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Safarpour D, Stover N, Shprecher DR, Hamedani AG, Pfeiffer RF, Parkman HP, Quigley EM, Cloud LJ. Consensus practice recommendations for management of gastrointestinal dysfunction in Parkinson disease. Parkinsonism Relat Disord 2024; 124:106982. [PMID: 38729797 DOI: 10.1016/j.parkreldis.2024.106982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Gastrointestinal (GI) dysfunction is a common non-motor feature of Parkinson disease (PD). GI symptoms may start years before the onset of motor symptoms and impair quality of life. Robust clinical trial data is lacking to guide screening, diagnosis and treatment of GI dysfunction in PD. OBJECTIVE To develop consensus statements on screening, diagnosis, and treatment of GI dysfunction in PD. METHODS The application of a modified Delphi panel allowed for the synthesis of expert opinions into clinical statements. Consensus was predefined as a level of agreement of 100 % for each item. Five virtual Delphi rounds were held. Two movement disorders neurologists reviewed the literature on GI dysfunction in PD and developed draft statements based on the literature review. Draft statements were distributed among the panel that included five movement disorder neurologists and two gastroenterologists, both experts in GI dysmotility and its impact on PD symptoms. All members reviewed the statements and references in advance of the virtual meetings. In the virtual meetings, each statement was discussed, edited, and a vote was conducted. If there was not 100 % consensus, further discussions and modifications ensued until there was consensus. RESULTS Statements were developed for screening, diagnosis, and treatment of common GI symptoms in PD and were organized by anatomic segments: oral cavity and esophagus, stomach, small intestine, and colon and anorectum. CONCLUSIONS These consensus recommendations offer a practical framework for the diagnosis and treatment of GI dysfunction in PD.
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Affiliation(s)
- Delaram Safarpour
- Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Natividad Stover
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Ali G Hamedani
- Departments of Neurology, Ophthalmology, and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ronald F Pfeiffer
- Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Henry P Parkman
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Eamonn Mm Quigley
- Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital and Weill Cornell Medical College, Houston, TX, USA
| | - Leslie J Cloud
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
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2
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Hirsch TI, Wang SZ, Fligor SC, Quigley M, Gura KM, Puder M, Tsikis ST. Fat malabsorption in short bowel syndrome: A review of pathophysiology and management. Nutr Clin Pract 2024; 39 Suppl 1:S17-S28. [PMID: 38429962 PMCID: PMC10914324 DOI: 10.1002/ncp.11119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/13/2023] [Accepted: 12/28/2023] [Indexed: 03/03/2024] Open
Abstract
Fat malabsorption is central to the pathophysiology of short bowel syndrome (SBS). It occurs in patients with insufficient intestinal surface area and/or function to maintain metabolic and growth demands. Rapid intestinal transit and impaired bile acid recycling further contribute to fat malabsorption. A significant portion of patients require parenteral nutrition (PN) for their survival but may develop sepsis and liver dysfunction as a result. Despite advancements in the treatment of SBS, fat malabsorption remains a chronic issue for this vulnerable patient population. Peer-reviewed literature was assessed on the topic of fat malabsorption in SBS. Current management of patients with SBS involves dietary considerations, PN management, antidiarrheals, glucagon-like peptide 2 agonists, and multidisciplinary teams. Clinical trials have focused on improving intestinal fat absorption by facilitating fat digestion with pancreatic enzymes. Targeting fat malabsorption in SBS is a potential pathway to improving lifestyle and reducing morbidity and mortality in this rare disease.
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Affiliation(s)
- Thomas I. Hirsch
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Z. Wang
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott C. Fligor
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Mikayla Quigley
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathleen M. Gura
- Department of Pharmacy and the Division of Gastroenterology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark Puder
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Savas T. Tsikis
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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3
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Guenzi E, Poté N. [Lymphocytic "…itis", from esophagus to large bowel]. Ann Pathol 2023:S0242-6498(23)00032-9. [PMID: 36828723 DOI: 10.1016/j.annpat.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 02/24/2023]
Abstract
Intra-epithelial lymphocytosis is an elementary lesion frequently observed in the gastrointestinal tract, which can be found from the esophagus to the colon. Many conditions of a varied nature (dysimmunitary diseases, drugs, infections…) are associated with intra-epithelial lymphocytosis, and the etiological diagnosis most often requires an anatomo-clinical correlation. The pathologist will have to identify histological lesions associated with intra-epithelial lymphocytosis allowing the diagnosis to be oriented in order to propose appropriate treatment. In this review, the main entities associated with digestive intra-epithelial lymphocytosis will be presented, detailing the key elements allowing their diagnosis.
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Affiliation(s)
- Edouard Guenzi
- Département de pathologie, hôpital Bichat, assistance publique-hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France
| | - Nicolas Poté
- Département de pathologie, hôpital Bichat, assistance publique-hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France.
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4
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Singh J, Dinkar A, Kumar N, Kumar K. Recurrent Nausea and Vomiting with Weight Loss Associated with Hypothyroidism: Fact or Myth. Endocr Metab Immune Disord Drug Targets 2023; 23:867-872. [PMID: 36475337 DOI: 10.2174/1871530323666221205110210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/30/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hypothyroidism is a commonly encountered endocrine disorder presenting in various clinical settings. It usually presents with classic manifestations, which are readily recognized and, therefore, easy to diagnose. However, occasionally, patients present with unusual symptoms, which becomes a challenge to diagnose. Thyroid dysfunction affects many body organs, including the gut and viscera. Studies show that intestinal motility might be affected by multiple factors, such as neuromuscular dysfunction, myopathy, or alterations in hormone receptors. CASE PRESENTATION Here, we present the first case of a 21-year-old female student who had complaints of recurrent nausea, vomiting, loose stool, abdominal pain, and weight loss. In the second case, a 25-year-old male student presented with recurrent nausea, vomiting, loose stool, and weight loss. Their unremarkable blood routines and gastrointestinal-specific investigations failed to ascertain the diagnosis. Later, primary hypothyroidism was established by typical biochemical abnormalities. CONCLUSION Thyroxine replacement treatment successfully resolved the presenting symptoms and normalized biochemical reports.
