utility of SeHCAT test (Group B). RESULTS In Group A 39.2% (n = 107/273) of patients had a positive SeHCAT result. The median time from first hospital visit to SeHCAT result was 30 weeks. Predictive factors for BAM: terminal ileal Crohn's disease (p < 0.01), terminal ileal resection (p < 0.01), and previous cholecystectomy (p < 0.01). 33.6% of patients who had a positive SeHCAT also had Rome II D-IBS. In Group B the D-IBS control cohort only 1.9% of patients had undergone a SeHCAT scan (p < 0.001 compared to Group A). CONCLUSION BAM is common and should be considered earlier when investigating unselected patients with D-IBS type symptoms.
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Affiliation(s)
- Matthew Kurien
- Gastroenterology & Liver Unit, Royal Hallamshire Hospital, Sheffield, UK.
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38
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Abstract
AIM To determine the evidence for the effect of gluten ingestion on gastrointestinal symptoms, intestinal permeability and other indices of small intestinal injury in non-coeliac, gluten intolerant individuals. METHODS A literature review was performed searching for interventional studies that addressed the issue. RESULTS One unblinded study that identified symptomatic response to gluten did not effectively exclude patients with coeliac disease, since many had intraepithelial lymphocytosis. A double-blinded, randomised, placebo-controlled rechallenge trial was recently reported in patients in whom coeliac disease had been excluded by either normal duodenal histology on a gluten containing diet, or absence of the HLA DQ2 or DQ8 haplotype (56%). Participants were randomly assigned to receive either 16 g/day carbohydrate-free gluten or placebo for six weeks. Participants were enrolled if they had gastrointestinal symptoms that had improved on a GFD and had been on a gluten free diet for at least 6 weeks prior to enrollment. 19 received gluten and 15 received placebo. Change between baseline and final weeks were greater for patients receiving gluten in overall symptom severity compared with those receiving placebo (p=0.047). and were worse with gluten within one week for pain (p=0.016), bloating (p=0.031), satisfaction with stool consistency (p=0.024), and tiredness (p=0.001). Mechanisms for symptom induction were not identified. CONCLUSIONS Non-coeliac gluten intolerance does exist. Future studies need to identify issues of the dose of gluten needed and mechanisms of action.
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Affiliation(s)
- Evan D Newnham
- Eastern Health Clinical School, Monash University and Department of Gastroenterology & Hepatology, Eastern Health, Victoria 3128, Australia.
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39
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Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol 2011; 106:508-14; quiz 515. [PMID: 21224837 DOI: 10.1038/ajg.2010.487] [Citation(s) in RCA: 458] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Despite increased prescription of a gluten-free diet for gastrointestinal symptoms in individuals who do not have celiac disease, there is minimal evidence that suggests that gluten is a trigger. The aims of this study were to determine whether gluten ingestion can induce symptoms in non-celiac individuals and to examine the mechanism. METHODS A double-blind, randomized, placebo-controlled rechallenge trial was undertaken in patients with irritable bowel syndrome in whom celiac disease was excluded and who were symptomatically controlled on a gluten-free diet. Participants received either gluten or placebo in the form of two bread slices plus one muffin per day with a gluten-free diet for up to 6 weeks. Symptoms were evaluated using a visual analog scale and markers of intestinal inflammation, injury, and immune activation were monitored. RESULTS A total of 34 patients (aged 29-59 years, 4 men) completed the study as per protocol. Overall, 56% had human leukocyte antigen (HLA)-DQ2 and/or HLA-DQ8. Adherence to diet and supplements was very high. Of 19 patients (68%) in the gluten group, 13 reported that symptoms were not adequately controlled compared with 6 of 15 (40%) on placebo (P=0.0001; generalized estimating equation). On a visual analog scale, patients were significantly worse with gluten within 1 week for overall symptoms (P=0.047), pain (P=0.016), bloating (P=0.031), satisfaction with stool consistency (P=0.024), and tiredness (P=0.001). Anti-gliadin antibodies were not induced. There were no significant changes in fecal lactoferrin, levels of celiac antibodies, highly sensitive C-reactive protein, or intestinal permeability. There were no differences in any end point in individuals with or without DQ2/DQ8. CONCLUSIONS "Non-celiac gluten intolerance" may exist, but no clues to the mechanism were elucidated.
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Abstract
Despite the current increase in interest in the role of the microbiota in health and disease and the recognition, for over 50 years, that an excess of colonic-type flora in the small intestine could lead to a malabsorption syndrome, small intestinal overgrowth remains poorly defined. This lack of clarity owes much to the difficulties that arise in attempting to arrive at consensus with regard to the diagnosis of this condition: there is currently no gold standard and the commonly available methodologies (the culture of jejunal aspirates and a variety of breath tests) suffer from considerable variations in their performance and interpretation, leading to variations in the prevalence of overgrowth in a variety of clinical contexts. Treatment is similarly supported by a scant evidence base and the most commonly used antibiotic regimens owe more to custom than clinical trials.
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Walters JRF. Defining primary bile acid diarrhea: making the diagnosis and recognizing the disorder. Expert Rev Gastroenterol Hepatol 2010; 4:561-7. [PMID: 20932141 DOI: 10.1586/egh.10.54] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Chronic diarrhea due to bile acid malabsorption may be considered as contributing to the diagnosis when it results from secondary causes, such as ileal resection affecting the enterohepatic circulation. However, the primary form (also known as idiopathic bile acid malabsorption) is not well recognized as a common condition and patients are left undiagnosed. Primary bile acid diarrhea can be diagnosed by the nuclear medicine 75Se-homocholyltaurine (SeHCAT) test, although this is unavailable or underutilized in many settings. A systematic review suggests that approximately 30% of patients who would otherwise be diagnosed with diarrhea-predominant irritable bowel syndrome or functional diarrhea have abnormal SeHCAT retention. Serum 7α-hydroxy-4-cholesten-3-one can also be measured to show increased bile acid synthesis. The reasons for the lack of recognition of primary bile acid diarrhea are discussed, and these are compared with the other common cause of malabsorption, celiac disease. The lack of a clear pathophysiological mechanism has been a problem, but recent evidence suggests that impaired feedback control of hepatic bile acid synthesis by the ileal hormone FGF19 results in overproduction of bile acids. The identification of FGF19 as the central mechanism opens up new areas for development in the diagnosis and treatment of primary bile acid diarrhea.
