Short-chain fatty acids in bowel contents after intestinal surgery

The molecular mechanism of polysaccharides in combating major depressive disorder: A comprehensive review

Major depressive disorder (MDD) is a complex psychiatric condition with diverse etiological factors. Typical pathological features include decreased cerebral cortex, subcortical structures, and grey matter volumes, as well as monoamine transmitter dysregulation. Although medications exist to treat MDD, unmet needs persist due to limited efficacy, induced side effects, and relapse upon drug withdrawal. Polysaccharides offer promising new therapies for MDD, demonstrating antidepressant effects with minimal side effects and multiple targets. These include neurotransmitter, neurotrophin, neuroinflammation, hypothalamic-pituitary-adrenal axis, mitochondrial function, oxidative stress, and intestinal flora regulation. This review explores the latest advancements in understanding the pharmacological actions and mechanisms of polysaccharides in treating major depression. We discuss the impact of polysaccharides' diverse structures and properties on their pharmacological actions, aiming to inspire new research directions and facilitate the discovery of novel anti-depressive drugs.

Effectiveness of diet, psychological, and exercise therapies for the management of bile acid diarrhoea in adults: A systematic review

BACKGROUND

Bile acid diarrhoea (BAD) causes chronic diarrhoea and is primarily treated pharmacologically. This systematic review aimed to evaluate the effectiveness of non-pharmacological therapies for evidence-based management of BAD in adults.

METHODS

A systematic review of the medical literature was performed from 1975 to 13 July 2021 to identify studies on diet, psychological, and exercise therapies that met diagnostic criteria for BAD in adults with diarrhoea. Effectiveness was judged by responder or improvement in diarrhoea at study endpoint according to each study's definition of diarrhoea. Therapeutic effect on abdominal pain and flatulence was also measured. Risk of bias was assessed using the Risk Of Bias In Non-Randomised Studies of Interventions tool. A narrative review was conducted using 'Synthesis Without Meta-analysis' guidance. Certainty of the evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Eight prospective cohort studies were identified on diet therapies from 2 weeks to over 2 years involving 192 patients. No psychological or exercise therapies were found. Carbohydrate modification (one study, n = 2) in primary BAD, and dietary fat intake reductions (five studies, n = 181) and an exclusive elemental diet therapy (two studies, n = 9) in secondary BAD, showed beneficial directions of effect on diarrhoea, abdominal pain, and flatulence. Risks of bias for each study and across studies for each therapy type were serious. Certainty of the evidence was very low for all outcomes.

CONCLUSIONS

No conclusions could be drawn on the effectiveness of diet, psychological, or exercise therapies on diarrhoea, abdominal pain, and flatulence for the management of BAD in adults. High-quality randomised controlled trials are needed.

A review of enteral strategies in infant short bowel syndrome: evidence-based or NICU culture?

INTRODUCTION

Short bowel syndrome (SBS) is an increasingly common condition encountered across neonatal intensive care units. Improvements in parenteral nutrition (PN), neonatal intensive care and surgical techniques, in addition to an improved understanding of SBS pathophysiology, have contributed in equal parts to the survival of this fragile subset of infants. Prevention of intestinal failure associated liver disease (IFALD) and promotion of intestinal adaptation are primary goals of all involved in the care of these patients. While enteral nutritional and pharmacological strategies are necessary to achieve these goals, there remains great variability in the application of therapeutic strategies in units that are not necessarily evidence-based.

MATERIALS AND METHODS

A search of major English language medical databases (SCOPUS, Index Medicus, Medline, and the Cochrane database) was conducted for the key words short bowel syndrome, medical management, nutritional management and intestinal adaptation. All pharmacological and nutritional agents encountered in the literature search were classified based on their effects on absorptive capacity, intestinal adaptation and bowel motility that are the three major strategies employed in the management of SBS. The Oxford Center for Evidence-Based Medicine (CEBM) classification for levels of evidence was used to develop grades of clinical recommendation for each variable studied.