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Affiliation(s)
- Jitendra Singh
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Anju Dinkar
- Department of Microbiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Nilesh Kumar
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Kailash Kumar
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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5
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Schiepatti A, Sanders DS, Baiardi P, Caio G, Ciacci C, Kaukinen K, Lebwohl B, Leffler D, Malamut G, Murray JA, Rostami K, Rubio-Tapia A, Volta U, Biagi F. Nomenclature and diagnosis of seronegative coeliac disease and chronic non-coeliac enteropathies in adults: the Paris consensus. Gut 2022; 71:2218-2225. [PMID: 35676085 PMCID: PMC9554081 DOI: 10.1136/gutjnl-2021-326645] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/02/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Differential diagnosis of villous atrophy (VA) without coeliac antibodies in adults includes seronegative coeliac disease (CD) and chronic enteropathies unrelated to gluten, ie. non-coeliac enteropathies (NCEs). There is currently no international consensus on the nomenclature and diagnostic criteria for these enteropathies. In this work, a Delphi process was conducted to address this diagnostic and clinical uncertainty. DESIGN An international task force of 13 gastroenterologists from six countries was recruited at the 16th International Coeliac Disease Symposium, Paris, 2019. Between September 2019 and July 2021, a Delphi process was conducted through mail surveys to reach a consensus on which conditions to consider in the differential diagnosis of VA with negative coeliac serology and the clinical diagnostic approaches required for these conditions. A 70% agreement threshold was adopted. RESULTS Chronic enteropathies characterised by VA and negative coeliac serology can be attributed to two main clinical scenarios: forms of CD presenting with negative serology, which also include seronegative CD and CD associated with IgA deficiency, and NCEs, with the latter recognising different underlying aetiologies. A consensus was reached on the diagnostic criteria for NCEs assisting clinicians in differentiating NCEs from seronegative CD. Although in adults seronegative CD is the most common aetiology in patients with VA and negative serology, discriminating between seronegative CD and NCEs is key to avoid unnecessary lifelong gluten-free diet, treat disease-specific morbidity and contrast poor long-term outcomes. CONCLUSION This paper describes the Paris consensus on the definitions and diagnostic criteria for seronegative CD and chronic NCEs in adults.
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Affiliation(s)
- Annalisa Schiepatti
- Dipartimento di Medicina Interna e Terapia Medica, University of Pavia, Pavia, Italy .,Istituti Clinici Scientifici Maugeri, IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Paola Baiardi
- Direzione Scientifica Centrale, Fondazione S. Maugeri, IRCCS, Pavia, Italy
| | - Giacomo Caio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy,Celiac Center and Mucosal Immunology and Biology Research Center Massachusetts General Hospital- Harvard Medical School, Boston, Massachusetts, USA
| | - Carolina Ciacci
- AOU San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, Baronissi, Italy
| | - Katri Kaukinen
- Faculty of Medicine and Health Technology, Tampere University and Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York City, New York, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Daniel Leffler
- The Celiac Center at BIDMC, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Georgia Malamut
- Université de Paris, Department of Gastroenterology, AP-HP, Hôpital Cochin, Paris, France
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kamran Rostami
- Departments of Gastroenterology, Mid Central DHB, Palmerston Hospital, Palmerston North, Palmerston North, New Zealand
| | - Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Federico Biagi
- Dipartimento di Medicina Interna e Terapia Medica, University of Pavia, Pavia, Italy,Istituti Clinici Scientifici Maugeri, IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
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6
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Understanding Cystic Fibrosis Comorbidities and Their Impact on Nutritional Management. Nutrients 2022; 14:nu14051028. [PMID: 35268004 PMCID: PMC8912424 DOI: 10.3390/nu14051028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/17/2022] Open
Abstract
Cystic fibrosis (CF) is a chronic, multisystem disease with multiple comorbidities that can significantly affect nutrition and quality of life. Maintaining nutritional adequacy can be challenging in people with cystic fibrosis and has been directly associated with suboptimal clinical outcomes. Comorbidities of CF can result in significantly decreased nutritional intake and intestinal absorption, as well as increased metabolic demands. It is crucial to utilize a multidisciplinary team with expertise in CF to optimize growth and nutrition, where patients with CF and their loved ones are placed in the center of the care model. Additionally, with the advent of highly effective modulators (HEMs), CF providers have begun to identify previously unrecognized nutritional issues, such as obesity. Here, we will review and summarize commonly encountered comorbidities and their nutritional impact on this unique population.
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7
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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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8
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Schiepatti A, Cincotta M, Biagi F, Sanders DS. Enteropathies with villous atrophy but negative coeliac serology in adults: current issues. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000630. [PMID: 34764141 PMCID: PMC8587352 DOI: 10.1136/bmjgast-2021-000630] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/21/2021] [Indexed: 12/26/2022] Open
Abstract
Objective The differential diagnosis and management of seronegative enteropathies is challenging due to the rarity of these conditions, the overlap of clinical and histopathological features and the current lack of an international consensus on their nomenclature. Design This is a narrative review providing pragmatic guide on the investigation and clinical management of seronegative enteropathies in adults based on the available literature and our clinical experience. Conclusions Seronegative coeliac disease is the most frequent cause among the heterogeneous group of seronegative enteropathies and its diagnosis is confirmed by the clinical and histological response to a gluten-free diet after the exclusion of other causes of villous atrophy. Correct identification and targeted management of seronegative enteropathies is mandatory because of the variation in terms of clinical outcomes and prognosis.
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Affiliation(s)
- Annalisa Schiepatti
- Gastroenterology Unit of Pavia Institute, Maugeri Clinical Research Institutes IRCCS, University of Pavia, Pavia, Italy
| | - Marta Cincotta
- Gastroenterology Unit of Pavia Institute, Maugeri Clinical Research Institutes IRCCS, University of Pavia, Pavia, Italy
| | - Federico Biagi
- Gastroenterology Unit of Pavia Institute, Maugeri Clinical Research Institutes IRCCS, University of Pavia, Pavia, Italy
| | - David S Sanders
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kigdom
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9
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Szaflarska-Popławska A. The Role of the Gluten-Free Diet in the Management of Seronegative Enteropathy. Nutrients 2021; 13:nu13114027. [PMID: 34836279 PMCID: PMC8619095 DOI: 10.3390/nu13114027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
The differential diagnosis and treatment of seronegative enteropathy, also termed seronegative villous atrophy (SNVA), is a clinical challenge. Although seronegative coeliac disease (CD) is a frequent cause of SNVA, the aetiology can include immune-mediated, inflammatory, infectious, and drug-related forms. As a misdiagnosis of SNVA can result in patients being unnecessarily placed on a lifelong strict gluten-free diet or even given incorrect immunosuppressive therapy, the aim of this paper is to provide an evidence-based and practical approach for the workup and management of SNVA.
