research article increased chromogranin a cell density in...

Research ArticleIncreased Chromogranin A Cell Density inthe Large Intestine of Patients with Irritable BowelSyndrome after Receiving Dietary Guidance

Tarek Mazzawi123 Doris Gundersen4 Trygve Hausken23 and Magdy El-Salhy123

1Division of Gastroenterology Department of Medicine Stord Hospital 5416 Stord Norway2Division of Gastroenterology Department of Clinical Medicine University of Bergen 5020 Bergen Norway3National Centre for Functional Gastrointestinal Disorders Department of Medicine Haukeland University Hospital5021 Bergen Norway4Department of Research Helse-Fonna 5528 Haugesund Norway

Correspondence should be addressed to Tarek Mazzawi tarekmazzawimeduibno

Received 19 October 2014 Revised 7 February 2015 Accepted 15 February 2015

Academic Editor Peter J Whorwell

Copyright copy 2015 Tarek Mazzawi et alThis is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

The large intestine contains five types of endocrine cells that regulate its functions by sensing its luminal contents and releasingspecific hormones Chromogranin A (CgA) is a common marker for the gastrointestinal endocrine cells and it is abnormal inirritable bowel syndrome (IBS) patients Most IBS patients relate their symptoms to certain food elements The present studyinvestigated the effect of dietary guidance on the total endocrine cells of the large intestine as detected by CgA in 13 IBSpatientsThirteen control subjects were also included Each patient received three sessions of dietary guidance Colonoscopies wereperformed on controls and patients (at baseline and at 3ndash9 months after receiving guidance) Biopsy samples from the colon andrectum were immunostained for CgA and quantified by computerized image analysis The densities of CgA cells in the total colon(mean plusmn SEM) among the controls and the IBS patients before and after receiving dietary guidance were 833 plusmn 101 386 plusmn 37 and647 plusmn 42 cellsmm2 respectively (119875 = 00004) and were unchanged in the rectum In conclusion the increase in CgA cell densityafter receiving dietary guidance may reflect a change in the densities of the large intestinal endocrine cells causing an improvementin the IBS symptoms

1 Introduction

Irritable bowel syndrome (IBS) is a common gastrointestinal(GI) disorder that is present in almost one-third of con-sultations with gastroenterologists [1 2] IBS predominatesamong females and its reported prevalenceworldwide rangesfrom 5 to 20 [1ndash6] The symptoms of IBS vary from mildto severe and are attributed to visceral hypersensitivity dis-turbedGImotility or abnormal GI secretion [7ndash9] Gastroin-testinal sensation motility and secretion are regulated by theneuroendocrine systemof theGI tract [7 8] which comprisesthe GI endocrine cells and the enteric nervous system [1 10]The GI endocrine cells comprise almost 1 of all epithelialcells in the GI tract and are considered the largest endocrineorgan in the body [11ndash13] These cells project specialized

microvilli into the lumen which sense its contents (mainlynutrients) and release specific hormones into the lamina pro-pria [14ndash26] The large intestines namely the colon and rec-tum contain five types of endocrine cell serotonin- peptide-YY- somatostatin- oxyntomodulin- (enteroglucagon-) andpancreatic-polypeptide-producing cells [27ndash29]

Chromogranin A (CgA) is considered to be a commonmarker for the GI endocrine cells [30ndash32] The CgA celldensity was previously found to be abnormal in the colonof patients with IBS [33] but not in the rectum [27] Suchabnormalities in the gastrointestinal cells in IBS patientsinvolving not only the large intestines but also the gastricmucosa have been suggested to play a major role in thepathophysiology of IBS [7 34ndash36]

Hindawi Publishing CorporationGastroenterology Research and PracticeVolume 2015 Article ID 823897 8 pageshttpdxdoiorg1011552015823897

2 Gastroenterology Research and Practice

Most patients with IBS relate their symptomdevelopmentto the consumption of certain food elements [37 38] Dietarymanagement achieved by providing individualized guidancehas been reported to improve the symptoms and qualityof life of IBS patients [39 40] The same dietary guidancenormalizes the gastric endocrine cells [41 42] and thus thepresent study investigated whether dietary guidance affectsthe total endocrine cells of the large intestine as detected byCgA

2 Material and Methods

21 Patients and Controls Patients referred to the Gastroen-terology Division Stord Hospital Norway who were aged18ndash70 years and had IBS according to the Rome-III criteriawere recruited for this study Women who were pregnant orlactating or who received a caesarean section or hysterectomyand patients who had organic gastrointestinal or any othersystemic diseases abused drugs or suffered from seriouspsychiatric illness were excluded Patients with previousabdominal surgery with the exception of appendectomywere also excluded