RESULTS

We reviewed various medications used and nutritional strategies included soluble fiber, enteral fat, glutamine, probiotics and sodium supplementation. Most interventions have scientific rationale but little evidence to support their role in the management of infant SBS. While some of these agents symptomatically improve diarrhea, they can adversely influence pancreatico-biliary function or actually impair intestinal adaptation. Surgical anatomy and liver function are two important variables that should determine the selection of pharmacological and nutritional interventions.

DISCUSSION

There is a paucity of research investigating optimal clinical practice in infant SBS and the little evidence available is consistently of lower quality, resulting in a wide variation of clinical practices among NICUs. Prospective trials should be encouraged to bridge the evidence gap between research and clinical practice to promote further progress in the field.

Role of colonic short-chain fatty acid transport in diarrhea

Short-chain fatty acids (SCFA) are the major anion in stool and are synthesized from nonabsorbed carbohydrate by the colonic microbiota. Nonabsorbed carbohydrate are not absorbed in the colon and induce an osmotically mediated diarrhea; in contrast, SCFA are absorbed by colonic epithelial cells and stimulate Na-dependent fluid absorption via a cyclic AMP-independent process involving apical membrane Na-H, SCFA-HCO(3), and Cl-SCFA exchanges. SCFA production represents an adaptive process to conserve calories, fluid, and electrolytes. Inhibition of SCFA synthesis by antibiotics and administration of PEG, a substance that is not metabolized by colonic microbiota, both result in diarrhea. In contrast, increased production of SCFA as a result of providing starch that is relatively resistant to amylase digestion [so-called resistant starch (RS)] to oral rehydration solution (RS-ORS) improves the efficacy of ORS and represents an important approach to improve the effectiveness of ORS in the treatment of acute diarrhea in children under five years of age.

Fecal short-chain fatty acids in patients with diarrhea-predominant irritable bowel syndrome: in vitro studies of carbohydrate fermentation

Colonic bacterial production of short-chain fatty acids (SCFA) plays an important role in the salvage of unabsorbed carbohydrate and in colonic absorption of electrolytes and water. The objective of this study was to determine whether patients with diarrhea-predominant irritable bowel syndrome (DP-IBS) have a different pattern and rate of fermentation of carbohydrate and fiber to SCFA compared with controls. Fecal homogenates from 10 patients with DP-IBS and 10 age-matched controls were studied. SCFA were measured by gas chromatography in baseline fecal samples and in fecal homogenates in an in vitro anaerobic fermentation system after incubation with no additional substrate, lactulose, potato starch, citrus pectin, and hemicellulose over a 24-hour period. Net SCFA production rates were calculated for the first 6 h of the incubation period. Patients with DP-IBS had a consistently different pattern of less total SCFA, a lower percentage of acetate (p < 0.05), and a higher proportion of n-butyrate (p < 0.05) than controls. In stool homogenates from both controls and DP-IBS patients, lactulose fermentation resulted in the highest rate of SCFA production followed by pectin, starch, and hemicellulose. However, at all time points, the fecal homogenates from controls generated a higher concentration of total SCFA, acetate, and propionate with all substrates tested. SCFA production rates were higher in controls incubated with lactulose, starch, and hemicellulose. The fecal SCFA profile of patients with DP-IBS is characterized by lower concentrations of total SCFA, acetate, and propionate and a higher concentration and percentage of n-butyrate. Fecal flora from these patients produced less SCFA in an in vitro fermentation system in response to incubations with various carbohydrates and fibers. Differences in SCFA production by colonic bacterial flora in patients with DP-IBS may be related to the development of gastrointestinal symptoms.

Luminal short-chain fatty acids and postresection intestinal adaptation

BACKGROUND

Short-chain fatty acids (SCFAs) reportedly have a trophic effect on the small intestine. However, it is unclear if this is a local or primarily systemic effect. Loss of the ileocolonic junction (ICJ) may result in increased SCFAs and bacteria in the small intestine from colonic reflux. Our aim was to evaluate the effect of bypass of the ICJ on intestinal SCFA content and postresection adaptation.

METHODS

Thirty dogs were studied: transection control (TC, n = 10), distal resection of 50% intestine (DR, n = 10), and distal resection with bypass of ICJ (DRBP, n = 10). Animals were killed at 4 and 12 weeks. Luminal SCFAs and bacteria and adaptation of the small intestine were evaluated.