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Affiliation(s)
- Anna Szaflarska-Popławska
- Department of Paediatric Endoscopy and Gastrointestinal Function Testing, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, ul. Jagiellonska 13-15, 85-067 Bydgoszcz, Poland
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10
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Small Intestinal Bacterial Overgrowth as Potential Therapeutic Target in Parkinson's Disease. Int J Mol Sci 2021; 22:ijms222111663. [PMID: 34769091 PMCID: PMC8584211 DOI: 10.3390/ijms222111663] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/17/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022] Open
Abstract
Increasing evidence suggests that the gut microbiota and the brain are closely connected via the so-called gut–brain axis. Small intestinal bacterial overgrowth (SIBO) is a gut dysbiosis in which the small intestine is abundantly colonized by bacteria that are typically found in the colon. Though not a disease, it may result in intestinal symptoms caused by the accumulation of microbial gases in the intestine. Intestinal inflammation, malabsorption and vitamin imbalances may also develop. SIBO can be eradicated by one or several courses of antibiotics but reappears if the predisposing condition persists. Parkinson’s disease (PD) is a common neurodegenerative proteinopathy for which disease modifying interventions are not available. Sporadic forms may start in the gut years before the development of clinical features. Increased gastrointestinal transit time is present in most people with PD early during the course of the disease, predisposing to gut dysbiosis, including SIBO. The role that gut dysbiosis may play in the etiopathogenesis of PD is not fully understood yet. Here, we discuss the possibility that SIBO could contribute to the progression of PD, by promoting or preventing neurodegeneration, thus being a potential target for treatments aiming at slowing down the progression of PD. The direct symptomatic impact of SIBO and its impact on symptomatic medication are also briefly discussed.
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11
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Modi BP, Galloway DP, Gura K, Nucci A, Plogsted S, Tucker A, Wales PW. ASPEN definitions in pediatric intestinal failure. JPEN J Parenter Enteral Nutr 2021; 46:42-59. [PMID: 34287974 DOI: 10.1002/jpen.2232] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 11/09/2022]
Abstract
Pediatric intestinal failure (PIF) is a relatively rare disease entity which requires focused interdisciplinary care and specialized nutrition management. There has long been a lack of consensus in the definition of key terms related to PIF due to its rarity and plethora of small studies rather than large trials. As such, the American Society for Parenteral and Enteral Nutrition (ASPEN) Pediatric Intestinal Failure Section, composed of clinicians from a variety of disciplines caring for children with intestinal failure, is uniquely poised to provide insight into this definition void. This document is the product of an effort by the Section to create evidence-based consensus definitions, with the goal of allowing for appropriate comparisons between clinical studies and measurement of longterm patient outcomes. This manuscript was approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David P Galloway
- Division of Gastroenterology, Hepatology and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kathleen Gura
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anita Nucci
- Department of Nutrition, Georgia State University, Atlanta, Georgia, USA
| | | | - Alyssa Tucker
- Department of Clinical Nutrition, Children's National Medical Center, Washington, District of Columbia, USA
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment, Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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12
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Abstract
The term "small intestinal bacterial overgrowth" (SIBO) has been used to refer to a disorder resulting from the colonization of the small bowel by an increased number of microorganisms or by the presence of bacteria that are not usual constituents of this part of the gastrointestinal tract. Clinical presentations, often in patients with certain risk factors, can range from a full-blown malabsorption syndrome to such "functional" complaints as bloating and flatulence. SIBO is diagnosed by either culture of a small bowel aspirate or one of several breath tests. Treatment of SIBO entails risk factor modification, correction of nutritional deficiencies, and oral antibiotics.
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Affiliation(s)
- Daniel Bushyhead
- Division of Gastroenterology and Hepatology, Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital, 6550 Fannin Street Suite 1201, Houston, TX 77030, USA.
| | - Eamonn M Quigley
- Division of Gastroenterology and Hepatology, Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital, 6550 Fannin Street Suite 1201, Houston, TX 77030, USA
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13
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Wang B, Xu Y, Hou X, Li J, Cai Y, Hao Y, Ouyang Q, Wu B, Sun Z, Zhang M, Ban Y. Small Intestinal Bacterial Overgrowth in Subclinical Hypothyroidism of Pregnant Women. Front Endocrinol (Lausanne) 2021; 12:604070. [PMID: 34108932 PMCID: PMC8181748 DOI: 10.3389/fendo.2021.604070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 05/03/2021] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To evaluate the small intestinal bacterial overgrowth (SIBO) of subclinical hypothyroidism of pregnant women, and explore their possible relevance. METHODS In total, 224 pregnant women with subclinical hypothyroidism during pregnancy (study group) and 196 pregnant women whose thyroid function was normal (control group) were enrolled in this study. Lactulose-based hydrogen and methane breath test was performed to evaluate the growth of intestinal bacteria. The serum-free thyroid hormone (FT4), thyroid-stimulating hormone (TSH), thyroid peroxidase antibody (TPOAb), body mass index (BMI) and gastrointestinal symptoms were detected and recorded. RESULTS The positive rates of SIBO were 56.7% and 31.6% in study group and control group, respectively. The levels of C response protein (CRP), abdominal distension and constipation in study group were higher than those in the control group. The risk of abdominal distension and constipation in SIBO-positive pregnant women were higher than that in SIBO-negative pregnant women, and the BMI of SIBO-positive patients in the two groups was lower than that of SIBO-negative patients in each group. In addition, the TPOAb-positive rate and TSH levels were higher but the FT4 level was lower in SIBO-positive patients compared to SIBO-negative patients in study group. CONCLUSION The occurrence of subclinical hypothyroidism is related to SIBO, and the excessive growth of small intestinal bacteria may affect gastrointestinal symptoms. CLINICAL TRIAL http://www.chictr.org.cn/index.aspx, identifier ChiCTR1900026326.
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Brown I, Bettington M, Rosty C. The role of histopathology in the diagnosis and management of coeliac disease and other malabsorptive conditions. Histopathology 2020; 78:88-105. [PMID: 33382496 DOI: 10.1111/his.14262] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 12/17/2022]
Abstract
Most absorption of nutrients takes place in the proximal small intestine, and the most common disorders leading to malabsorption are associated with a morphological abnormality in the duodenal mucosa that is appreciable in histological sections of biopsy specimens. Coeliac disease is the most well-known example, causing intraepithelial lymphocytosis, inflammation and villous atrophy in the duodenum. Remarkably similar inflammatory changes can be induced by other processes, including medications, e.g. angiotensin II receptor blockers and immune checkpoint inhibitors, immune dysregulation disorders, e.g. common variable immunodeficiency and autoimmune enteropathy, infections, collagenous sprue, and tropical sprue. However, there are often subtle histological differences from coeliac disease in the type of inflammatory infiltrate, the presence of crypt apoptosis, and the extent and type of inflammation beyond the duodenum. The clinical setting and serological investigation usually allow diagnostic separation, but some cases remain challenging. Histopathology is also important in assessing the response to treatment, such as the change in villous architecture caused by a gluten-free diet, or the response to cessation of a potentially causative medication. This review examines the practical role that histopathology of duodenal biopsy specimens plays in the assessment and management of inflammatory malabsorptive processes of the proximal small intestine, with a particular emphasis on coeliac disease.
