Terry D. Bolin

Luminal Bacteria and Small-Intestinal Permeability

BACKGROUND The influence of luminal bacteria on small-intestinal permeability has not been fully assessed. This study addressed this issue. METHODS Thirty-four subjects (mean age 64 years; range 22-95 years) were investigated for possible small-intestinal bacterial overgrowth (SIBO) with culture of a small-intestinal aspirate. A lactulose/mannitol small-intestinal permeability test was performed, small-intestinal histology assessed and serum vitamin B12 concentrations measured in all subjects. Permeability was also assessed in a control group of 34 asymptomatic volunteers. RESULTS Urinary lactulose/mannitol ratios were significantly increased in subjects with SIBO with colonic-type flora (P < 0.0005), even in the absence of villous atrophy. Urinary lactulose/mannitol ratios were increased in this group due to significantly increased urinary lactulose concentrations (P < 0.0005) rather than reduced urinary mannitol levels, after correcting for inter-subject variations in renal function. Counts of intraepithelial lymphocytes of CD8 phenotype were significantly increased in this group (P = 0.003). Although a significant correlation was found between intraepithelial lymphocyte counts and small-intestinal permeability overall (P < 0.002), these counts were not significantly different in subjects with SIBO with colonic-type flora whose permeability values were < or = > 0.028, the upper limit of normal in asymptomatic controls. Serum vitamin B12 concentrations did not differ significantly between groups (P > 0.5). Ageing did not independently influence small-intestinal permeability (P > 0.5). CONCLUSIONS Small-intestinal permeability is increased in subjects with SIBO with colonic-type bacteria. This effect is independent of ageing and not mediated by vitamin B12 deficiency. Although counts of intraepithelial lymphocytes of CD8 phenotype are increased in this disorder, it is also unlikely that these cells play an important causative role in this process. Routine light microscopic assessment underestimates the prevalence of small-intestinal functional disturbance in this disorder.

Appendicectomy as a therapy for ulcerative proctitis.

OBJECTIVES:Available data regarding whether appendicectomy performed after the onset of ulcerative colitis can modulate its clinical course are currently limited. This study aimed at addressing this issue.METHODS:In this study, we report a prospective case series of 30 adult patients (median age 35 years, range 17–70 years; male/female: 11/19) with ulcerative proctitis (median duration of symptoms 5 years, range 8 months to 30 years; median Simple Clinical Colitis Activity Index score 9, range 7–12), who underwent appendicectomy in the absence of any history suggestive of previous appendicitis. Patients were subsequently followed up clinically with the assessment of the Simple Clinical Colitis Activity Index for a median of 14 months (range 9–32 months).RESULTS:After appendicectomy, the clinical activity index improved significantly to a median score of 2 (range 0–12) (P<0.0005). The improvement in the clinical activity index occurred in 27 of 30 (90%) patients, whereas the index remained unchanged in the remaining 3 of 30 (10%) patients. Furthermore, 12 of 30 (40%) patients experienced a complete resolution of symptoms (clinical activity index score of 0) by 12 months, such that all pharmacological treatments could be withdrawn, and have remained in remission off all previous treatments for a median 9 months (range 6–25 months). The time required for a complete resolution of symptoms post appendicectomy ranged from 1 to 12 months (median 3 months) (Kaplan–Meier analysis). None of the clinical or histological factors analyzed were significantly associated with post-appendicectomy outcome.CONCLUSIONS:This case series, the largest reported so far, provides rationale for controlled trials to properly evaluate the possible role of appendicectomy in the treatment of ulcerative proctitis.

Heartburn: Community perceptions

Background and Aims : To determine the prevalence of heartburn in the Australian community, and document factors precipitating it and medications used in treatment.

Small intestinal mucosal immunity and morphometry in luminal overgrowth of indigenous gut flora.