Seven patients did not use medications prior to thestudy while six patients consumed one or a combination ofseveral medications Four patients consumed proton pumpinhibitors (PPI) one used an antihypertensive angiotensinII receptor antagonist three used medications against aller-gies two consumed contraceptive pills two took thyroxinsubstitution tablets one used inhalator against asthma andtwo used antidepressantsanxiolytics These patients wereinformed not to take any kind of PPI during the study

Patients with gastrointestinal bleeding where the sourceof bleeding was identified as hemorrhoids (119899 = 3) orangiodysplasia (119899 = 1) or healthy subjects who underwenta colonoscopy due to health worries caused by family mem-ber(s) having been diagnosed with gastrointestinal cancer(119899 = 9) were used as controls The control group consistedof nine females and four males with a mean age of 54 years(range 26ndash70 years)

The study was approved by the local Committee forMedical Research Ethics West Bergen Norway and wasperformed in accordance with the Declaration of HelsinkiThe patients provided both oral and written consent toparticipate

22 Study Design A total of 46 patients were included inthe study comprising 35 females and 11 males with a meanage of 35 years (range 18ndash69 years) All of the patients wereexamined physically and had their blood tested in order toexclude the presence of inflammation infection and otherorganic diseases Segmental biopsy samples were taken dur-ing the colonoscopies in order to exclude microscopic colitisAll of the patients received three sessions of individualizeddietary guidance lasting about 45min each The sessionswere scheduled at intervals of at least 2 weeks and wereconducted by a nurse experienced in dietary guidance in IBSThepatients underwent colonoscopies before the first dietary

guidance session and at 3ndash9 months (median 4 months) afterthe third session

23 Individualized Dietary Guidance The information aboutIBS and dietary guidance was delivered both orally with thehelp of charts and as written illustrated information Duringthe first session the patients received general informationabout IBS the importance of regular and healthy eatinghabits and the food elements that trigger IBS symptoms thatis insoluble dietary fiber and poorly absorbed FODMAPs(fermentable oligosaccharides disaccharides monosaccha-rides and polyols) The daily consumption of dairy prod-ucts was allowed during the study with the patients beinginformed that lactose-free milk and lactose-free dairy prod-ucts do not provoke IBS symptoms The patients were askedto test a fat- protein- or carbohydrate-richpoor diet for2 weeks During this period the patients were instructedto register in a diary their daily intake of food and fluidsalong with any symptoms they experienced including thefrequency and degree of abdominal pain abdominal dis-tension and stool frequency and consistency Consumingfood items supplemented with probiotics antibiotics andother medications was not permitted during the course ofthe study unless otherwise specified In the second sessionthe nurse briefly repeated the information given at the firstsession and together with the patient identified the symptom-triggering food elements based on an assessment of thepatientrsquos diary The patients were then encouraged to changethe proportions of protein fat and carbohydrate in their dietavoid FODMAPs-rich items and insoluble fiber and consumevegetables and fruits with lower amounts of FODMAPs andinsoluble fiber During the third session the patients sharedtheir experiences concerning the dietary guidance with thenurse The nurse together with the patient then designeda suitable diet for the patient to strictly follow until theendpoint of the study

24 Dietary Assessment Dietary intake was assessed byusing MoBa food frequency questionnaire (MoBa FFQ)This questionnaire is semiquantitative and self-administeredand reports the frequency and meal size related to a seriesof foods and beverages consumed over a defined periodof time The data were then analyzed using software tocalculate the nutrient content of the diet TheMoBa FFQ wasdeveloped and validated by the Norwegian Institute of PublicHealth in Oslo Norway [43 44] This questionnaire inquiresabout the consumption of 225 food items and identifies therespondentrsquos dietary habits including the consumption oforal supplements (if any) according to typical Norwegianmeal patterns The participants completed the MoBa FFQform before the first session and again at least 3 months afterthe last session of dietary guidance [39]

25 Colonoscopies Tissue Sampling Histopathology andImmunohistochemistry Colonoscopies were performed onboth patients and controls Biopsy samples were taken fromthe right colon (the cecum the ascending colon and theright half of the transverse colon) the left colon (the left

Gastroenterology Research and Practice 3

half of the transverse colon the descending colon and thesigmoid colon) and the rectum about 15 cm from the anusFour biopsies were taken from each segment