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Affiliation(s)
- Ian Brown
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Mark Bettington
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Christophe Rosty
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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15
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Clinical phenotype and mortality in patients with idiopathic small bowel villous atrophy: a dual-centre international study. Eur J Gastroenterol Hepatol 2020; 32:938-949. [PMID: 32282540 DOI: 10.1097/meg.0000000000001726] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Causes of small-bowel villous atrophy (VA) include coeliac disease (CD), its complications and other rare non-coeliac enteropathies. However, forms of VA of unknown aetiology may also exist. We defined them as idiopathic VA (IVA). To retrospectively classify the largest cohort of IVA patients and compare their natural history with CD. METHODS Notes of 76 IVA patients attending two tertiary centres between January 2000 and March 2019 were retrospectively reviewed. CD, its complications and all the known causes of VA were excluded in all of them. Persistence of VA during follow-up and lymphoproliferative features were used to retrospectively classify IVA, as follows. Group 1: IVA with spontaneous histological recovery (50 patients). Group 2: persistent IVA without lymphoproliferative features (14 patients). Group 3: persistent IVA with lymphoproliferative features (12 patients). Survival was compared between IVA groups and 1114 coeliac patients. HLA was compared between IVA patients, coeliac patients and appropriate controls. RESULTS Five-year survival was 96% in IVA group 1, 100% in IVA group 2, 27% in IVA group 3 and 97% in CD. On a multivariate analysis hypoalbuminemia (P = 0.002) and age at diagnosis (P = 0.04) predicted mortality in IVA. Group 2 showed association with HLA DQB1*0301 and DQB1*06. CONCLUSION IVA consists of three groups of enteropathies with distinct clinical phenotypes and prognoses. Mortality in IVA is higher than in CD and mainly due to lymphoproliferative conditions necessitating more aggressive therapies.
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16
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Avelar Rodriguez D, Ryan PM, Toro Monjaraz EM, Ramirez Mayans JA, Quigley EM. Small Intestinal Bacterial Overgrowth in Children: A State-Of-The-Art Review. Front Pediatr 2019; 7:363. [PMID: 31552207 PMCID: PMC6737284 DOI: 10.3389/fped.2019.00363] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/20/2019] [Indexed: 12/11/2022] Open
Abstract
Small intestinal bacterial overgrowth (SIBO) is a heterogenous and poorly understood entity characterised by an excessive growth of select microorganisms within the small intestine. This excessive bacterial biomass, in turn, disrupts host physiology in a myriad of ways, leading to gastrointestinal and non-gastrointestinal symptoms and complications. SIBO is a common cause of non-specific gastrointestinal symptoms in children, such as chronic abdominal pain, abdominal distention, diarrhoea, and flatulence, amongst others. In addition, it has recently been implicated in the pathophysiology of stunting, a disease that affects millions of children worldwide. Risk factors such as acid-suppressive therapies, alterations in gastrointestinal motility and anatomy, as well as impoverished conditions, have been shown to predispose children to SIBO. SIBO can be diagnosed via culture-dependant or culture-independent approaches. SIBO's epidemiology is limited due to the lack of uniformity and consensus of its diagnostic criteria, as well as the paucity of literature available. Antibiotics remain the first-line treatment option for SIBO, although emerging modalities such as probiotics and diet manipulation could also have a role. Herein, we present a state-of-the-art-review which aims to comprehensively outline the most current information on SIBO in children, with particular emphasis on the gut microbiota.
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Affiliation(s)
- David Avelar Rodriguez
- Pediatric Gastroenterology and Nutrition Unit, National Institute of Pediatrics, Mexico City, Mexico
| | | | | | | | - Eamonn Martin Quigley
- Lynda K. and David M. Underwood Center for Digestive Disorders, Houston Methodist Hospital, Houston, TX, United States
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17
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Zhao Y, Zhang J, Han X, Fan S. Total body irradiation induced mouse small intestine senescence as a late effect. JOURNAL OF RADIATION RESEARCH 2019; 60:442-450. [PMID: 31165161 PMCID: PMC6641339 DOI: 10.1093/jrr/rrz026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/08/2019] [Indexed: 05/10/2023]
Abstract
Radiation can induce senescence in many organs and tissues; however, it is still unclear how radiation stimulates senescence in mouse small intestine. In this study, we use the bone marrow transplantation mouse model to explore the late effects of total body irradiation on small intestine. Our results showed that almost all of the body hairs of the irradiated mice were white (which is an indication of aging) 10 months after the exposure to radiation. Furthermore, compared with the age-matched control mice, there were more SA-β-galactosidase (SA-β-gal)-positive cells and an upregulation of p16 and p21 in 8 Gy-irradiated mice intestinal crypts, indicating that radiation induced senescence in the small intestine. Intestinal bacterial flora profile analysis showed that the diversity of the intestinal bacterial flora decreased in irradiated mice; in addition it showed that the principal components of the irradiated and control mice differed: there was increased abundance of Bacteroidia and a decreased abundance of Clostridia in irradiated mice. To explore the underlying mechanism, an RNA-sequence was executed; the results suggested that pancreatic secretion, and the digestion and absorption of proteins, carbohydrates, fats and vitamins were damaged in irradiated mice, which may be responsible for the body weight loss observed in irradiated mice. In summary, our study suggested that total body irradiation may induce senescence in the small intestine and damage the health status of the irradiated mice.
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Affiliation(s)
- Yu Zhao
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Peking Union Medical College and Chinese Academy of Medical Science, Tianjin, China
| | - Junling Zhang
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Peking Union Medical College and Chinese Academy of Medical Science, Tianjin, China
- Corresponding author. Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Peking Union Medical College and Chinese Academy of Medical Science, Tianjin 300192, China. Tel: +8622-85682291; Fax: +8622-85683033; (J. Zhang)
| | - Xiaodan Han
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Peking Union Medical College and Chinese Academy of Medical Science, Tianjin, China
| | - Saijun Fan
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Peking Union Medical College and Chinese Academy of Medical Science, Tianjin, China
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18
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Madden SK, Flanagan KL, Jones G. How lifestyle factors and their associated pathogenetic mechanisms impact psoriasis. Clin Nutr 2019; 39:1026-1040. [PMID: 31155371 DOI: 10.1016/j.clnu.2019.05.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 04/11/2019] [Accepted: 05/06/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUNDS AND AIMS Psoriasis is a skin disorder affecting approximately 2-3% of the global population. While research has revealed a strong genetic component, there are few studies exploring the extent to which lifestyle factors influence psoriasis pathogenesis. The aim of this review was to describe the role of lifestyle factors as both a potential cause and treatment for psoriasis. The review also examines the underlying mechanisms through which these lifestyle factors may operate. METHODS This narrative review aims to incorporate current knowledge relating to both lifestyle and pathogenetic factors that contribute to and alleviate psoriasis presentation. Studies reporting the effect of an inflammatory diet and potential dietary benefits are reported, as well as insights into the effects of stress, smoking and alcohol, insulin resistance and exercise. RESULTS Poor nutrition and low Omega 3 fatty acid intake, likely combined with fat malabsorption caused by gut dysbiosis and systemic inflammation, are associated with psoriasis. The data strongly suggest that improvements to disease severity can be made through dietary and lifestyle interventions and increased physical activity. Less conclusive, although worthy of mention, is the beneficial effect of bile acid supplementation. CONCLUSIONS Lifestyle interventions are a promising treatment for psoriasis and its associated co-morbidities. However, gaps and inadequacies exist within the literature, e.g. methodology, absence of a unified scoring system, lack of controlled clinical data and lack of studies without simultaneous usage of biologics or alternative therapies. Future directions should focus on high quality cohort studies and clinical trials.
