Syndrome of increased epithelial permeability in clinical practice. Multidisciplinary national Consensus

Intestinal Barrier and Gut Microbiota in Patients with Overlapping Irritable Bowel Syndrome and Functional Dyspepsia

BACKGROUND

Disturbances in the intestinal barrier and gut dysbiosis have been observed in patients with functional bowel diseases.

AIMS

To investigate the correlation between biomarkers of intestinal barrier disorders at different layers and the severity of symptoms in patients with overlapping diarrhea-predominant irritable bowel syndrome and functional dyspepsia (IDFO), as well as with gut microbiota taxa.

METHODS

This study included 45 patients with IDFO and 16 healthy controls. Endoscopy with biopsy of the duodenum and sigmoid colon (SC) was performed to count intraepithelial lymphocytes (IELs) and mucosal eosinophils (subepithelial layer), assess fatty acid binding protein (FABP; epithelial layer) level, and stain for mucin-2 (MUC-2; pre-epithelial layer). Composition of the gut microbiota was evaluated using 16S rRNA gene sequencing.

RESULTS

Patients with IDFO exhibited an increase in biomarkers of intestinal barrier disorders at all layers studied. IEL count in the duodenum was correlated with the severity of bloating (r = 0.336; p = 0.024) and, in the SC, was correlated with tenesmus severity (r = 0.303; p = 0.042). FABP-1 level in the SC was correlated with the severity of diarrhea (r = 0.577; p = 0.001), and FABP-5 concentration in the SC was correlated with abdominal distension (r = 0.477; p = 0.010). MUC-2 concentration in the duodenum was correlated with the severity of heartburn (r = 0.572; p = 0.025) and burning sensation in the epigastrium (r = 0.518; p = 0.048). All biomarkers of intestinal barrier permeability were correlated with the abundance of some gut microbiota taxa.

CONCLUSION

Patients with IDFO exhibited disrupted intestinal barrier function in all layers, which was associated with clinical symptom severity and changes in the gut microbiota.

[Long-term probiotic administration for irritable bowel syndrome: a legal need]

BACKGROUND

Irritable bowel syndrome (IBS) is one of the most common functional diseases of the gastrointestinal tract. Violations in the intestinal microbiocenosis play a significant role in the pathogenesis of this suffering. The probiotic strain Bifidobacterium longum 35624® has a strong evidence base for use in the management of patients with IBS. The duration of probiotic therapy and the need for repeated courses of probiotics require further study, which determined the need for this observational study.

AIM

To compare the results of prolonged (12 weeks) and usual duration of courses of probiotic Bifidobacterium longum 35624® in patients with IBS.

MATERIALS AND METHODS

42 patients with a verified diagnosis of IBS of moderate and severe severity who met the inclusion criteria were recruited into the study. Patients were prescribed probiotic Bifidobacterium longum 35624® at a dose of 1 capsule (1×109 CFU), 1 time per day for 12 weeks. The course of the disease was assessed using the visual analogue scale, visceral sensitivity index (VSI), IBS symptom severity scale (IBS-SSS), quality of life indicators were assessed using the IBS-QoL questionnaire scales. Evaluation of indicators was carried out at the inclusion visit, on days 14, 28, 56, 84 of probiotic intake and on day 112 (28 days after the last dose of Bifidobacterium longum 35624®).

RESULTS

The results obtained confirmed the ability of the probiotic Bifidobacterium longum 35624® to positively influence the course of IBS. The addition of the main therapy with a probiotic made it possible to achieve a significant decrease in the severity of abdominal pain, bloating, and stool disorders. The severity of IBS significantly decreased according to the results of IBS-SSS. Reliable positive dynamics of indicators on the scales IBS-QoL, VSI is shown. The most pronounced changes were observed by the end of the third month of taking Bifidobacterium longum 35624®. Thus, according to the IBS-SSS indicators, only by the end of the third month of observation, some patients achieved remission of the disease. All described changes were persistent and persisted one month after the end of the probiotic intake.