RESULTS

Caloric intake was significantly less in the two resected groups (67 +/- 3 DR and 63 +/- 3, DRBP vs 78 +/- 5 kcal/kg/d TC, p < .05). Body weight and albumin levels were decreased at 12 weeks but were similar between the resected groups (81% +/- 3% and 74% +/- 6% initial and 1.9 +/- 0.1 and 2.1 +/- 0.2 g/dL, DR and DRBP, respectively). Steatorrhea was present for 12 weeks after resection and was greater after DRBP (14.2% +/- 3.8% vs 8.6% +/- 1.9% at 4 weeks and 13.6% +/- 2.5% vs 6.7% +/- 0.6% at 12 weeks, p < .05). Bypassed animals had elevated intraluminal SCFA content (3126 +/- 1094 vs 1791 +/- 538 DR and 1600 +/- 446 micrograms/mL TC, p < .05) and anaerobic bacterial counts (100% vs 50% and 44%, respectively). Tissue inflammation and myeloperoxidase activity were similar. Small intestinal length (174 +/- 10 and 180 +/- 10 cm) and circumference (5.2 +/- 0.4 and 5.2 +/- 0.3 cm) increased to a similar extent in both resected groups at 12 weeks. Thickness of mucosa (1939 +/- 162 vs 1662 +/- 162 microns) and muscle (865 +/- 45 vs 978 +/- 79 microns) layers were similar after DR and DRBP.

CONCLUSION

(1) Bypass of the ICJ after distal resection results in increased growth of anaerobic bacteria and luminal SCFA and is associated with more marked steatorrhea. (2) Bypass of the ICJ does not influence structural adaptation of the small intestine. (3) These findings do not support a local trophic effect for SCFA.

Short-chain fatty acids in the human colon: relation to gastrointestinal health and disease

Fermentation, the process whereby anaerobic bacteria break down carbohydrates to short-chain (C2-C6) fatty acids (SCFAs), is an important function of the large bowel. SCFAs constitute approximately two-thirds of the colonic anion concentration (70-130 mmol/l), mainly as acetate, propionate, and butyrate. Gastroenterologists have, in spite of these facts, addressed this scientific field surprisingly late, in contrast to veterinarians, for whom the fermentative production of SCFAs has been acknowledged as a principal mechanism of intestinal digestion in plant-eating animals for decades. Interest in the effects of SCFA production on the human organism has been growing rapidly in the last 10 years, because gastrointestinal functions and beneficial effects are associated with these acids. SCFAs are of major importance in the understanding of the physiological function of dietary fibre and their possible role for colonic neoplasia. SCFA production and absorption are closely related to the nourishment of the colonic mucosa and sodium and water absorption, and mechanisms of diarrhoea. Patients with severe malabsorption compensate by the fermentation of otherwise osmotic active saccharides to SCFAs, which are readily absorbed and used as energy fuels in the organism. SCFA production from dietary carbohydrates is a mechanism whereby considerable amounts of calories can be salvaged in short-bowel patients with remaining colonic function if dietary treatment is adjusted. SCFA enemas are a new and promising treatment modality for patients with ulcerative colitis. The effect has been attributed to the oxidation of SCFAs in the colonocytes. An impressive number of papers have described the effects of butyrate on various cell functions, the significance of which is still unknown. Up until now, attention has been related especially to cancer prophylaxis and treatment. Diminished production of SCFAs appears to be involved in antibiotic-associated diarrhoea, diversion colitis, and possibly in pouchitis. The interaction between bacterial fermentation, ammonia metabolism, and bacterial growth and protein synthesis appears to be the main mechanism of action of lactulose treatment in hepatic coma. Pathological and extremely high rates of saccharide fermentation explain the severe deterioration in patients with D-lactate acidosis. Hence, this scientific field has come late to clinical working gastroenterologists, but as work is progressing the production of SCFAs in the large bowel becomes involved in several well-known intestinal disorders.

