Mrs Anita JatanaMrs Anita Jatana

Chief Dietitian Chief Dietitian

Batra HospitalBatra Hospital

70% of our immune system is located in the gut.70% of our immune system is located in the gut.

Keeping it healthy is the key to good health.Keeping it healthy is the key to good health.

The average human body consists of about 10The average human body consists of about 10¹³¹³ (10,000,000,000,000 or ten trillion) (10,000,000,000,000 or ten trillion) cellscells, has about , has about ten times that number of microorganisms and about ten times that number of microorganisms and about 500-1000 different bacterial species in the 500-1000 different bacterial species in the gut.gut.

The metabolic activity performed by these bacteria is The metabolic activity performed by these bacteria is equal to that of a virtual organ making the gut bacteria equal to that of a virtual organ making the gut bacteria termed as a termed as a “Forgotten organ”.“Forgotten organ”.

GUT HEALTHGUT HEALTH

INTESTINAL FLORA (A BALANCED ECOSYSTEM)Pseudomonas

Proteus

Staphylococci

Clostridia

Enterococci

E. coli

Lactobacilli

Streptococci

Eubacteria

Bifidobacteria

Bacteroides

Potentially Harmful Bacteria• Diarrhea/constipation• Infections• Production of Toxins

Potentially Helpful Bacteria

• Inhibition of exogeneous and/or harmful bacteria

• Stimulation of immune functions

• Aid in digestion and/or absorption

• Synthesis of vitamins

From: Gibson GR. J Nutrition 1995; 125:1401-1412.

Lactobacillus

Bifidobacterium

Staphylococcus

Bacteroides

E. coli

C. perfringens

A closer look at our intestinal bacteria

A closer look at our intestinal bacteria

500 - 1000 species

Stomach104 CFU/gCandida albicansHelicobacter pyloriLactobacillusStreptococcus

EsophagusNo own microbiotaMicrobes from food

and oral cavity

Duodenum103-104 CFU/g

BacteroidesCandida albicans

LactobacillusStreptococcus

Jejunum105-107 CFU/gBacteroidesCandida albicansLactobacillusStreptococcus

Ileum107-108 CFU/gBacteroidesClostridiumEnterobacteriaceaeEnterococcusLactobacillusVeillonella

Colon1010-1011 CFU/g

BacteroidesBacillus

BifidobacteriumClostridium

EnterococcusEubacterium

FusobacteriumPeptostreptococcus

RuminococcusStreptococcus

Adult Microbiota: A Complex EcosystemAdult Microbiota: A Complex Ecosystem

The Mucosal surface of the GI tract forms an The Mucosal surface of the GI tract forms an important organ of host defense.important organ of host defense.

Anaerobic bacteria influence gut physiology & health by Anaerobic bacteria influence gut physiology & health by exerting a number of activities including:-exerting a number of activities including:-

Barrier protection against colonization of pathogens;Barrier protection against colonization of pathogens; Regulation of Intestinal transit;Regulation of Intestinal transit; Deconjugation of bile acids and promotion of enterohepatic Deconjugation of bile acids and promotion of enterohepatic

circulation;circulation; Degradation and digestion of some undigested carbohydrates;Degradation and digestion of some undigested carbohydrates; Improvement of lactose intolerance;Improvement of lactose intolerance; Limitation of bacterial translocation and thus dissemination of Limitation of bacterial translocation and thus dissemination of

bacteria in the peripheral organs;bacteria in the peripheral organs; Production of vitamins and growth factors for host intestinal Production of vitamins and growth factors for host intestinal

cells;cells; Maturation and stimulation of the gut immune system.Maturation and stimulation of the gut immune system.

Studies show that intestinal flora remains quite Studies show that intestinal flora remains quite stable despite the variation in the ingested micro stable despite the variation in the ingested micro organisms in food. organisms in food.