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Affiliation(s)
- Julian R F Walters
- Section of Hepatology & Gastroenterology, Department of Medicine, Imperial College London and, Imperial College Healthcare, London, UK.
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42
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Miyata M, Yamakawa H, Hamatsu M, Kuribayashi H, Takamatsu Y, Yamazoe Y. Enterobacteria modulate intestinal bile acid transport and homeostasis through apical sodium-dependent bile acid transporter (SLC10A2) expression. J Pharmacol Exp Ther 2010; 336:188-96. [PMID: 20884752 DOI: 10.1124/jpet.110.171736] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
In our study, ampicillin (AMP)-mediated decrease of enterobacteria caused increases in hepatic bile acid concentration through (at least in part) elevation of bile acid synthesis in C57BL/6N mice. We investigated the involvement of enterobacteria on intestinal bile acid absorption in AMP-treated mice in the present study. Fecal enterobacterial levels and fecal bile acid excretion rates were markedly decreased in mice treated with AMP (100 mg/kg) for 3 days, whereas bile acid concentrations in portal blood were significantly increased compared with those in mice treated with a vehicle. Ileal apical sodium-dependent bile acid transporter (SLC10A2) mRNA levels and ileal SLC10A2 protein levels in brush-border membranes were significantly increased compared with those in mice treated with the vehicle. In AMP-treated mice, total bile acid levels were increased, whereas levels of enterobacteria-biotransformed bile acid, taurodeoxycholic acid, and cholic acid were decreased in intestinal lumen. These phenomena were also observed in farnesoid X receptor-null mice treated with AMP for 3 days. Discontinuation of AMP administration after 3 days (vehicle administration for 4 days) increased levels of fecal enterobacteria, fecal bile acid excretion, and taurodeoxycholic acid and cholic acid in the intestinal lumen, whereas the discontinuation decreased ileal SLC10A2 expression and bile acid concentrations in the portal blood. Coadministration of taurodeoxycholic acid or cholic acid decreased ileal SLC10A2 expression in mice treated with AMP. These results suggest that enterobacteria-mediated bile acid biotransformation modulates intestinal bile acid transport and homeostasis through down-regulation of ileal SLC10A2 expression.
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Affiliation(s)
- Masaaki Miyata
- Division of Drug Metabolism and Molecular Toxicology, Graduate School of Pharmaceutical Sciences, Tohoku University, 6-3, Aoba, Aramaki, Aoba-ku, Sendai, 980-8578, Japan.
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Bures J, Cyrany J, Kohoutova D, Förstl M, Rejchrt S, Kvetina J, Vorisek V, Kopacova M. Small intestinal bacterial overgrowth syndrome. World J Gastroenterol 2010; 16:2978-90. [PMID: 20572300 PMCID: PMC2890937 DOI: 10.3748/wjg.v16.i24.2978] [Citation(s) in RCA: 334] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Human intestinal microbiota create a complex polymicrobial ecology. This is characterised by its high population density, wide diversity and complexity of interaction. Any dysbalance of this complex intestinal microbiome, both qualitative and quantitative, might have serious health consequence for a macro-organism, including small intestinal bacterial overgrowth syndrome (SIBO). SIBO is defined as an increase in the number and/or alteration in the type of bacteria in the upper gastrointestinal tract. There are several endogenous defence mechanisms for preventing bacterial overgrowth: gastric acid secretion, intestinal motility, intact ileo-caecal valve, immunoglobulins within intestinal secretion and bacteriostatic properties of pancreatic and biliary secretion. Aetiology of SIBO is usually complex, associated with disorders of protective antibacterial mechanisms (e.g. achlorhydria, pancreatic exocrine insufficiency, immunodeficiency syndromes), anatomical abnormalities (e.g. small intestinal obstruction, diverticula, fistulae, surgical blind loop, previous ileo-caecal resections) and/or motility disorders (e.g. scleroderma, autonomic neuropathy in diabetes mellitus, post-radiation enteropathy, small intestinal pseudo-obstruction). In some patients more than one factor may be involved. Symptoms related to SIBO are bloating, diarrhoea, malabsorption, weight loss and malnutrition. The gold standard for diagnosing SIBO is still microbial investigation of jejunal aspirates. Non-invasive hydrogen and methane breath tests are most commonly used for the diagnosis of SIBO using glucose or lactulose. Therapy for SIBO must be complex, addressing all causes, symptoms and complications, and fully individualised. It should include treatment of the underlying disease, nutritional support and cyclical gastro-intestinal selective antibiotics. Prognosis is usually serious, determined mostly by the underlying disease that led to SIBO.
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Abstract
In addition to their roles in facilitating lipid digestion and absorption, bile acids are recognized as important regulators of intestinal function. Exposure to bile acids can dramatically influence intestinal transport and barrier properties; in recent years, they have also become appreciated as important factors in regulating cell growth and survival. Indeed, few cells reside within the intestinal mucosa that are not altered to some degree by exposure to bile acids. The past decade saw great advances in the knowledge of how bile acids exert their actions at the cellular and molecular levels. In this review, we summarize the current understanding of the role of bile acids in regulation of intestinal physiology.
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