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Affiliation(s)
- Seonad K Madden
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Australia.
| | - Katie L Flanagan
- School of Medicine, College of Health and Medicine, University of Tasmania, Australia; School of Health & Biomedical Science, Royal Melbourne Institute of Technology, Australia; Infectious Diseases Service, Launceston General Hospital, Australia; Dept. of Immunology and Pathology, Monash University, Australia
| | - Graeme Jones
- Menzies Institute for Medical Research, University of Tasmania, Australia
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19
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Abstract
Differential diagnosis and management of enteropathies found in the context of seronegative villous atrophy (VA) are still a clinical challenge. Although seronegative coeliac disease may be the most frequent cause of serology-negative VA, other conditions must be taken into account in the differential diagnosis of seronegative VA. The rarity of these enteropathies with frequent overlapping of histological features may result in misclassification of such patients as affected by a seronegative or a refractory form of coeliac disease with consequent inappropriate treatments and long-term morbidity. The aim of this review is to summarize the current knowledge and to provide an evidence base and practical algorithmic approach for the investigation and management of seronegative VA.
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20
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Abstract
Celiac disease features duodenal intraepithelial lymphocytosis with or without villous atrophy. Lymphocytosis without villous atrophy will be proven to represent celiac disease in 10% to 20% of cases. The differential diagnosis is broad: Helicobacter pylori gastritis, NSAID injury and bacterial overgrowth are considerations. Lymphocytosis with villous atrophy is very likely to be celiac disease, but there are mimics to consider, including collagenous sprue, tropical sprue, drug injury, and common variable immunodeficiency. Histologic clues to a diagnosis other than celiac disease include paucity of plasma cells, excess of neutrophils, granulomas, and relative paucity of intraepithelial lymphocytes.
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Affiliation(s)
- Thomas C Smyrk
- Department of Pathology, Mayo Clinic, Hilton 11, 200 First Street Southwest, Rochester, MN 55902, USA.
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21
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Clinical and Histologic Mimickers of Celiac Disease. Clin Transl Gastroenterol 2017; 8:e114. [PMID: 28817113 PMCID: PMC5587842 DOI: 10.1038/ctg.2017.41] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 07/02/2017] [Indexed: 02/07/2023] Open
Abstract
Celiac disease is an autoimmune disorder of the small bowel, classically associated with diarrhea, abdominal pain, and malabsorption. The diagnosis of celiac disease is made when there are compatible clinical features, supportive serologic markers, representative histology from the small bowel, and response to a gluten-free diet. Histologic findings associated with celiac disease include intraepithelial lymphocytosis, crypt hyperplasia, villous atrophy, and a chronic inflammatory cell infiltrate in the lamina propria. It is important to recognize and diagnose celiac disease, as strict adherence to a gluten-free diet can lead to resolution of clinical and histologic manifestations of the disease. However, many other entities can present with clinical and/or histologic features of celiac disease. In this review article, we highlight key clinical and histologic mimickers of celiac disease. The evaluation of a patient with serologically negative enteropathy necessitates a carefully elicited history and detailed review by a pathologist. Medications can mimic celiac disease and should be considered in all patients with a serologically negative enteropathy. Many mimickers of celiac disease have clues to the underlying diagnosis, and many have a targeted therapy. It is necessary to provide patients with a correct diagnosis rather than subject them to a lifetime of an unnecessary gluten-free diet.
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22
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Lerner A, Arleevskaya M, Schmiedl A, Matthias T. Microbes and Viruses Are Bugging the Gut in Celiac Disease. Are They Friends or Foes? Front Microbiol 2017; 8:1392. [PMID: 28824555 PMCID: PMC5539691 DOI: 10.3389/fmicb.2017.01392] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/10/2017] [Indexed: 12/17/2022] Open
Abstract
The links between microorganisms/viruses and autoimmunity are complex and multidirectional. A huge number of studies demonstrated the triggering impact of microbes and viruses as the major environmental factors on the autoimmune and inflammatory diseases. However, growing evidences suggest that infectious agents can also play a protective role or even abrogate these processes. This protective crosstalk between microbes/viruses and us might represent a mutual beneficial equilibrium relationship between two cohabiting ecosystems. The protective pathways might involve post-translational modification of proteins, decreased intestinal permeability, Th1 to Th2 immune shift, induction of apoptosis, auto-aggressive cells relocation from the target organ, immunosuppressive extracellular vesicles and down regulation of auto-reactive cells by the microbial derived proteins. Our analysis demonstrates that the interaction of the microorganisms/viruses and celiac disease (CD) is always a set of multidirectional processes. A deeper inquiry into the CD interplay with Herpes viruses and Helicobacter pylori demonstrates that the role of these infections, suggested to be potential CD protectors, is not as controversial as for the other infectious agents. The outcome of these interactions might be due to a balance between these multidirectional processes.
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Affiliation(s)
- Aaron Lerner
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of TechnologyHaifa, Israel.,Department of Research, AESKU.KIPP InstituteWendelsheim, Germany
| | - Marina Arleevskaya
- Central Research Laboratory, Kazan State Medical Academy KazanKazan, Russia
| | - Andreas Schmiedl
- Department of Research, AESKU.KIPP InstituteWendelsheim, Germany
| | - Torsten Matthias
- Department of Research, AESKU.KIPP InstituteWendelsheim, Germany
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23
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Ponziani FR, Gerardi V, Gasbarrini A. Diagnosis and treatment of small intestinal bacterial overgrowth. Expert Rev Gastroenterol Hepatol 2016; 10:215-27. [PMID: 26636484 DOI: 10.1586/17474124.2016.1110017] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A huge number of bacteria are hosted in the gastrointestinal tract, following a gradient increasing towards the colon. Gastric acid secretion and intestinal clearance provide the qualitative and quantitative partitioning of intestinal bacteria; small intestinal bacteria overgrowth (SIBO) occurs when these barrier mechanisms fail. Diagnosis of SIBO is challenging due to the low specificity of symptoms, the frequent association with other diseases of the gastrointestinal tract and the absence of optimal objective diagnostic tests. The therapeutic approach to SIBO is oriented towards resolving predisposing conditions, and is supported by antibiotic treatment to restore the normal small intestinal microflora and by modifications of dietary habits for symptomatic relief. In the near future, metagenomics and metabolomics will help to overcome the uncertainties of SIBO diagnosis and the pitfalls of therapeutic management, allowing the design of a personalized strategy based on the direct insight into the small intestinal microbial community.
