1
|
Mohammed AD, Ball RAW, Jolly A, Nagarkatti P, Nagarkatti M, Kubinak JL. Studying the cellular basis of small bowel enteropathy using high-parameter flow cytometry in mouse models of primary antibody deficiency. bioRxiv 2024:2024.01.25.577009. [PMID: 38352330 PMCID: PMC10862736 DOI: 10.1101/2024.01.25.577009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Background Primary immunodeficiencies are heritable defects in immune system function. Antibody deficiency is the most common form of primary immunodeficiency in humans, can be caused by abnormalities in both the development and activation of B cells, and may result from B-cell-intrinsic defects or defective responses by other cells relevant to humoral immunity. Inflammatory gastrointestinal complications are commonly observed in antibody-deficient patients, but the underlying immune mechanisms driving this are largely undefined. Methods In this study, several mouse strains reflecting a spectrum of primary antibody deficiency (IgA -/- , Aicda -/- , CD19 -/- and J H -/- ) were used to generate a functional small-bowel-specific cellular atlas using a novel high-parameter flow cytometry approach that allows for the enumeration of 59 unique cell subsets. Using this cellular atlas, we generated a direct and quantifiable estimate of immune dysregulation. This estimate was then used to identify specific immune factors most predictive of the severity of inflammatory disease of the small bowel (small bowel enteropathy). Results Results from our experiments indicate that the severity of primary antibody deficiency positively correlates with the degree of immune dysregulation that can be expected to develop in an individual. In the SI of mice, immune dysregulation is primarily explained by defective homeostatic responses in T cell and invariant natural killer-like T (iNKT) cell subsets. These defects are strongly correlated with abnormalities in the balance between protein (MHCII-mediated) versus lipid (CD1d-mediated) antigen presentation by intestinal epithelial cells (IECs) and intestinal stem cells (ISCs), respectively. Conclusions Multivariate statistical approaches can be used to obtain quantifiable estimates of immune dysregulation based on high-parameter flow cytometry readouts of immune function. Using one such estimate, we reveal a previously unrecognized tradeoff between iNKT cell activation and type 1 immunity that underlies disease in the small bowel. The balance between protein/lipid antigen presentation by ISCs may play a crucial role in regulating this balance and thereby suppressing inflammatory disease in the small bowel.
Collapse
|
2
|
Narciso-Schiavon JL, Schiavon LL. Fatty liver and celiac disease: Why worry? World J Hepatol 2023; 15:666-674. [PMID: 37305374 PMCID: PMC10251279 DOI: 10.4254/wjh.v15.i5.666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/27/2023] [Accepted: 04/18/2023] [Indexed: 05/24/2023] Open
Abstract
Celiac disease (CD) is a chronic inflammatory intestinal disorder mediated by the ingestion of gluten in genetically susceptible individuals. Liver involvement in CD has been widely described, and active screening for CD is recommended in patients with liver diseases, particularly in those with autoimmune disorders, fatty liver in the absence of metabolic syndrome, noncirrhotic intrahepatic portal hypertension, cryptogenic cirrhosis, and in the context of liver transplantation. Non-alcoholic fatty liver disease is estimated to affect approximately 25% of the world’s adult population and is the world’s leading cause of chronic liver disease. In view of both diseases’ global significance, and to their correlation, this study reviews the available literature on fatty liver and CD and verifies particularities of the clinical setting.
Collapse
Affiliation(s)
- Janaina Luz Narciso-Schiavon
- Department of Internal Medicine, Gastroenterology Division, Federal University of Santa Catarina, Florianópolis 88040-900, Santa Catarina, Brazil
| | - Leonardo Lucca Schiavon
- Department of Internal Medicine, Gastroenterology Division, Federal University of Santa Catarina, Florianópolis 88040-900, Santa Catarina, Brazil
| |
Collapse
|
3
|
Tansel A, Levinthal DJ. Understanding Our Tests: Hydrogen-Methane Breath Testing to Diagnose Small Intestinal Bacterial Overgrowth. Clin Transl Gastroenterol 2023; 14:e00567. [PMID: 36744854 PMCID: PMC10132719 DOI: 10.14309/ctg.0000000000000567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 01/26/2023] [Indexed: 02/07/2023] Open
Abstract
There is increasing appreciation that small intestinal bacterial overgrowth (SIBO) drives many common gastrointestinal symptoms, including diarrhea, bloating, and abdominal pain. Breath testing via measurement of exhaled hydrogen and methane gases following ingestion of a readily metabolized carbohydrate has become an important noninvasive testing paradigm to help diagnose SIBO. However, because of a number of physiological and technical considerations, how and when to use breath testing in the diagnosis of SIBO remains a nuanced clinical decision. This narrative review provides a comprehensive overview of breath testing paradigms including the indications for testing, how to administer the test, and how patient factors influence breath testing results. We also explore the performance characteristics of breath testing (sensitivity, specificity, positive and negative predictive values, likelihood ratios, and diagnostic odds ratio). Additionally, we describe complementary and alternative tests for diagnosing SIBO. We discuss applications of breath testing for research. Current estimates of SIBO prevalence among commonly encountered high-risk populations are reviewed to provide pretest probability estimates under a variety of clinical situations. Finally, we discuss how to integrate breath test performance characteristics into clinical care decisions using clinical predictors and the Fagan nomogram.