Factors influencing the balance of intestinal bacteria flora Factors influencing the balance of intestinal bacteria flora adversely are :-adversely are :-

Congenital or acquired immuno-deficiencies.Congenital or acquired immuno-deficiencies. IllnessIllness Intestinal motility disordersIntestinal motility disorders Digestive stasisDigestive stasis Parenteral nutrition Parenteral nutrition Antibiotic treatment Antibiotic treatment

These can act by inhibiting certain commensal bacterial strains These can act by inhibiting certain commensal bacterial strains and by making the normal flora unable to act as barrier. This may and by making the normal flora unable to act as barrier. This may promote the growth of potentially pathogenic germs ( eg. promote the growth of potentially pathogenic germs ( eg. Clostridium difficle, Klebsiella oxytoca).Clostridium difficle, Klebsiella oxytoca).

Potential beneficial effects of colonic Potential beneficial effects of colonic foods mediated by the human large gut foods mediated by the human large gut microbiotamicrobiota

Alleviate the symptoms of lactose malabsorptionAlleviate the symptoms of lactose malabsorption Boost natural resistance to infectious disease of Boost natural resistance to infectious disease of

the intestinal tractthe intestinal tract Neutralize certain toxins Neutralize certain toxins Suppress cancerSuppress cancer Supply SCFA as energy substratesSupply SCFA as energy substrates Lower serum lipidsLower serum lipids Affect hormonal regulationAffect hormonal regulation Aid digestionAid digestion Produce vitaminsProduce vitamins Stimulate gastrointestinal immunityStimulate gastrointestinal immunity

Inflammatory Bowel DiseaseInflammatory Bowel Disease

An open label preliminary trial conducted on 10 patients with An open label preliminary trial conducted on 10 patients with mildly to moderately active Ulcerative Colitis (UC)mildly to moderately active Ulcerative Colitis (UC)

Intervention: LcS (8x10Intervention: LcS (8x101010 CFU/day) in addition to conventional CFU/day) in addition to conventional therapy daily for 8 weekstherapy daily for 8 weeks

Significantly better clinical activity index score seen after LcS Significantly better clinical activity index score seen after LcS treatment as compared with pre-treatment and control grouptreatment as compared with pre-treatment and control group

[Mitsuyama K et al 2008, J Clin Biochem Nutr 43 (Suppl.1):78-81]

CONLUSION: LcS effectively treats UC at least in part through the inhibition of interleukin-6 signalling

Inflammatory Bowel Inflammatory Bowel DisordersDisorders

Meta-analysis of thirteen randomized controlled Meta-analysis of thirteen randomized controlled studies - seven studies evaluated the remission rate studies - seven studies evaluated the remission rate and eight studies estimated the recurrence rate, two and eight studies estimated the recurrence rate, two studies evaluated both remission and recurrence rate. studies evaluated both remission and recurrence rate.

Compared with the non probiotic group, the remission Compared with the non probiotic group, the remission rate for ulcerative colitis patients who received rate for ulcerative colitis patients who received probiotics was better.probiotics was better.

In the mild to moderate group who received probiotics In the mild to moderate group who received probiotics compared to the group who did not receive probiotics, compared to the group who did not receive probiotics, the recurrence rate was less.the recurrence rate was less.

CONCLUSION: Probiotic treatment was more effective CONCLUSION: Probiotic treatment was more effective than placebo in maintaining remission in ulcerative than placebo in maintaining remission in ulcerative colitis.colitis.

[Sang et al, 2010 World of Gastroenterol 16:(15)1908-1915]

Probiotics useful in Celiac Probiotics useful in Celiac DiseaseDisease Probiotics have shown promise for treating autoimmune and allergic Probiotics have shown promise for treating autoimmune and allergic

disorders by altering intestinal microbiota composition and disorders by altering intestinal microbiota composition and fermentation derived metabolite, thereby regulating epithelial cell fermentation derived metabolite, thereby regulating epithelial cell barrier function and modulating immune response. barrier function and modulating immune response. (Licciardi PV (Licciardi PV et al et al 20102010, , Gut Pathol Gut Pathol 2-24)2-24)

Dietary changes include probiotics/prebiotics may help Dietary changes include probiotics/prebiotics may help alleviate the severity of celiac disease for some patients.alleviate the severity of celiac disease for some patients.