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Affiliation(s)
| | - Viviana Gerardi
- a Internal Medicine and Gastroenterology , Agostino Gemelli Hospital , Rome , Italy
| | - Antonio Gasbarrini
- a Internal Medicine and Gastroenterology , Agostino Gemelli Hospital , Rome , Italy
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24
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Enko D, Halwachs-Baumann G, Stolba R, Mangge H, Kriegshäuser G. Refining small intestinal bacterial overgrowth diagnosis by means of carbohydrate specificity: a proof-of-concept study. Therap Adv Gastroenterol 2016; 9:265-72. [PMID: 27134657 PMCID: PMC4830096 DOI: 10.1177/1756283x15621231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Diagnosis of small intestinal bacterial overgrowth (SIBO) remains challenging. This study aimed at proving the diagnostic concept of carbohydrate-specific SIBO (cs-SIBO) using glucose, fructose and sorbitol hydrogen (H2)/methane (CH4) breath testing (HMBT). METHODS In this study 125 patients referred to our outpatient clinic for SIBO testing were included. All individuals underwent glucose (50 g), fructose (25 g) and sorbitol (12.5 g) HMBT at 3 consecutive days. Patients with cs-SIBO (i.e. early H2/CH4 peak) were given rifaximin (600 mg/day) in a 10-day treatment. HMBT results were reassessed in a subset of patients 3-6 months after antibiotic therapy. In view of cs-SIBO diagnosis, agreements between HMBT results obtained for different sugars were calculated using Cohen's kappa (κ) with 95% confidence intervals (CIs). RESULTS A total of 59 (47.2%) patients presented an early H2/CH4 peak with one or more sugars. Among these, 21 (16.8%), 10 (8.0%) and 7 (5.6%) individuals had a positive HMBT result with either glucose, fructose or sorbitol, respectively. Another 21 (16.8%) patients with a positive glucose HMBT result were also found positive with an early H2/CH4 peak obtained after ingestion of fructose and/or sorbitol. Fair agreement was observed between glucose and fructose (κ = 0.26, p = 0.0018) and between glucose and sorbitol (κ = 0.18, p = 0.0178) HMBT results. Slight agreement was observed between fructose and sorbitol (κ = 0.03, p = 0.6955) HMBT results only. Successful antibiotic therapy with rifaximin could be demonstrated in 26/30 (86.7%) of patients as indicated by normal HMBT results and symptom remission. CONCLUSIONS Combined glucose, fructose and sorbitol HMBT has the potential to optimize cs-SIBO diagnosis. Furthermore, the majority of patients with cs-SIBO seem to benefit from rifaximin therapy regardless of its carbohydrate specificity.
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Affiliation(s)
- Dietmar Enko
- Institute of Clinical Chemistry and Laboratory Medicine and Department of Gastroenterology, General Hospital Steyr, Sierningerstraße 170, 4400 Steyr, Austria
| | | | - Robert Stolba
- Institute of Clinical Chemistry and Laboratory Medicine, General Hospital Steyr, Steyr, Austria
| | - Harald Mangge
- Clinical Institute of Medical and Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Gernot Kriegshäuser
- Institute of Clinical Chemistry and Laboratory Medicine and Department of Gastroenterology, General Hospital Steyr, Steyr, Austria
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25
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Abstract
Tropical sprue (TS) is a malabsorption syndrome of presumed infectious aetiology that affects residents of (or visitors to) the tropics. The histological changes of TS are similar to those of coeliac disease, with increased intraepithelial lymphocytes being central to both. Unlike in coeliac disease, however, a completely flat small bowel biopsy is uncommon in TS. TS typically involves the terminal ileum, whereas coeliac disease does not. Small intestinal bacterial overgrowth (SIBO) has been defined as an increase in number and/or a change in the type of bacteria in the upper gut. Conditions that predispose to SIBO are largely those that decrease or interfere with small bowel motility. The mucosal histology is variable, and may include modest villous blunting accompanied by increased lamina propria and epithelial inflammation. Autoimmune enteropathy (AE) is a family of rare diseases that share common themes such as immunodeficiency states and autoantibodies. AE cases typically have marked villous atrophy similar to that in fully developed coeliac disease, but they lack the intense surface epithelial lymphocytosis. Apoptosis and lymphocyte infiltration at the base of the crypts, crypt abscesses and cryptitis are also seen. Patients with anti-goblet cell antibodies can have a lack of goblet cells, endocrine cells, and Paneth cells.
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26
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Davidovics ZH, Carter BA, Luna RA, Hollister EB, Shulman RJ, Versalovic J. The Fecal Microbiome in Pediatric Patients With Short Bowel Syndrome. JPEN J Parenter Enteral Nutr 2015; 40:1106-1113. [PMID: 26059898 DOI: 10.1177/0148607115591216] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 05/18/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Changes in the intestinal microbiome of patients with short bowel syndrome (SBS) are thought to significantly affect clinical outcome. These changes may not only delay enteral diet advancement but may also predispose patients to bacterial translocation, bacteremia, and liver disease. Patients with SBS are thought to be more susceptible to changes in gut microbial communities due to intestinal dysmotility and/or lack of anatomic safeguards such as the ileocecal valve. MATERIALS AND METHODS We analyzed the bacterial composition of 21 fecal specimens from 9 children with SBS and 8 healthy children ages 4 months to 8 years by 16S ribosomal RNA gene sequencing. The sequences were quality filtered and analyzed using QIIME, the Ribosomal Database Project Classifier, and the randomForest supervised learning algorithm. RESULTS The fecal microbiome of patients with SBS is different from that of healthy controls. Stool from patients with SBS had a significantly greater abundance of the bacterial classes Gammaproteobacteria and Bacilli. Stool from patients with SBS who experienced increased stool frequency tended to have increased abundance of Lactobacillus (P = .057) and decreased abundance of Ruminococcus. CONCLUSION This study shows that the fecal microbiome of patients with SBS is significantly different from that of healthy controls when analyzed by 16S metagenomics. Differences in the composition and function of gut microbiomes in children with SBS may affect bowel physiology, and these findings may provide new opportunities for intestinal rehabilitation and clinical management.