OBJECTIVE:The aim of this study was to investigate the separate effects of indigenous oropharyngeal- and colonic-type flora on small intestinal mucosal immunity and morphometry in small intestinal bacterial overgrowth (SIBO).METHODS:A duodenal aspirate and random biopsies of underlying mucosa were obtained from 52 adult subjects (age range, 18–90 yr; median, 60 yr) without disorders that may otherwise disturb small intestinal histology or mucosal immunity. Villus height, crypt depth, villus/crypt ratios, counts of intraepithelial lymphocytes (IELs) and lamina propria total mononuclear cells, IgA, IgM, and IgG plasma cells, mast cells, and B and T lymphocytes were determined in relation to the presence or absence of SIBO and the nature of the overgrowth flora in all subjects. CD4+ve and CD8+ve T-cell counts were determined in 24 subjects.RESULTS:SIBO was present in 26 of 52 (50%) subjects. Overgrowth flora included colonic-type bacteria in 20 subjects and oropharyngeal-type flora alone in 6 subjects. Lamina propria IgA plasma cell counts were significantly increased in subjects with SIBO, irrespective of whether the overgrowth flora comprised oropharyngeal-type flora alone or included colonic-type bacteria. Neither villus height, crypt depth, villus/crypt ratios, nor total or other mononuclear cell counts in lamina propria differed significantly between subjects with and without SIBO, irrespective of the nature of the overgrowth flora. IEL counts were significantly higher than in culture-negative subjects only when the overgrowth flora included colonic-type bacteria. Even then, IEL counts were within a range currently considered normal. A significant, inverse correlation between advancing age and IEL counts became apparent after adjusting for the effect of SIBO of colonic-type flora.CONCLUSIONS:SIBO of oropharyngeal- and colonic-type flora are associated with differing disturbances of local duodenal mucosa. Nonetheless, these would not be readily apparent during routine histological assessment. Old age independently influences duodenal IEL counts.

Primary Lactase Deficiency: Genetic or Acquired?

SummaryFrom a critical review of the literature, it would appear that, in animals, intestinal lactase is an adaptive enzyme, with adaptation occurring in 5–8 weeks. In man, short-term attempts at adaptation have not been successful, although a fall in lactase activity or lactose absorption has been found after substrate withdrawal in some subjects.The expression of any biologic phenomenon is related to the sum of the effects of numerous genetic or environmental factors. It would seem that in the Chinese, at least, and presumably in other ethnic groups, the major factor influencing lactase activity is the dietary content of lactose. Adaptation of intestinal lactase occurs, provided milk intake continues at the high level found in most Western European populations, beyond the normal age of weaning. If lactose intake is reduced at or shortly after weaning, then lactase activity appears to decline over a period of years. This is analogous to the postweaning decline in lactase activity found in animals.

A Pattern of Breath Hydrogen Excretion Suggesting Small Bowel Bacterial Overgrowth in Burmese Village Children

Breath hydrogen tests (BHTs) were performed on 340 Burmese village children aged 1–59 months. Normalization (correction of breath H2 values to a constant mean O2 level) eliminated the variations in H2 levels due to sleep, storage temperature, or duration of storage. After a 10 g lactulose test meal, 145 (42.6%) children produced <10 ppm H2 above basal values (non-H2 producers). Of 195 H2 producers, a pattern of breath hydrogen excretion suggesting small bowel bacterial overgrowth (SBBO)—recognized as a transient peak at the 20, 40, or 60 min breath samples following the lactulose test meal and distinguishable from the later colonic peak— was observed in 53 (27.2%), being significantly more frequent in male children, and exhibiting an age-prevalence pattern similar to that of acute childhood diarrhea in these villages. Diarrhea did not alter the state of H2 production (non-H2 producers remain non-H2 producers, and H2 producers remain H2 producers) although the magnitude of peak breath H2 changed.

Small intestinal bacterial overgrowth and the irritable bowel syndrome

for overgrowth. Secondly, Mishkinet al. principally tested subjects with functional dyspepsia. Although a proportion of their subjects also had IBS, we included patients on the basis of their meeting only the criteria for IBS. Because functional dyspepsia represents a heterogeneous collection of conditions including problems such as gastroesophageal reflux disease (3), the prevalence of SIBO in this group of patients may well be lower than that in IBS alone. What is most interesting is that, in addition to Mishkin et al. (1), Galatolaet al. (4) report a positiveC-xylose breath test in up to 56% of subjects with IBS. The difference in prevalence between all three studies (1, 2, 4) could be based on the technique used. However, in our study we took this one step further by demonstrating that normalization of the abnormal breath test finding with antibiotics was associated with symptomatic improvement in IBS. This point is very important in the argument that the breath test findings do indeed represent overgrowth (as opposed to a false positive test result) because clinical outcomes improve and are linked to the abnormality of the test.