CONCLUSION

The addition of a prolonged course of the probiotic Bifidobacterium longum 35624® to the basic therapy in patients with IBS allows a more pronounced and lasting effect to be achieved. A "post-probiotic" effect was shown - a decrease in VSI after the end of the intake of the probiotic strain. Given the chronic relapsing course of IBS, the use of repeated probiotic courses was proposed to prevent exacerbation of the disease.

Esophageal Mucosal Resistance in Reflux Esophagitis: What We Have Learned So Far and What Remains to Be Learned

Gastroesophageal reflux disease (GERD) has the highest prevalence among diseases of the digestive system and is characterized by a significant decrease in patients' quality of life, comparable to arterial hypertension and coronary heart disease. One in every ten cases of reflux esophagitis leads to the formation of Barrett's esophagus, which is associated with a high risk of esophagus adenocarcinoma. The key factors determining the progression of the disease are the frequency and duration of the reflux of the stomach's contents. As a result, refluxate, which includes hydrochloric acid, pepsin, and, in the case of concomitant duodeno-gastric reflux, bile acids and lysolecithin, is thrown into the overlying sections of the digestive tract. At the same time, in addition to aggression factors, it is necessary to take into account the state of resistance in the esophageal mucosa to the effects of aggressive refluxate molecules. This review was prepared using systematized data on the protective properties of the esophageal mucosa and modern methods to assess the mucosal barrier in reflux esophagitis. Lesions of the epithelial barrier structure in the esophagus are recognized as the main pathogenetic factor in the development of reflux esophagitis and are a potentially significant therapeutic target in the treatment of GERD and Barrett's esophagus. This article presents the characteristics of the esophageal mucosal barrier and the protective mechanisms of the esophagus's mucous membrane in conditions of gastroesophageal reflux. Diagnostic approaches for assessing the course of reflux esophagitis are described for both histological criteria and the possibility of a comprehensive assessment of the state of mucins, tight-junction proteins, and the proliferative activity of the mucosa, including under the conditions of ongoing therapy.

Hepatobiliary system and intestinal injury in new coronavirus infection (COVID-19): A retrospective study

BACKGROUND

An important area of effective control of the coronavirus disease 19 (COVID-19) pandemic is the study of the pathogenic features of severe acute respiratory syndrome coronavirus 2 infection, including those based on assessing the state of the intestinal microbiota and permeability.

AIM

To study the clinical features of the new COVID-19 in patients with mild and moderate severity at the stage of hospitalization, to determine the role of hepatobiliary injury, intestinal permeability disorders, and changes in the qualitative and quantitative composition of the microbiota in the development of systemic inflammation in patients with COVID-19.

METHODS

The study was performed in 80 patients with COVID-19, with an average age of 45 years, 19 of whom had mild disease, and 61 had moderate disease severity. The scope of the examination included traditional clinical, laboratory, biochemical, instrumental, and radiation studies, as well as original methods for studying microbiota and intestinal permeability.

RESULTS

The clinical course of COVID-19 was studied, and the clinical and biochemical features, manifestations of systemic inflammation, and intestinal microbiome changes in patients with mild and moderate severity were identified. Intestinal permeability characteristics against the background of COVID-19 were evaluated by measuring levels of proinflammatory cytokines, insulin, faecal calprotectin, and zonulin.

CONCLUSION

This study highlights the role of intestinal permeability and microbiota as the main drivers of gastroenterological manifestations and increased COVID-19 severity.

The effect of the FODMAP and rebamipid diet on the activity of disaccharidases in patients with enteropathy with impaired membrane digestion