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Affiliation(s)
- Zev H Davidovics
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Division of Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, Texas
| | - Beth A Carter
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Division of Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, Texas
| | - Ruth Ann Luna
- Texas Children's Microbiome Center, Houston, Texas.,Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas.,Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Emily B Hollister
- Texas Children's Microbiome Center, Houston, Texas.,Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas.,Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Robert J Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Division of Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, Texas.,Children's Nutrition Research Center, Houston, Texas
| | - James Versalovic
- Texas Children's Microbiome Center, Houston, Texas .,Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas.,Department of Pathology, Texas Children's Hospital, Houston, Texas
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27
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Miazga A, Osiński M, Cichy W, Żaba R. Current views on the etiopathogenesis, clinical manifestation, diagnostics, treatment and correlation with other nosological entities of SIBO. Adv Med Sci 2015; 60:118-24. [PMID: 25657082 DOI: 10.1016/j.advms.2014.09.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 09/24/2014] [Accepted: 09/26/2014] [Indexed: 02/06/2023]
Abstract
Small intestinal bacterial overgrowth (SIBO) is a disease of great clinical and socioeconomic importance caused by an excessive amount of bacteria in the upper alimentary tract. Physiological microbiota are replaced by pathogenic bacteria mainly from large intestine, which is called dysbacteriosis. SIBO disturbs digestion and absorption in the alimentary tract, which seems to cause inflammation. SIBO affects the morphology and function of the digestive system and causes systemic complications (e.g. osteoporosis, macrocytic anemia). Inflammation interferes with gene expression responsible for producing and secreting mucus, therefore, a correlation between SIBO and cystic fibrosis, irritable bowel syndrome and chronic abdominal pain are postulated. All conditions leading to bacterial growth such as congenital and anatomical abnormalities in the digestive tract, motility disorder or immunological deficits are risk factors of SIBO. A typical clinical manifestation of SIBO comprises meteorism, enterectasia, abdominal discomfort and diarrhea. Diagnostic procedures such as glucose, lactulose, methane, 13C mixed triglyceride breath tests are being used in diagnosing SIBO.
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28
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Bazett M, Honeyman L, Stefanov AN, Pope CE, Hoffman LR, Haston CK. Cystic fibrosis mouse model-dependent intestinal structure and gut microbiome. Mamm Genome 2015; 26:222-34. [PMID: 25721416 DOI: 10.1007/s00335-015-9560-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 02/13/2015] [Indexed: 01/15/2023]
Abstract
Mice with a null mutation in the cystic fibrosis transmembrane conductance regulator (Cftr) gene show intestinal structure alterations and bacterial overgrowth. To determine whether these changes are model-dependent and whether the intestinal microbiome is altered in cystic fibrosis (CF) mouse models, we characterized the ileal tissue and intestinal microbiome of mice with the clinically common ΔF508 Cftr mutation (FVB/N Cftr(tm1Eur)) and with Cftr null mutations (BALB/c Cftr(tm1UNC) and C57BL/6 Cftr(tm1UNC)). Intestinal disease in 12-week-old CF mice, relative to wild-type strain controls, was measured histologically. The microbiome was characterized by pyrosequencing of the V4-V6 region of the 16S rRNA gene and intestinal load was measured by RT-PCR of the 16S rRNA gene. The CF-associated increases in ileal crypt to villus axis distention, goblet cell hyperplasia, and muscularis externa thickness were more severe in the BALB/c and C57BL/6 Cftr(tm1UNC) mice than in the FVB/N Cftr(tm1Eur) mice. Intestinal bacterial load was significantly increased in all CF models, compared to levels in controls, and positively correlated with circular muscle thickness in CF, but not wild-type, mice. Microbiome profiling identified Bifidobacterium and groups of Lactobacillus to be of altered abundance in the CF mice but overall bacterial frequencies were not common to the three CF strains and were not correlative of major histological changes. In conclusion, intestinal structure alterations, bacterial overgrowth, and dysbiosis were each more severe in BALB/c and C57BL/6 Cftr(tm1UNC) mice than in the FVB/N Cftr(tm1Eur) mice. The intestinal microbiome differed among the three CF mouse models.
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Affiliation(s)
- Mark Bazett
- Meakins-Christie Laboratories, Departments of Medicine and Human Genetics, McGill University, 3626 St. Urbain, Montreal, QC, H2X 2P2, Canada
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29
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Abstract
Altered gastrointestinal (GI) motility is seen in many pathological conditions. Reduced motility is one of the risk factors for development of a small intestinal bacterial overgrowth (SIBO). Hypothyroidism is associated with altered GI motility. The aim of this article was to study the link between hypothyroidism, altered GI motility and development of SIBO. Published literature was reviewed to study the association of altered GI motility, SIBO and hypothyroidism. Altered GI motility leads to SIBO. SIBO is common in patients with hypothyroidism. Patients with chronic GI symptoms in hypothyroidism should be evaluated for the possibility of SIBO. Both antibiotics and probiotics have been studied and found to be effective in management of SIBO.
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Affiliation(s)
- Anant D. Patil
- Freelance Consultant, Medical Communication and Training, India
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30
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Abstract
While celiac disease is the most common cause of villous remodeling and intraepithelial lymphocytosis in the proximal small bowel, there are many entities that can mimic its histologic appearance. The purpose of this review is to discuss normal small bowel histology and the differential diagnosis of celiac disease. Approaches to evaluate increased intraepithelial lymphocytes are presented, followed by a detailed discussion of the pathology of celiac disease. Particular emphasis is given to those conditions that cause intraepithelial lymphocytosis in the setting of preserved villous architecture, although other important entities, such as peptic injury, idiopathic inflammatory bowel disease, medication injury, eosinophilic (allergic) gastroenteritis, autoimmune enteropathy, common variable immunodeficiency, and infections are also reviewed.
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Affiliation(s)
- Rish K Pai
- Department of Anatomic Pathology, Robert J Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio 44195.
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31
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Harrison E, Hayes S, Howell L, Lal S. All that glitters is not always gold. BMJ Case Rep 2014; 2014:bcr-2013-201963. [PMID: 24515230 DOI: 10.1136/bcr-2013-201963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Biopsies from the second part of the duodenum are routinely performed in patients with unintentional weight loss. When villous atrophy and an increased intraepithelial lymphocytosis are detected, the commonest cause of it is coeliac disease. Severe villous atrophy with increased intraepithelial lymphocytosis (Marsh IIIc) is highly specific for coeliac disease. However, coeliac disease with this presentation is very rare. Milder abnormalities such as Marsh I-II (microscopic enteritis) and Marsh IIIa are not specific for coeliac disease and could occur in other conditions like those listed in the discussion. We present the case of a 74-year-old woman who, after being diagnosed with seronegative coeliac disease, failed to improve on a gluten-free diet. We discuss the differential diagnosis of coeliac disease and the possible alternative causes for villous blunting, paying particular attention to the diagnosis of small intestinal bacterial overgrowth.