The biopsy samples were fixed overnight in 4 bufferedparaformaldehyde embedded in paraffin wax and then cutinto 5 120583m thick sections The sections were stained withhematoxylin-eosin and immunostained using the methodinvolving the Avidin-Biotin complex (ABC) with the Vectas-tain ABC kit (Vector Laboratories Burlingame CA USA)and the chromogen 331015840-diaminobenzidine peroxidase sub-strate (DAB) kit (Vector Laboratories) as described in detailpreviously [27] Briefly after 2 hours of incubation with amonoclonal mouse anti-N-terminal of purified CgA primaryantibody (code number M869 Dako Glostrup Denmark)diluted to 1 1000 at room temperature the sections werewashed in phosphate-buffered-saline (PBS pH 74) and incu-bated for another 30min at room temperature with biotiny-lated swine anti-mouse IgG (diluted to 1 200)The antibodieswere raised to N-terminal of purified chromogranin ATheseantibodies reacted with human chromogranin A as validatedearlier [33]The slides were then washed with PBS incubatedfor a further 30min with ABC (diluted to 1 100) andthen submerged in DAB followed by counterstaining withhematoxylin

26 Computerized Image Analysis The densities of CgA inthe right colon left colon and rectum of patients with IBSand controls were evaluated using computer software (CellandD Olympus Tokyo Japan) under a times40 objective Thenumber of CgA positive cells and the area of the epithelialcells were measured in ten randomly chosen fields Each fieldrepresented a tissue area of 014mm2 The CgA cell density isexpressed herein as the number of cells per square millimetreof epithelium All of the slides were quantified by the sameperson (Tarek Mazzawi) who was unaware of the identity ofthe sections

27 Statistical Analysis Thepaired t-test was used to comparepatients before and after receiving dietary guidance and theunpaired t-test was used to compare between themale and thefemale patients before and after receiving dietary guidanceThe data are presented as mean plusmn SEM values 119875 values lt 005were considered indicative of statistical significance

3 Results

31 Patients and Controls Of the 46 patients recruited in thestudy 24 lost theirmotivation to continue participating in thestudy and withdrew their consent due to symptom improve-ment as a consequence of receiving dietary guidance andorbeing unwilling for a second colonoscopy to be performedTwo patients were excluded because of noncompliance twowere diagnosed with celiac disease one was diagnosedwith lupus and one received antibiotic treatment becauseof gastroenteritis A further three patients were excludedbecause they became pregnant during the study and movedabroad or technical difficulties were experienced during thecolonoscopy Thus 13 of the original 46 patients completed

the entire study these patients comprised 8 females and 5males with a mean age of 34 years (range 20ndash45 years)

32 Colonoscopies Histopathology and Immunohistochemis-try The colon and rectumwere macroscopically normal andthe histopathological examinations revealed normal struc-tures in both patients and controls CgA-immunoreactivecells were found in the mucosa of both the colon and rectumof the patients and controls These cells were either basket-or flask-shaped and sometimes had a long basal cytoplasmicprocess

33 Dietary Assessment The effect of dietary guidancehas been described in detail elsewhere [39] In brief thepatients had a significantly lower daily total consumption ofFODMAPs-rich fruits and vegetables after receiving dietaryguidance (92 plusmn 32 g) than before receiving dietary guidance(162 plusmn 53 g 119875 = 0016) On the other hand the dailyconsumption of dietary fiber did not differ significantlybetween before (274 plusmn 25 g) and after (231 plusmn 22 g) receivingdietary guidance (119875 = 0093)

34 Computerized Image Analyses

341 Colon In the control group the densities of CgA cellsin the total colon right colon and left colon were 833 plusmn 101337 plusmn 53 and 496 plusmn 60 cellsmm2 respectively

The densities of CgA cells in the total colon of IBSpatients were 386 plusmn 37 and 647 plusmn 42 cellsmm2 before andafter receiving dietary guidance respectively this increasewas statistically significant (119875 = 00004) (Figures 1(a) and2) The densities of CgA cells before and after receivingdietary guidance were 167 plusmn 19 and 244 plusmn 21 cellsmm2respectively in the right colon and 219 plusmn 27 and 403 plusmn36 cellsmm2 in the left colon The increases in CgA celldensities in both the right colon (Figure 1(b)) and left colon(Figure 1(c)) were statistically significant (119875 = 00157 and00039 resp) By comparing CgA cell densities betweenmales and females no statistically significant difference wasfound before and after receiving dietary guidance (Table 1)

342 Rectum The densities of the CgA cells in the rectumwere 490 plusmn 79 427 plusmn 65 and 476 plusmn 50 cellsmm2 in thecontrols and in the IBS patients before and after receivingdietary guidance respectively (Figures 3 and 4) The celldensity in the rectum did not differ significantly betweenbefore and after receiving dietary guidance in the IBS patients(119875 = 047) In addition no significant difference was found inCgA cell density between males and females before and afterreceiving dietary guidance (Table 1)

4 Discussion

The dropout rate of patients with IBS is reportedly high inclinical studies ranging between 33 and 48 [40 45ndash48]The current study included two colonoscopies and neededthe patients to follow a strict diet for at least 3 months


Before After0

50

100

150

a

b

c

lowastlowastlowast

Chro

mog

rani

n A

cell

dens

itym

m2

epith

elium

(a)