Aim. To compare the effect of a diet low in fermentable oligo-, di-, monosaccharides and polyols (fermentable oligosaccharides, disaccharides, monosaccharides and polyols FODMAP) and rebamipide on carbohydrate tolerance and disaccharidases activity in patients with maldigestive enteropathy (ENMP). Materials and methods. The study included 61 patients with ENMP with reduced small intestine carbohydrases. Their glucoamylase activity was 100 ng glucose/mg tissue min (quartile 53, 72), maltase 504 (quartile 258, 708), sucrase 43 (quartile 25, 58), lactase 8 (quartile 4, 20). Group 1 included 19 people on a low FODMAP diet. The 2nd group included 42 patients who were on a normal diet and received rebamipide 300 mg/day. Patients were monitored weekly for 8 weeks. Results. In 16 patients of the 1st group, abdominal pain and stool disorders decreased, in 15 patients, swelling and rumbling in the abdomen stopped. Glucoamylase activity increased to 196 (quartile 133, 446, р0.024) ng glucose/mg tissue min, maltase activity increased to 889 (quartile 554, 1555, p0.145), sucrase activity increased to 67 (quartile 43, 175, p0.039), lactase activity increased to 13 (quartile 9, 21, p0.02). After the diet was discontinued, intestinal symptoms in patients of group 1 resumed. In 27 patients of the 2nd group after 4 weeks dyspeptic manifestations decreased, in 34 patients the tolerability of products containing FODMAP improved. Continuation of treatment up to 8 weeks contributed to a further improvement in well-being. Glucoamylase activity increased after 4 and 8 weeks to 189 (quartile 107, 357, p0.013) and 203 (quartile 160, 536, p0.005), respectively; maltase up to 812 (quartile 487, 915, p0.005) and 966 (quartile 621, 2195, р0.0012); sucrases up to 60 (quartile 34, 105, p0.013) and 75 (quartile 52, 245, р=0.003); lactase up to 12 (quartile 8, 12, p0.132) and 15 ng glucose/mg tissue min (quartile 10, 20, р0.092). Conclusion. The clinical symptoms of fermentable carbohydrate intolerance and increased membrane enzyme activity are reduced by a low FODMAP diet in patients with ENMT, but clinical symptoms of food intolerance reappear when switching to a normal diet. Treatment with rebamipide improves food tolerance and consistently increases the activity of TSOTS enzymes after 4 and 8 weeks.

[Pharmacokinetics and pharmacodynamics of rebamipide. New possibilities of therapy: A review]

The MedLine database contains 570 publications, including 71 randomized clinical trials and 6 meta-analyses on the rebamipide molecule in 2022. Indications for the use of rebamipide are gastric ulcer, chronic gastritis with hyperacidityin the acute stage, erosive gastritis, prevention of damage to the gastrointestinal mucosa while taking non-steroidal anti-inflammatory drugs, eradication of Helicobacter pylori. Currently trials are studying the efficacy and safety of the drug in gouty and rheumatoid arthritis, osteoarthritis, Sjögren's syndrome, bronchial asthma, vitiligo, atherosclerosis, diseases of the kidneys and liver; using in traumatology to accelerate bone regeneration; in ophthalmology to improve the regeneration of corneal epithelium; in oncology to reduce inflammatory changes in the oral mucosa after chemoradiotherapy. The review article is about the main pharmacokinetic and pharmacodynamic characteristics of rebamipide. A detailed understanding of pharmacodynamics and pharmacokinetics allows for individual selection of therapy based on the characteristics of the patient's body - gender, age, comorbidities; choose the optimal route of administration and dosing regimen; predict adverse effects and drug interactions; be determined with new clinical indications.

Zonulin — regulation of tight contacts in the brain and intestine — facts and hypotheses

In recent years, the interrelationship between the brain and the gut has become an area of high scientific interest. The intestine is responsible not only for digestion, as it contains millions of neurons, its own immune system, and affects the emotional and cognitive processes. The relationship between the gut and the brain suggests that the processes carried out by the gut microbiota play a significant role in the regulation of brain function, and vice versa. A special role here is played by intercellular tight junctions (TJ), where the zonulin protein holds an important place. Zonulin, an unprocessed precursor of mature haptoglobin, is the only physiological modulator of intercellular TJ that can reversibly regulate the permeability of the intestinal (IB) and blood-brain (BBB) barriers in the human body. BBB disruption and altered microbiota composition are associated with many diseases, including neurological disorders and neuroinflammation. That is, there is a gut-brain axis (GBA) — a communication system through which the brain modulates the functions of the gastrointestinal tract (GIT) and vice versa. GBA is based on neuronal, endocrine, and immunological mechanisms that are interconnected at the organismal, organ, cellular, and molecular levels.