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Affiliation(s)
- E Harrison
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
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Shah SC, Day LW, Somsouk M, Sewell JL. Meta-analysis: antibiotic therapy for small intestinal bacterial overgrowth. Aliment Pharmacol Ther 2013; 38:925-34. [PMID: 24004101 PMCID: PMC3819138 DOI: 10.1111/apt.12479] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 05/26/2013] [Accepted: 08/16/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Small intestinal bacterial overgrowth (SIBO) is an under-recognised diagnosis with important clinical implications when untreated. However, the optimal treatment regimen remains unclear. AIM To perform a systematic review and meta-analysis comparing the clinical effectiveness of antibiotic therapies in the treatment of symptomatic patients with documented SIBO. METHODS Four databases were searched to identify clinical trials comparing effectiveness of: (i) different antibiotics, (ii) different doses of the same antibiotic and (iii) antibiotics compared with placebo. Data were independently extracted according to predetermined inclusion and exclusion criteria. Study quality was independently assessed. The primary outcome was normalisation of post-treatment breath testing. The secondary outcome was post-treatment clinical response. RESULTS Of 1356 articles identified, 10 met inclusion criteria. Rifaximin was the most commonly studied antibiotic (eight studies) with overall breath test normalisation rate of 49.5% (95% confidence interval, CI 44.0-55.1) (44.0%-55.1%) then (46.7%-55.5%), then (4.6%-17.8%). Antibiotic efficacy varied by antibiotic regimen and dose. Antibiotics were more effective than placebo, with a combined breath test normalisation rate of 51.1% (95% CI 46.7-55.5) for antibiotics compared with 9.8% (95% CI 4.6-17.8) for placebo. Meta-analysis of four studies favoured antibiotics over placebo for breath test normalisation with an odds ratio of 2.55 (95% CI 1.29-5.04). Clinical response was heterogeneously evaluated among six studies, but tended to correlate with breath test normalisation. CONCLUSIONS Antibiotics appear to be more effective than placebo for breath test normalisation in patients with symptoms attributable to SIBO, and breath test normalisation may correlate with clinical response. Studies were limited by modest quality, small sample size and heterogeneous design. Additional higher quality clinical trials of SIBO therapy are warranted.
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Affiliation(s)
- Shailja C. Shah
- Department of Medicine, University of California, San Francisco, CA
| | - Lukejohn W. Day
- Center for Innovation in Access and Quality, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA,GI Health, Outcomes, Policy and Economics (GI-HOPE) Program, Division of Gastroenterology, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Ma Somsouk
- GI Health, Outcomes, Policy and Economics (GI-HOPE) Program, Division of Gastroenterology, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Justin L. Sewell
- Center for Innovation in Access and Quality, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA,GI Health, Outcomes, Policy and Economics (GI-HOPE) Program, Division of Gastroenterology, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA
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33
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Erkrankungen und Therapieformen des unteren Gastrointestinaltrakts. PÄDIATRISCHE GASTROENTEROLOGIE, HEPATOLOGIE UND ERNÄHRUNG 2013. [PMCID: PMC7498818 DOI: 10.1007/978-3-642-24710-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Duodenalatresien sind Hemmungsfehlbildungen und können proximal oder distal der Papilla Vateri entstehen, wobei die präpapillären Obstruktionen selten sind. Grundsätzlich kann zwischen einer Membranatresie und einer Defektatresie unterschieden werden. Die Unterscheidung beruht nicht nur auf embryologischen Gesichtspunkten, sondern hat auch eine klinische Bedeutung: Bei der Membranatresie kann die quergestellte, partiell offene oder geschlossene Membran weit in den distalen Duodenalanteil reichen („Windsackphänomen“), was zu diagnostischen und auch intraoperativen Problemen führen kann. Ein Pancreas anulare findet sich bei etwa 20 % aller Patienten mit Duodenalatresie.
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Steegenga WT, de Wit NJ, Boekschoten MV, Ijssennagger N, Lute C, Keshtkar S, Bromhaar MMG, Kampman E, de Groot LC, Muller M. Structural, functional and molecular analysis of the effects of aging in the small intestine and colon of C57BL/6J mice. BMC Med Genomics 2012; 5:38. [PMID: 22929163 PMCID: PMC3534289 DOI: 10.1186/1755-8794-5-38] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 08/17/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND By regulating digestion and absorption of nutrients and providing a barrier against the external environment the intestine provides a crucial contribution to the maintenance of health. To what extent aging-related changes in the intestinal system contribute to the functional decline associated with aging is still under debate. METHODS Young (4 M) and old (21 M) male C57BL/6J mice were fed a control low-fat (10E%) or a high-fat diet (45E%) for 2 weeks. During the intervention gross energy intake and energy excretion in the feces were measured. After sacrifice the small and large intestine were isolated and the small intestine was divided in three equal parts. Swiss rolls were prepared of each of the isolated segments for histological analysis and the luminal content was isolated to examine alterations in the microflora with 16S rRNA Q-PCR. Furthermore, mucosal scrapings were isolated from each segment to determine differential gene expression by microarray analysis and global DNA methylation by pyrosequencing. RESULTS Digestible energy intake was similar between the two age groups on both the control and the high-fat diet. Microarray analysis on RNA from intestinal scrapings showed no marked changes in expression of genes involved in metabolic processes. Decreased expression of Cubilin was observed in the intestine of 21-month-old mice, which might contribute to aging-induced vitamin B12 deficiency. Furthermore, microarray data analysis revealed enhanced expression of a large number of genes involved in immune response and inflammation in the colon, but not in the small intestine of the 21-month-old mice. Aging-induced global hypomethylation was observed in the colon and the distal part of the small intestine, but not in the first two sections of the small intestine. CONCLUSION In 21-month old mice the most pronounced effects of aging were observed in the colon, whereas very few changes were observed in the small intestine.
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Affiliation(s)
- Wilma T Steegenga
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands.
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Lugli A. Archaeology dig into the duodenal biopsy. Dig Liver Dis 2010; 42:470-1. [PMID: 20471923 DOI: 10.1016/j.dld.2010.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 04/22/2010] [Indexed: 12/11/2022]
Affiliation(s)
- Alessandro Lugli
- Gastrointestinal Pathology Division, Institute of Pathology, University Hospital of Basel, Basel, Switzerland.
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