Before After0

10

20

30

40

50a

b

c

lowast

Chro

mog

rani

n A

cell

dens

itym

m2

epith

elium

(b)

lowastlowast

Before After0

20

40

60

80

a

b

c

Chro

mog

rani

n A

cell

dens

itym

m2

epith

elium

(c)

Figure 1 CgA cell densities in the total colon (a) right colon (b) and left colon (c) of IBS patients before and after receiving dietary guidanceThe dashed lines labeled ldquoardquo and ldquocrdquo indicate the upper and lower limits of the 95 confidence interval for control subjects respectively whileline ldquobrdquo indicates the mean CgA cell density lowast119875 lt 005 lowastlowast119875 lt 0001 lowastlowastlowast119875 lt 00001

Table 1 Densities of chromogranin A cells in the total colon right colon left colon and rectum of the patients defined by their genderbefore and after receiving dietary guidance

LocationEndocrine cell densities (cellsmm2)

119875 values beforeguidance

119875 values afterguidanceMales before

guidanceFemales before

guidanceMales afterguidance

Females afterguidance

Total colon 378 411 686 659 07 08Right colon 182 17 214 281 08 01Left colon 196 234 472 36 05 01Rectum 538 366 558 431 02 02

This demanding design may have contributed to the evenhigher dropout rate of 52 Most of these dropouts were dueto improvements in the patientsrsquo symptoms after receivingdietary guidance Additional factors further increased thedropout rate to 72 such as exclusion after being diagnosedwith celiac disease lupus pregnancy moving abroad andtechnical difficulties experienced during the colonoscopy

CgA is a member of the granin (chromogranin-secretogranin) family located within the vesicles of neuronsand endocrine cells [30 31 49] and it serves as a markerfor the GI endocrine cells endocrine tumors and gut

inflammation [30ndash33] A significant change in the densitiesof the endocrine cells of the colon occurred followingchanges in the diet in the IBS patients with the valuesmoving towards those measured for the control subjectsThe density of CgA cells in the colon was abnormal inIBS patients before receiving dietary guidance which isin line with a previous report [33] However the densityof CgA cells in the rectum of IBS patients did not differfrom the control subjects which was in line with what wasreported previously [27] Such findings were attributed tothe physiological functions differing between the colon and


(a) (b)

(c)

Figure 2 CgA-immunoreactive cells in the total colon of a control subject (a) and of an IBS patient before (b) and after (c) receiving dietaryguidance

Chro

mog

rani

n A

cell

dens

itym

m2

epith

elium

Before After0

20

40

60

80

100

a

b

c

Figure 3 CgA cell density in the rectum of IBS patients before andafter receiving dietary guidance The symbols are the same as inFigure 1

rectum in that the colon absorbs water sodium and somefat-soluble vitamins whereas the rectumrsquos sole role is as areservoir for the feces prior to defecation [27]

There are contradictory results concerning the blood lev-els of CgA in IBS Some results show low levels of serumCgA[50] and others show higher levels of CgA [51] or unchangedlevels in IBS patients [33] As CgA-immunoreactive cellsoccur in all the segments of the GI tract the different

serum levels reflected segments other than large intestine orstomach

As described previously the main triggers of the GIendocrine cells are the luminal contents of the GI tractespecially the nutrients [7 36] The turnover from stemcells to mature endocrine cells is rapid [52 53] It can bespeculated that changing the pattern of food intakemdashwiththe subsequent improvement in IBS symptomsmdashcan alter thedifferentiation of the endocrine cells and explain the observedincrease in the CgA cell density in both the colon and rectumtowards the values measured for the control subjects Theinteraction between food type and food intake is a dynamicprocess [54]

The CgA cell densities in the colon and the rectum didnot differ betweenmales and females before receiving dietaryguidance which is in line with previous results [28] nor wasthere any difference in the cell densities after receiving dietaryguidance as shown in Table 1

A previous study has shown that the density of CgA cellsis abnormal in IBS patients and was reduced in the colonindicating a reduction in the density of total endocrine cells[27] These cells interact with intraluminal nutrients in thegut and release different hormones accordingly and controlthe functions of the GI tract Since the symptoms of mostIBS patients developed after consuming certain foods onecould speculate that there might be a relationship betweendiet and the GI endocrine cells The findings of the present


(a) (b)

(c)

Figure 4 CgA-immunoreactive cells in the rectum of a control subject (a) and of an IBS patient before (b) and after (c) receiving dietaryguidance

study show that the GI endocrine cells may be involved in thepathophysiology of IBS and symptom development and thatdietary guidance is an important key factor in managing andimproving IBS symptoms After receiving dietary guidancethe densities of these cells normalize as well as the IBSsymptoms which indicates that these cells play a role inthe pathogenesis of IBS providing that they were abnormalunder symptom development and normal again when thesymptoms improved The change in the CgA cell densityafter receiving dietary guidance may reflect a change in thedensities of the large intestinal endocrine cells Future studiesshould attempt to determine which endocrine cell type(s) is(are) affected