Estimation of the fermentability of dietary fibre in vitro: a European interlaboratory study

Five European laboratories tested a simple in vitro batch system for dietary fibre fermentation studies. The inoculum was composed of fresh human faeces mixed with a carbonate-phosphate buffer complex supplemented with trace elements and urea. Five dietary fibre sources (cellulose, sugarbeet fibre, soyabean fibre, maize bran and pectin) were used by each laboratory on three occasions to determine pH, residual non-starch polysaccharides (NSP) and short-chain fatty acid production during fermentation. Cellulose and maize bran degradabilities were very low (7.2(SE 10.8) and 6.2 (SE 9.1)% respectively after 24 h), whereas pectin and soyabean fibre were highly degraded (97.4 (SE 4.4) and 91.1 (SE 3.4)% respectively after 24 h). Sugarbeet fibre exhibited an intermediate level of degradability (59.5 (SE 14.9)%). Short-chain fatty acid production was closely related to NSP degradation (r 0.99). Although each variable was ranked similarly by all laboratories, some differences occurred with respect to absolute values. However, the adaptation of donors to the experimental substrates was not an influential factor. Interlaboratory differences could be reduced either by adding less substrate during incubations or using less-diluted inocula. In vitro fermentations with inocula made from human faeces and from rat caecal contents gave similar results. There was a close correspondence between the data obtained in the present experiment and those previously published in in vivo studies in the rat using the same fibres. The in vitro batch system tested during the present study provides a rapid means of obtaining quantitative estimates of the fermentation and the estimation of the energy content of new sources of dietary fibre.

Breath hydrogen analysis in patients with ileoanal pouch anastomosis

The possible influence on functional outcomes of hydrogen production in the ileoanal pouch after restorative proctocolectomy was investigated by means of lactulose H2 breath tests. Eight of 15 patients had significant increases in breath hydrogen after 10 g lactulose. One patient declined to participate in further investigations, the remaining seven responders had no evidence of small bowel bacterial overgrowth after glucose H2 breath tests. The ability to produce hydrogen by anaerobic fermentation of lactulose in the pouch was unrelated to the age of the patients or of the pouch. Seven of eight responders had successive breath tests after ingestion of lactulose 20 g and wheat starch 100 g. Five of seven had significant increases after lactulose but none after wheat starch. The overall function of the pouch continence, spontaneity of defecation, and 24 hour stool frequency was significantly better in responders than in non-responders. The absence of H2 production of 100 g wheat starch may indicate either increased absorption or defective fermentation.

Influence of intestinal inflammation (IBD) and small and large bowel length on fecal short-chain fatty acids and lactate

Treatment with short-chain fatty acids (SCFAs) seems promising in ulcerative colitis and changes in colonocyte oxidation of butyrate have been suggested to be of importance for the development of this disease. The influence of small and large bowel length after surgery on SCFAs is only partly known. SCFAs and lactate were measured in consecutive fecal samples from 300 patients with ulcerative colitis (103), Crohn's disease (127), and noninflammatory bowel disease (70); 205 had had surgery, 52 had short bowels (< 200 cm). Lactate (mainly the L-isomer) was elevated in ulcerative colitis patients with pancolitis (mean +/- SEM, 17 +/- 5 mmol/liter) and proctitis (12 +/- 3 mmol/liter) compared with quiescent ulcerative colitis (3 +/- 1 mmol/liter, P < 0.01), and correlated with the index of Truelove (R = 0.52, P < 0.0005). Lactate was also increased in Crohn's colitis (21 +/- 8 mmol/liter), but not in isolated ileitis (4 +/- 2 mmol/liter), compared with quiescent Crohn's disease (7 +/- 2 mmol/liter, P < 0.02), but did not correlate with the activity index (CDAI; R = 0.18, P = 0.12). In contrast to earlier reports, SCFAs (including butyrate) did not correlate with inflammatory activity or localization in either ulcerative colitis or Crohn's disease. The length of the small bowel had no influence on SCFAs and lactate in patients with either no colonic function (ileostomies), or with > 50% and < 50% preserved colorectal length, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacology of dietary fibre

"Dietary fibre" includes a range of relatively poorly digested food substances mainly composed of non-starch polysaccharides. Pectins and gums are multi-branched hydrophilic substances, forming viscous solutions that delay gastric emptying and nutrient absorption from the small bowel. They are used to delay gastric emptying and improve glycemic control in diabetes, as well as to alleviate constipation. Other fibres, including cellulose and lignins, are insoluble and have little effect on gastric emptying and small bowel transit. They markedly accelerate colonic transit and are frequently used as laxatives. Other important, less well-characterised effects of fibre include lowering of blood cholesterol, increase in satiety and possibly reduction in colon neoplasia.