Fasting breath hydrogen concentrations in gastric and small-intestinal bacterial overgrowth

BACKGROUND Although elevated fasting breath hydrogen concentrations have been reported in small-intestinal bacterial overgrowth, this diagnosis has been presumptive or based on definitions that vary from study to study. The influence of gastric bacterial overgrowth and gastroduodenal pH has not been documented. Conflicting evidence exists as to the reproducibility of breath hydrogen measurements. METHODS Forty-two subjects underwent culture of gastric and duodenal aspirates. The pH was measured by indicator paper. Paired fasting breath hydrogen concentrations were measured by gas chromatography within 7 days of endoscopy. RESULTS Paired fasting breath hydrogen concentrations differed in terms of normality or abnormality in 21% of subjects. Paired concentrations correlated significantly in overgrowth but not in culture-negative subjects. Sensitivity for bacterial overgrowth was 4-29%, and specificity 71-100%. No correlation with gastroduodenal pH was found. CONCLUSIONS The clinical relevance of a single fasting breath hydrogen concentration is limited. The efficacy of paired measurements for gastric or small-intestinal bacterial overgrowth is poor.

Evaluation of the rice breath hydrogen test for small intestinal bacterial overgrowth

OBJECTIVES:The aims of this study were 1) to document the sensitivity, specificity, and predictive values of the rice breath hydrogen test for small intestinal bacterial overgrowth; 2) to determine the possible influence of concurrent gastric bacterial overgrowth and gastroduodenal pH on the efficacy of this test; and 3) to investigate whether reliability is limited by an inability of small intestinal luminal flora to ferment rice or its product of hydrolysis, maltose.METHODS:Twenty adult subjects were investigated with microbiological culture of proximal small intestinal aspirate and a 3-g/kg rice breath hydrogen test. Gastroduodenal pH, the presence or absence of gastric bacterial overgrowth, and the in vitro capability of small intestinal luminal flora to ferment rice and maltose, its product of hydrolysis, were determined.RESULTS:Sensitivity of the rice breath hydrogen test for small intestinal bacterial overgrowth was 33% and remained low even when subjects with small intestinal overgrowth with oropharyngeal-type (38%) and colonic-type flora (20%) and those with concurrent small intestinal and gastric bacterial overgrowth (40%) were considered separately. Sensitivity remained suboptimal despite favorable gastroduodenal luminal pH and documented ability of bacterial isolates to ferment rice and maltose in vitro. Specificity of the rice breath hydrogen test for small intestinal bacterial overgrowth was 91%. Positive predictive value, negative predictive value, and predictive accuracy were 75%, 63%, and 65%, respectively.CONCLUSIONS:Clinical value of the rice breath hydrogen test for detecting small intestinal bacterial overgrowth is limited. The rice breath hydrogen test is not a suitable alternative to small intestinal intubation and culture of secretions for the detection of small intestinal bacterial overgrowth.

Mucosal Cytokine Production in Small-Intestinal Bacterial Overgrowth

BACKGROUND Mucosal production of interferon-gamma, interleukin-6, and tumour necrosis factor-alpha is increased in inflammatory bowel disease and parallels disease activity. Interferon-gamma production is also increased in coeliac disease. Conversely, local cytokine profiles have not been investigated in small-intestinal bacterial overgrowth. This study addressed this issue. METHODS Eighteen adult subjects were studies with culture of proximal small-intestinal luminal secretion and measurement of luminal interferon-gamma, interleukin-6, and tumour necrosis factor-alpha concentrations by enzyme-linked immunosorbent assay. Small-intestinal histology was assessed by light microscopy. RESULTS Interferon-gamma, interleukin-6, and tumour necrosis factor-alpha were measurable in proximal small-intestinal luminal secretions of all subjects, even in the absence of light microscopic evidence of enteropathy. Small-intestinal bacterial overgrowth was present in 12 of 18 (66.7%) subjects. Luminal concentrations of neither interferon-gamma nor tumour necrosis factor-alpha differed significantly in subjects with and without small-intestinal bacterial overgrowth (P + 0.06 and P = 1.0, respectively). Conversely, luminal interleukin-6 concentrations were significantly increased in subjects with this disorder (P = 0.02). Multivariate linear regression analysis suggested that colonic-type rather than salivary-type flora mediated this increased interleukin-6 response (P = 0.02 and P = 0.64, respectively). No correlation was found between luminal interleukin-6 and tumour necrosis factor-alpha concentrations, even after the confounding influence of colonic-type bacteria was excluded (P = 0.60). CONCLUSIONS These findings suggest that increased mucosal production of interleukin-6 occurs in small-intestinal bacterial overgrowth, particularly when the overgrowth flora includes colonic-type bacteria. Conversely, luminal levels of neither interferon-gamma nor tumour necrosis factor-alpha are increased in the circumstance, distinguishing the local cytokine profile in this disorder from those that occur in coeliac disease and inflammatory bowel disease.