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

Acknowledgments

The authors thank Professor Hans Olav Fadnes Head of theDepartment of Medicine Stord Hospital for his support andfor reading the paper This study was supported by a grantfrom Helse-Fonna

References

[1] M El-Salhy D Gundersen J G Hatlebakk and T HauskenIrritable Bowel Syndrome Nova Scientific New York NY USA2012

[2] M El-Salhy H Oslashstgaard D Gundersen J G Hatlebakk and THausken ldquoThe role of diet in the pathogenesis andmanagementof irritable bowel syndrome (review)rdquo International Journal ofMolecular Medicine vol 29 no 5 pp 723ndash731 2012

[3] L Agreus K Svardsudd O Nyren and G Tibblin ldquoIrritablebowel syndrome and dyspepsia in the general populationoverlap and lack of stability over timerdquo Gastroenterology vol109 no 3 pp 671ndash680 1995

[4] D A Drossman Z Li E Andruzzi et al ldquoU S Householdersurvey of functional gastrointestinal disordersmdashPrevalencesociodemography and health impactrdquo Digestive Diseases andSciences vol 38 no 9 pp 1569ndash1580 1993

[5] M El-Salhy ldquoIrritable bowel syndrome diagnosis and patho-genesisrdquo World Journal of Gastroenterology vol 18 no 37 pp5151ndash5163 2012

[6] W G Thompson and K W Heaton ldquoFunctional bowel disor-ders in apparently healthy peoplerdquoGastroenterology vol 79 no2 pp 283ndash288 1980

[7] M El-Salhy D Gundersen O H Gilja J G Hatlebakk and THausken ldquoIs irritable bowel syndrome an organic disorderrdquoWorld Journal of Gastroenterology vol 20 no 2 pp 384ndash4002014


[8] Y J Lee and K S Park ldquoIrritable bowel syndrome emergingparadigm in pathophysiologyrdquo World Journal of Gastroenterol-ogy vol 20 no 10 pp 2456ndash2469 2014

[9] M Camilleri ldquoPhysiological underpinnings of irritable bowelsyndrome neurohormonal mechanismsrdquo The Journal of Physi-ology vol 592 no 14 pp 2967ndash2980 2014

[10] M El-Salhy ldquoThe possible role of the gut neuroendocrine sys-tem in diabetes gastroenteropathyrdquo Histology and Histopathol-ogy vol 17 no 4 pp 1153ndash1161 2002

[11] G W Moran F C Leslie S E Levison J Worthington andJ T McLaughlin ldquoEnteroendocrine cells neglected players ingastrointestinal disordersrdquo Therapeutic Advances in Gastroen-terology vol 1 no 1 pp 51ndash60 2008

[12] SMoran-Ramos A R Tovar andN Torres ldquoDiet friend or foeof enteroendocrine cells how it interacts with enteroendocrinecellsrdquo Advances in Nutrition vol 3 no 1 pp 8ndash20 2012

[13] R Buffa C Capella P Fontana L Usellini and E Solcia ldquoTypesof endocrine cells in the human colon and rectumrdquo Cell andTissue Research vol 192 no 2 pp 227ndash240 1978

[14] O Sandstrom and M El-Salhy ldquoAgeing and endocrine cells ofhuman duodenumrdquo Mechanisms of Ageing and Developmentvol 108 no 1 pp 39ndash48 1999

[15] M El-Salhy ldquoGhrelin in gastrointestinal diseases and disordersa possible role in the pathophysiology and clinical implications(review)rdquo International Journal of Molecular Medicine vol 24no 6 pp 727ndash732 2009

[16] G Tolhurst F Reimann and F M Gribble ldquoIntestinal sensingof nutrientsrdquoHandbook of Experimental Pharmacology vol 209pp 309ndash335 2012

[17] J Lee B P Cummings E Martin et al ldquoGlucose sensing bygut endocrine cells and activation of the vagal afferent pathwayis impaired in a rodent model of type 2 diabetes mellitusrdquoAmerican Journal of PhysiologymdashRegulatory Integrative andComparative Physiology vol 302 no 6 pp R657ndashR666 2012

[18] H E Parker F Reimann and F M Gribble ldquoMolecularmechanisms underlying nutrient-stimulated incretin secre-tionrdquo Expert Reviews in Molecular Medicine vol 12 article e12010

[19] H E Raybould ldquoNutrient sensing in the gastrointestinal tractpossible role for nutrient transportersrdquo Journal of Physiologyand Biochemistry vol 64 no 4 pp 349ndash356 2008