Differing intestinal bacteria in celiac patients could influence Differing intestinal bacteria in celiac patients could influence inflammation to varying degrees. This suggests that manipulating the inflammation to varying degrees. This suggests that manipulating the intestinal microbiota with dietary strategies such as probiotics and intestinal microbiota with dietary strategies such as probiotics and prebiotics, could improve the quality of life for celiac patients, as well prebiotics, could improve the quality of life for celiac patients, as well as patients with associated diseases such as type 1 diabetes and as patients with associated diseases such as type 1 diabetes and other autoimmune disorders. other autoimmune disorders. ((Rossi M Rossi M et alet al 2010 2010 Journal of Leukocyte Biology Journal of Leukocyte Biology 87:749 -751)87:749 -751)

CASE 1CASE 1 (Age- 2yrs) (Age- 2yrs)Celiac DiseaseCeliac Disease

PATIENT HISTORYPATIENT HISTORY

c/o loose stool ( 7-8 times) with vomiting on and off c/o loose stool ( 7-8 times) with vomiting on and off ( 2 months) and 1 episode of blood in stool.( 2 months) and 1 episode of blood in stool.

c/o abdominal distensionc/o abdominal distension Less oral intakeLess oral intake History of wt loss- 3-4kg in 2months.History of wt loss- 3-4kg in 2months. Feeding history- home based soft diet + milk.Feeding history- home based soft diet + milk. On examination stomach distended Bs (positive)On examination stomach distended Bs (positive) Liver spleen not palpableLiver spleen not palpable..

Biochemical investigationsBiochemical investigationsUreaCreatinineProteinAlbuminSGOTSGPTSodiumPotassiumHaemoglobin

9.00.26.83.234441354.37.6

INVESTIGATIONSINVESTIGATIONS

UltrasoundUltrasound- liver normal- gaseous distention of - liver normal- gaseous distention of stomachstomach

EndoscopyEndoscopy- pale mucosa seen of duodenal folds- pale mucosa seen of duodenal folds Blood test-Blood test- anti tissue tranglutaminase antibody anti tissue tranglutaminase antibody

( tTG) positive( tTG) positive Duodenal biopsy report-Duodenal biopsy report- partial villous atrophy partial villous atrophy

with intraepithelial lymphocytosis, possibility of with intraepithelial lymphocytosis, possibility of coeliac disease.coeliac disease.

Stool reportStool report - fat globules positive - fat globules positive - reducing substance negative- reducing substance negative

Endoscopic findingsEndoscopic findingsEsophagus: pale mucosaEsophagus: pale mucosa

Stomach: pale mucosa seenStomach: pale mucosa seen Duodenum: duodenal folds scalloping seenDuodenum: duodenal folds scalloping seen

Impression: celiac disease,biopsy took.Impression: celiac disease,biopsy took.

DIETARY MANAGEMENTDIETARY MANAGEMENT

Patient was put on a lactose and gluten free Patient was put on a lactose and gluten free diet.diet.

Probiotics (LcS) was introduced 1/dayProbiotics (LcS) was introduced 1/day Frequency of stools decreased to 5/day and Frequency of stools decreased to 5/day and

decreased stomach distensiondecreased stomach distension On 3On 3rdrd day- frequency of stools was 3 and day- frequency of stools was 3 and

semiformed. semiformed. Patient was discharged with instructions of Patient was discharged with instructions of

gluten free diet with probiotics (LcS) once a day.gluten free diet with probiotics (LcS) once a day.