[Prevalence of combination of functional dyspepsia and irritable bowel syndrome: a meta-analysis of studies using the Rome III-IV Criteria]

AIM

To systematize data on the prevalence of the combination of functional dyspepsia (FD) and irritable bowel syndrome (IBS) using the Rome IIIIV Criteria.

MATERIALS AND METHODS

A search in electronic databases MEDLINE/PubMed, EMBASE, and Cochrane was conducted. The depth of search was 17 years (from January 2006 to May 2022). Original publications from peer-reviewed periodicals that applied the Rome IIIIV Criteria for diagnosis of FD and IBS in an adult patient population with detailed descriptive statistics to allow the resulting data to be included in the meta-analysis were selected for final analysis.

RESULTS

The final analysis included 38 studies involving 17,993 patients with FD and 15,883 patients with IBS. In the overall pool of studies using the Rome IIIIV Criteria, the pooled prevalence of FD in patients with IBS was 34.625% (95% confidence interval [CI] 28.15941.390), and the pooled prevalence of IBS in patients with FD was 37.549% (95% [CI] 31.51143.787). A random-effects model was used in the analyses since significant heterogeneity between results was found (p0.0001; I298%). Using the Rome III Criteria, the pooled prevalence of FD in patients with IBS was 31.993% (95% CI 26.13538.150; I2=98.17%), while the prevalence of IBS in patients with FD was 34.694% (95% [CI] 29.31940.273; I2=97,89%). An analysis of papers using the Rome IV Criteria demonstrated that the pooled prevalence of FD in patients with IBS was 42.614% (95% CI 18.58868.675; I2=98.97%), and the prevalence of IBS in patients with FD was 50.444% (95% CI 37.95662.904; I2=94,39%).

CONCLUSION

This meta-analysis demonstrated that the prevalence of the combination of FD and IBS identified using the Rome IIIIV Criteria is high and is reported in approximately 1 in 3 patients with the functional gastrointestinal disorders concerned. The prevalence of a combination of FD and IBS identified using the Rome IV Criteria is at least 10% higher than that using the Rome III Criteria.

Esophagoprotective therapy in patients with erosive esophagitis

Aim. To evaluate the advantages of using combined therapy of proton-pump inhibitors (PPIs) and esophagoprotector in comparison with basic therapy of PPIs for 4 weeks based on the results of changes in the endoscopic picture.To compare the effectiveness of 4-week PPI therapy and 4-week combination therapy with PPI and esophagoprotector Alfasoxx (sodium hyaluronate, chondroitin sulfate, poloxomer 407) in patients with erosive esophagitis (EE) of any degree according to the Los Angeles Endoscopic Classification. Materials and methods. 81 patients with EE AC according to the Los Angeles endoscopic classification (1994) was enrolled in the study on the basis of the clinic of Peter the Great, Mechnikov North-Western State Medical University. By computer randomization, patients were divided into the control group 40 patients (pantoprazole 40 mg 1 time per day) and the intervention group 41 patients (pantoprazole 40 mg 1 time per day + Alfasoxx 1 sachet qid). The therapy was carried out for 4 weeks. In all patients before and after therapy, the frequency and severity of the main symptoms of gastroesophageal reflux disease (GERD) were assessed, esophagogastroduodenoscopy was performed. Results. The advantage of combination therapy over standard PPI monotherapy in patients with EE was revealed. According to the results of the control endoscopy, healing of erosions of the esophageal mucosa was observed in 39 out of 41 (95.1%) patients in the intervention group and 32 out of 39 (82.1%) in the control group. The proportion of patients who showed an improvement in the endoscopic picture before and after treatment for 4 weeks by at least 1 level according to the Los Angeles classification was significantly higher in the comparison group 41 patients (100%), while in the control group 33 patients (85%); p0.009. After treatment, the combination therapy group had a lower incidence (p0.01) and severity of heartburn (p0.01). The same results are demonstrated by combination therapy regarding the symptom belching of air: in the study group after treatment, this symptom occurred less frequently (p=0.014), its severity was significantly less than in the control group (p0.01). There was a statistically significant decrease in the need for on-demand antacid therapy in the study group. Conclusion. In this study involving 81 patients with erosive GERD, the benefits of combination therapy were demonstrated. The addition of Alfasoxx medical device to PPI therapy increases the clinical and endoscopic efficacy of therapy. This positive effect is associated with the esophagoprotective properties of the drug, based on unique pharmacodynamic characteristics. Combination therapy for GERD is preferred in patients with EE. Studies have shown the expediency of using Alfasoxx in case of insufficient effectiveness of classical acid-suppressive therapy for GERD.