Anaerobes and their fermentation products in faeces of patients with familial adenomatous polyposis before and after subtotal colectomy and ileorectal anastomosis

In view of the importance of short-chain fatty acids (SCFA) for the colonic epithelial function and their possible relation with the reported spontaneous regression of rectal polyps after subtotal colectomy with ileorectal anastomosis, we compared the SCFA concentrations in faeces of five familial adenomatous polyposis (FAP) patients before, and in 10 FAP patients after operation to each other and to those of 10 healthy controls. Anaerobe cultural counts and concentrations of organic acids were also investigated in the same faecal samples from FAP patients and controls. The preoperative cultural counts were not significantly different from those of the controls. After colectomy, the Bacteroides (P < 0.002; P < 0.02), and bifidobacteria counts (P < 0.02; P < 0.005) were decreased compared to controls and untreated FAP patients. The ratio of acetic acid to total SCFA significantly increased, which coincided with a proportional decrease of the other SCFA. The frequently observed regression of rectal polyps after colectomy cannot be explained from these results. One would rather expect a possible stimulation of polyp growth and dedifferentiation of colonic epithelial cells.

The starved colon--diminished mucosal nutrition, diminished absorption, and colitis

Nutrition of colonic epithelial cells is mainly from short chain fatty acids (SCFAs) produced by bacterial fermentation in the colonic lumen. n-Butyrate contributes more carbon of oxidation to epithelial cells than glucose or glutamine from the vasculature. Incomplete starvation of colonic epithelial cells through lack of luminal SCFAs leads, in the short term, to mucosal hypoplasia with either diminished absorption or diarrhea. A chronic lack of SCFAs or complete organ starvation in conjunction with other factors leads to nutritional colitis, either "diversion colitis" or "starvation colitis." Whether predominantly diarrhea or colitis develops in mucosal malnutrition appears to depend upon the severity and duration of starvation. Ulcerative colitis may be classified as a nutritional colitis in that colonic epithelial cells are unable to utilize SCFAs reflecting epithelial starvation despite abundant SCFAs.

Changes in mucosal nutrient transport in small and large ileal reservoirs after endorectal ileal pullthrough

It has been hypothesized that, following colectomy and endorectal ileal pullthrough with ileal reservoir (PTR), reservoir tissue might lose some of its normal nutrient transport capacity and assume properties of the colon. Whether reservoir size influences the expected alterations in normal mucosal absorption and thus contributes to changes in intraluminal ecology has not previously been investigated. To study this, the everted intestinal sleeve technique was used to measure uptake of four nutrients in two groups of dogs who underwent PTR: five with a small (5 cm) lateral reservoir and five with a large (18 cm) reservoir. Mucosal samples were taken from normal ileum and colon and from reservoirs 3 months postoperation. Active uptake of carbohydrates (glucose), amino acids (proline), and bile acids (taurocholate) and passive uptake of short chain fatty acids (propionate) were markedly decreased in mucosa of both reservoir sizes compared to normal ileum (P less than 0.05, t test) and more closely approximated that of normal colon. Uptake of glucose, proline, and taurocholate in large reservoirs was significantly less than that in small reservoirs (P less than 0.05). We conclude that (1) ileal reservoir mucosa has a significantly reduced capacity for nutrient uptake, (2) ileal mucosa in small reservoirs shows higher nutrient uptake rates than mucosa in large reservoirs, and (3) short, well-emptying reservoirs appear best suited to optimizing the intraluminal environment and thus enhance reservoir function when performing PTR.