CASE 2CASE 2 77 year 77 year -male -male

HISTORY:HISTORY: Carcinoma prostate Carcinoma prostate Post b/l orchidectomy on radical Radiation Post b/l orchidectomy on radical Radiation

and has completed 18 radiations.and has completed 18 radiations. Diabetes 25 yrs Diabetes 25 yrs CAD with CABGCAD with CABG

Loose motions, Loose motions, vomiting, vomiting, 2 day Blackstools ++2 day Blackstools ++ Poor oral intakePoor oral intake

Symptoms Patient Admitted WithSymptoms Patient Admitted With

MEDICATIONMEDICATION

Injection raciper 40mg IVBDInjection raciper 40mg IVBD Emset 8mg IVBDEmset 8mg IVBD PantocidPantocid MetrogylMetrogyl Monocef 2gmMonocef 2gm

INVESTIGATIONSINVESTIGATIONS

EndoscopyEndoscopy- antral gastritis- antral gastritis ColonoscopyColonoscopy- seen upto desending colon- seen upto desending colon

diffuse erythma with multiple ulcers in diffuse erythma with multiple ulcers in rectumrectum

Radiation proctitisRadiation proctitis Bone scanBone scan –no mets. –no mets. SPSASPSA- markedly elevated- markedly elevated

DIETARY MANAGEMENTDIETARY MANAGEMENT

19/3/2012- patient on clear liquid diet19/3/2012- patient on clear liquid diet

frequency of stool 6-8/dayfrequency of stool 6-8/day 20/3/2012-patient was on full liquid diet20/3/2012-patient was on full liquid diet

probiotic (LcS) introduced – 1BDprobiotic (LcS) introduced – 1BD

frequency of stools 4-5/dayfrequency of stools 4-5/day 21/3/2012-patient was on soft diet21/3/2012-patient was on soft diet

frequency of stools decreased to frequency of stools decreased to

2 but the stools were formed. 2 but the stools were formed.

CASE 3CASE 3age:58yrs male age:58yrs male Ulcerative ColitisUlcerative Colitis

General InformationGeneral Information Age : 58yrAge : 58yr Wt: 72kgWt: 72kg Ht: 175cmHt: 175cm BMI: 23.51kg/msqBMI: 23.51kg/msq BP: 130/90BP: 130/90

HISTORYHISTORY

h/o Diabetesh/o Diabetes Complain of bleeding per rectum.Complain of bleeding per rectum. Increased frequency of stools with mucosa Increased frequency of stools with mucosa

since 1-since 1-1/21/2 months.months. There was no history of fever.There was no history of fever. Also developed osteoporosis.Also developed osteoporosis. Patient was on steroids since 22yrs.Patient was on steroids since 22yrs.

MEDICATIONMEDICATION

Medication on admissionMedication on admission

1. Inj. Pantocid1. Inj. Pantocid

2. N. Saline2. N. Saline

3. Metrogyl3. Metrogyl

4. Inj. Forzid4. Inj. Forzid

5. Efcorlin 50ml/6hrly5. Efcorlin 50ml/6hrly

INVESTIGATIONSINVESTIGATIONS

Colonoscopy:Colonoscopy: Seen upto Caecum. Seen upto Caecum. Showed diffused mucosal ulceration with Showed diffused mucosal ulceration with

erosion. erosion. Chronic proctosigmoidotis and ulcerative Chronic proctosigmoidotis and ulcerative

colitis.colitis.

DIETARY MANAGEMENTDIETARY MANAGEMENT

DIET: The patient was kept on Bland soft – DIET: The patient was kept on Bland soft – Lactose free dietLactose free diet

2 probiotics (LcS) were introduced per day.2 probiotics (LcS) were introduced per day. On third day frequency of stools reduced to 3 On third day frequency of stools reduced to 3

from initial 5 from initial 5 Stools were formed.Stools were formed. Patient was discharged after a week on a Patient was discharged after a week on a

diabetic lactose free with instructions to continue diabetic lactose free with instructions to continue probiotics (LcS) BD.probiotics (LcS) BD.