Irritable bowel syndrome: current aspects of etiology, pathogenesis, clinic and treatment: A review

Among functional gastrointestinal disorders, Irritable bowel syndrome (IBS) rightfully continues to maintain its leading position. IBS is a kind of standard for understanding the pathogenetic essence of functional diseases of the digestive system, since it is the most common, studied and studied pathology. So, for the query "Irritable Bowel Syndrome" in the electronic database PubMed as of July 30, 2022, 16 599 sources were found, and for the query "Irritable Bowel Syndrome" in the scientific electronic library eLIBRARY.RU 6316. The first part of the review deals with topical aspects of the etiology, pathogenesis and clinical presentation of IBS. The urgency of the problem of IBS is associated with a significant decrease in the quality of life of patients. The review focuses on the role of psycho-emotional disorders, changes localized at the level of the intestinal wall; and a new coronavirus infection COVID-19 in the development of IBS. Abdominal pain as the leading manifestation of IBS is associated primarily with spasm. In this context, antispasmodic drugs can be considered not only as symptomatic agents, but also as pathogenetic therapy for IBS. In the second part of the review, the possibilities of one of the myotropic antispasmodics, mebeverine hydrochloride, in the treatment of IBS are considered in detail.

Epithelial protective therapy in comorbid diseases. Practical Guidelines for Physicians

In 2021 the first multidisciplinary National Consensus on the pathophysiological and clinical aspects of Increased Epithelial Permeability Syndrome was published. The proposed guidelines are developed on the basis of this Consensus, by the same team of experts. Twenty-eight Practical Guidelines for Physicians statements were adopted by the Expert Council using the "delphic" method. Such main groups of epithelial protective drugs as proton pump inhibitors, bismuth drugs and probiotics are discussed in these Guidelines from the positions of evidence-based medicine. The clinical and pharmacological characteristics of such a universal epithelial protector as rebamipide, acting at the preepithelial, epithelial and subepithelial levels, throughout gastrointestinal tract, are presented in detail.

Management of patients with digestive diseases during the COVID-19 pandemic. Clinical Practice Guidelines by the Russian scientific medical society of internal medicine (RSMSIM) and the Gastroenterological Scientific Society of Russia (2nd edition)

The presented clinical practice guidelines of the Gastroenterological Scientific Society of Russia (GSSR), diagnostic, and therapeutic approaches for patients with digestive diseases during the COVID-19 pandemic. The guidelines were approved by the XXIII Congress of the GSSR and the 22nd International Slavonic-Baltic Scientifi c Forum “St. Petersburg - Gastro-2020 ON-LINE” (St. Petersburg, June 11, 2020). The presented clinical practice guidelines of the Russian Scientific Medical Society of Internal Medicine (RSMSIM) and the Gastroenterological Scientific Society of Russia (GSSR), diagnostic, and therapeutic approaches for patients with digestive diseases during the COVID-19 pandemic. The recommendations were approved at the XV National Congress of Internal Medicine, XXIII Congress of NOGR on the basis of the 1st edition, adopted at the 22nd International Slavic- Baltic Scientific Forum “St. Petersburg - Gastro-2020 ON-LINE”.