[20] A san Gabriel E Nakamura H Uneyama and K Torii ldquoTastevisceral information and exocrine reflexes with glutamatethrough umami receptorsrdquoThe Journal of Medical Investigationvol 56 supplement pp 209ndash217 2009

[21] T Rudholm B Wallin E Theodorsson E Naslund and P MHellstrom ldquoRelease of regulatory gut peptides somatostatinneurotensin and vasoactive intestinal peptide by acid andhyperosmolal solutions in the intestine in conscious ratsrdquoRegulatory Peptides vol 152 no 1ndash3 pp 8ndash12 2009

[22] C Sternini L Anselmi and E Rozengurt ldquoEnteroendocrinecells a site of lsquotastersquo in gastrointestinal chemosensingrdquo CurrentOpinion in Endocrinology Diabetes and Obesity vol 15 no 1pp 73ndash78 2008

[23] C Sternini ldquoTaste receptors in the gastrointestinal tractIV Functional implications of bitter taste receptors in gas-trointestinal chemosensingrdquo American Journal of PhysiologymdashGastrointestinal and Liver Physiology vol 292 no 2 pp G457ndashG461 2007

[24] A M J Buchan ldquoNutrient tasting and signaling mechanismsin the gut III Endocrine cell recognition of luminal nutrientsrdquo

American Journal of PhysiologymdashGastrointestinal and LiverPhysiology vol 277 no 6 pp G1103ndashG1107 1999

[25] M Montero-Hadjadje S Elias L Chevalier et al ldquoChro-mogranin A promotes peptide hormone sorting to mobilegranules in constitutively and regulated secreting cells Roleof conserved N- and C-terminal peptidesrdquo The Journal ofBiological Chemistry vol 284 no 18 pp 12420ndash12431 2009

[26] P Shooshtarizadeh D Zhang J-F Chich et al ldquoThe antimicro-bial peptides derived from chromograninsecretogranin familynew actors of innate immunityrdquo Regulatory Peptides vol 165no 1 pp 102ndash110 2010

[27] M El-Salhy T Mazzawi D Gundersen and T HauskenldquoChromogranin A cell density in the rectum of patients withirritable bowel syndromerdquo Molecular Medicine Reports vol 6no 6 pp 1223ndash1225 2012

[28] O Sandstrom and M El-Salhy ldquoHuman rectal endocrine cellsand agingrdquoMechanisms of Ageing andDevelopment vol 108 no3 pp 219ndash226 1999

[29] K Sjolund G Sanden R Hakanson and F Sundler ldquoEndocrinecells in human intestine an immunocytochemical studyrdquo Gas-troenterology vol 85 no 5 pp 1120ndash1130 1983

[30] L Taupenot K L Harper and D T OrsquoConnor ldquoThechromogranin-secretogranin familyrdquoThe New England Journalof Medicine vol 348 no 12 pp 1134ndash1149 2003

[31] B Wiedenmann and W B Huttner ldquoSynaptophysin andchromograninssecretograninsmdashwidespread constituents ofdistinct types of neuroendocrine vesicles and new tools intumor diagnosisrdquo Virchows Archiv B Cell Pathology IncludingMolecular Pathology vol 58 no 2 pp 95ndash121 1989

[32] L J Deftos ldquoChromogranin A its role in endocrine functionand as an endocrine and neuroendocrine tumor markerrdquoEndocrine Reviews vol 12 no 2 pp 181ndash187 1991

[33] M El-Salhy B Lomholt-Beck and T Hausken ldquoChromogranina as a possible tool in the diagnosis of irritable bowel syndromerdquoScandinavian Journal of Gastroenterology vol 45 no 12 pp1435ndash1439 2010

[34] M El-Salhy J G Hatlebakk O H Gilja and T HauskenldquoIrritable bowel syndrome recent developments in diagnosispathophysiology and treatmentrdquo Expert Review of Gastroen-terology amp Hepatology vol 8 no 4 pp 435ndash443 2014

[35] M El-Salhy ldquoEndocrine cells in the oxyntic mucosa of thestomach in patients with irritable bowel syndromerdquo WorldJournal of Gastrointestinal Endoscopy vol 6 no 5 pp 176ndash1852014

[36] M El-Salhy J G Hatlebakk O H Gilja and T HauskenldquoIrritable bowel syndrome recent developments in diagnosispathophysiology and treatmentrdquo Expert Review of Gastroen-terology and Hepatology vol 8 no 4 pp 435ndash443 2014

[37] M Simren A Mansson A M Langkilde et al ldquoFood-relatedgastrointestinal symptoms in the irritable bowel syndromerdquoDigestion vol 63 no 2 pp 108ndash115 2001

[38] E A Williams X Nai and B M Corfe ldquoDietary intakes inpeople with irritable bowel syndromerdquo BMC Gastroenterologyvol 11 article 9 2011

[39] T Mazzawi T Hausken D Gundersen and E-S MagdyldquoEffects of dietary guidance on the symptoms quality of lifeand habitual dietary intake of patients with irritable bowelsyndromerdquo Molecular Medicine Reports vol 8 no 3 pp 845ndash852 2013

[40] H Oslashstgaard T Hausken D Gundersen andM El-Salhy ldquoDietand effects of diet management on quality of life and symptoms


in patients with irritable bowel syndromerdquoMolecular MedicineReports vol 5 no 6 pp 1382ndash1390 2012

[41] T Mazzawi D Gundersen T Hausken and M El-SalhyldquoIncreased gastric chromogranin A cell density followingchanges to diets of patients with irritable bowel syndromerdquoMolecular Medicine Reports vol 10 no 5 pp 2322ndash2326 2014

[42] TMazzawi T Hausken D Gundersen andM El-Salhy ldquoEffectof dietarymanagement on the gastric endocrine cells in patientswith irritable bowel syndromerdquo European Journal of ClinicalNutrition 2014

[43] L F Masson G McNeill J O Tomany et al ldquoStatisti-cal approaches for assessing the relative validity of a food-frequency questionnaire use of correlation coefficients and thekappa statisticrdquoPublicHealthNutrition vol 6 no 3 pp 313ndash3212003

[44] A L Brantsaeter M Haugen J Alexander and H M MeltzerldquoValidity of a new food frequency questionnaire for pregnantwomen in the Norwegian Mother and Child Cohort Study(MoBa)rdquoMaternal and Child Nutrition vol 4 no 1 pp 28ndash432008

[45] P Enck S Klosterhalfen and W Kruis ldquoDetermination ofplacebo effect in irritable bowel syndromerdquoDeutscheMedizinis-che Wochenschrift vol 130 no 34-35 pp 1934ndash1937 2005

[46] H Abdul-Baki I I El Hajj L Elzahabi et al ldquoA randomizedcontrolled trial of imipramine in patients with irritable bowelsyndromerdquoWorld Journal of Gastroenterology vol 15 no 29 pp3636ndash3642 2009

[47] K A Zernicke T S Campbell P K Blustein et alldquoMindfulness-based stress reduction for the treatment of irri-table bowel syndrome symptoms a randomized wait-list con-trolled trialrdquo International Journal of Behavioral Medicine vol20 no 3 pp 385ndash396 2013

[48] E P Halmos V A Power S J Shepherd P R Gibson and J GMuir ldquoA diet low in FODMAPs reduces symptoms of irritablebowel syndromerdquo Gastroenterology vol 146 no 1 pp 67ndash752014

[49] W I Khan and J E Ghia ldquoGut hormones emerging role inimmune activation and inflammationrdquo Clinical amp ExperimentalImmunology vol 161 no 1 pp 19ndash27 2010

[50] J Valeur A M Milde K B Helle and A Berstad ldquoLowserum chromogranin a in patients with self-reported foodhypersensitivityrdquo Scandinavian Journal of Gastroenterology vol43 no 11 pp 1403ndash1404 2008

[51] K B Helle A Corti M-H Metz-Boutigue and B Tota ldquoTheendocrine role for chromogranin A a prohormone for peptideswith regulatory propertiesrdquoCellular andMolecular Life Sciencesvol 64 no 22 pp 2863ndash2886 2007

[52] M Hocker and B Wiedenmann ldquoMolecular mechanismsof enteroendocrine differentiationrdquo Annals of the New YorkAcademy of Sciences vol 859 pp 160ndash174 1998

[53] H Inokuchi S Fujimoto and K Kawai ldquoCellular kinetics ofgastrointestinal mucosa with special reference to gut endocrinecellsrdquoArchivumHistologicum Japonicum vol 46 no 2 pp 137ndash157 1983

[54] M El-Salhy O H Gilja D Gundersen J G Hatlebakkand T Hausken ldquoInteraction between ingested nutrients andgut endocrine cells in patients with irritable bowel syndrome(review)rdquo International Journal of Molecular Medicine vol 34no 2 pp 363ndash371 2014

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Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


Most patients with IBS relate their symptomdevelopmentto the consumption of certain food elements [37 38] Dietarymanagement achieved by providing individualized guidancehas been reported to improve the symptoms and qualityof life of IBS patients [39 40] The same dietary guidancenormalizes the gastric endocrine cells [41 42] and thus thepresent study investigated whether dietary guidance affectsthe total endocrine cells of the large intestine as detected byCgA

2 Material and Methods

21 Patients and Controls Patients referred to the Gastroen-terology Division Stord Hospital Norway who were aged18ndash70 years and had IBS according to the Rome-III criteriawere recruited for this study Women who were pregnant orlactating or who received a caesarean section or hysterectomyand patients who had organic gastrointestinal or any othersystemic diseases abused drugs or suffered from seriouspsychiatric illness were excluded Patients with previousabdominal surgery with the exception of appendectomywere also excluded

Seven patients did not use medications prior to thestudy while six patients consumed one or a combination ofseveral medications Four patients consumed proton pumpinhibitors (PPI) one used an antihypertensive angiotensinII receptor antagonist three used medications against aller-gies two consumed contraceptive pills two took thyroxinsubstitution tablets one used inhalator against asthma andtwo used antidepressantsanxiolytics These patients wereinformed not to take any kind of PPI during the study

Patients with gastrointestinal bleeding where the sourceof bleeding was identified as hemorrhoids (119899 = 3) orangiodysplasia (119899 = 1) or healthy subjects who underwenta colonoscopy due to health worries caused by family mem-ber(s) having been diagnosed with gastrointestinal cancer(119899 = 9) were used as controls The control group consistedof nine females and four males with a mean age of 54 years(range 26ndash70 years)

The study was approved by the local Committee forMedical Research Ethics West Bergen Norway and wasperformed in accordance with the Declaration of HelsinkiThe patients provided both oral and written consent toparticipate

22 Study Design A total of 46 patients were included inthe study comprising 35 females and 11 males with a meanage of 35 years (range 18ndash69 years) All of the patients wereexamined physically and had their blood tested in order toexclude the presence of inflammation infection and otherorganic diseases Segmental biopsy samples were taken dur-ing the colonoscopies in order to exclude microscopic colitisAll of the patients received three sessions of individualizeddietary guidance lasting about 45min each The sessionswere scheduled at intervals of at least 2 weeks and wereconducted by a nurse experienced in dietary guidance in IBSThepatients underwent colonoscopies before the first dietary

guidance session and at 3ndash9 months (median 4 months) afterthe third session

23 Individualized Dietary Guidance The information aboutIBS and dietary guidance was delivered both orally with thehelp of charts and as written illustrated information Duringthe first session the patients received general informationabout IBS the importance of regular and healthy eatinghabits and the food elements that trigger IBS symptoms thatis insoluble dietary fiber and poorly absorbed FODMAPs(fermentable oligosaccharides disaccharides monosaccha-rides and polyols) The daily consumption of dairy prod-ucts was allowed during the study with the patients beinginformed that lactose-free milk and lactose-free dairy prod-ucts do not provoke IBS symptoms The patients were askedto test a fat- protein- or carbohydrate-richpoor diet for2 weeks During this period the patients were instructedto register in a diary their daily intake of food and fluidsalong with any symptoms they experienced including thefrequency and degree of abdominal pain abdominal dis-tension and stool frequency and consistency Consumingfood items supplemented with probiotics antibiotics andother medications was not permitted during the course ofthe study unless otherwise specified In the second sessionthe nurse briefly repeated the information given at the firstsession and together with the patient identified the symptom-triggering food elements based on an assessment of thepatientrsquos diary The patients were then encouraged to changethe proportions of protein fat and carbohydrate in their dietavoid FODMAPs-rich items and insoluble fiber and consumevegetables and fruits with lower amounts of FODMAPs andinsoluble fiber During the third session the patients sharedtheir experiences concerning the dietary guidance with thenurse The nurse together with the patient then designeda suitable diet for the patient to strictly follow until theendpoint of the study

24 Dietary Assessment Dietary intake was assessed byusing MoBa food frequency questionnaire (MoBa FFQ)This questionnaire is semiquantitative and self-administeredand reports the frequency and meal size related to a seriesof foods and beverages consumed over a defined periodof time The data were then analyzed using software tocalculate the nutrient content of the diet TheMoBa FFQ wasdeveloped and validated by the Norwegian Institute of PublicHealth in Oslo Norway [43 44] This questionnaire inquiresabout the consumption of 225 food items and identifies therespondentrsquos dietary habits including the consumption oforal supplements (if any) according to typical Norwegianmeal patterns The participants completed the MoBa FFQform before the first session and again at least 3 months afterthe last session of dietary guidance [39]

25 Colonoscopies Tissue Sampling Histopathology andImmunohistochemistry Colonoscopies were performed onboth patients and controls Biopsy samples were taken fromthe right colon (the cecum the ascending colon and theright half of the transverse colon) the left colon (the left






3 Results









4 Discussion



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OncologyJournal of





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3 Results









4 Discussion



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Acknowledgments


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OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















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Acknowledgments


References
































































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Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















(a) (b)

(c)


Chro

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Before After0

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(a) (b)

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Acknowledgments


References
































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















(a) (b)

(c)





Acknowledgments


References
































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of








































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















research article increased chromogranin a cell density in...

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