Collapse
Affiliation(s)
- Aylin Tansel
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - David J. Levinthal
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, USA
| |
Collapse
|
4
|
Shah A, Thite P, Hansen T, Kendall BJ, Sanders DS, Morrison M, Jones MP, Holtmann G. Links between celiac disease and small intestinal bacterial overgrowth: A systematic review and meta-analysis. J Gastroenterol Hepatol 2022; 37:1844-1852. [PMID: 35734803 PMCID: PMC9795979 DOI: 10.1111/jgh.15920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/19/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIM Symptoms of small intestinal bacterial overgrowth (SIBO) and celiac disease (CeD) often overlap, and studies suggest a link between SIBO and CeD. We thus conducted a systematic review and meta-analysis to compare SIBO prevalence in CeD patients and controls and assessed effects of antimicrobial therapy on gastrointestinal symptoms in SIBO positive CeD patients. METHODS Electronic databases were searched until February 2022 for studies reporting SIBO prevalence in CeD. Prevalence rates, odds ratio (OR), and 95% confidence intervals (CI) of SIBO in CeD and controls were calculated. RESULTS We included 14 studies, with 742 CeD patients and 178 controls. The pooled prevalence of SIBO in CeD was 18.3% (95% CI: 11.4-28.1), with substantial heterogeneity. Including case-control studies with healthy controls, SIBO prevalence in CeD patients was significantly increased (OR 5.1, 95% CI: 2.1-12.4, P = 0.0001), with minimal heterogeneity. Utilizing breath tests, SIBO prevalence in CeD patients was 20.8% (95% CI: 11.9-33.7), almost two-fold higher compared with culture-based methods at 12.6% (95% CI: 5.1-28.0), with substantial heterogeneity in both analyses. SIBO prevalence in CeD patients nonresponsive to a gluten free diet (GFD) was not statistically higher as compared with those responsive to GFD (OR 1.5, 95% CI: 0.4-5.0, P = 0.511). Antibiotic therapy of SIBO positive CeD patients resulted in improvement in gastrointestinal symptoms in 95.6% (95% CI: 78.0-99.9) and normalization of breath tests. CONCLUSIONS This study suggests a link between SIBO and CeD. While SIBO could explain nonresponse to a GFD in CeD, SIBO prevalence is not statistically higher in CeD patients non-responsive to GFD. The overall quality of the evidence is low, mainly due to substantial "clinical heterogeneity" and the limited sensitivity/specificity of the available diagnostic tests.
Collapse
Affiliation(s)
- Ayesha Shah
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia,Department of Gastroenterology and HepatologyPrincess Alexandra HospitalWoolloongabbaQueenslandAustralia,Translational Research InstituteWoolloongabbaQueenslandAustralia
| | - Parag Thite
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia,Department of Gastroenterology and HepatologyPrincess Alexandra HospitalWoolloongabbaQueenslandAustralia
| | - Teressa Hansen
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia,Department of Gastroenterology and HepatologyPrincess Alexandra HospitalWoolloongabbaQueenslandAustralia,Translational Research InstituteWoolloongabbaQueenslandAustralia
| | - Bradley J Kendall
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia,Department of Gastroenterology and HepatologyPrincess Alexandra HospitalWoolloongabbaQueenslandAustralia
| | - David S Sanders
- Academic Unit of GastroenterologySheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Mark Morrison
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia,Department of Gastroenterology and HepatologyPrincess Alexandra HospitalWoolloongabbaQueenslandAustralia,Diamantina InstituteThe University of QueenslandBrisbaneQueenslandAustralia
| | - Michael P Jones
- Department of PsychologyMacquarie UniversitySydneyNew South WalesAustralia
| | - Gerald Holtmann
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia,Department of Gastroenterology and HepatologyPrincess Alexandra HospitalWoolloongabbaQueenslandAustralia,Translational Research InstituteWoolloongabbaQueenslandAustralia
| |
Collapse
|
5
|
Shah A, Talley NJ, Holtmann G. Current and Future Approaches for Diagnosing Small Intestinal Dysbiosis in Patients With Symptoms of Functional Dyspepsia. Front Neurosci 2022; 16:830356. [PMID: 35600619 PMCID: PMC9121133 DOI: 10.3389/fnins.2022.830356] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/28/2022] [Indexed: 12/12/2022] Open
Abstract
The development and application of next generation sequencing technologies for clinical gastroenterology research has provided evidence that microbial dysbiosis is of relevance for the pathogenesis of gastrointestinal and extra-intestinal diseases. Microbial dysbiosis is characterized as alterations of diversity, function, and density of the intestinal microbes. Emerging evidence suggests that alterations of the gastrointestinal microbiome are important for the pathophysiology of a variety of functional gastrointestinal conditions, e.g., irritable bowel syndrome (IBS) and functional dyspepsia (FD), also known as disorders of brain-gut axis interaction. Clinicians have for many years recognized that small intestinal bacterial overgrowth (SIBO) is typified by a microbial dysbiosis that is underpinned by abnormal bacterial loads in these sites. SIBO presents with symptoms which overlap with symptoms of FD and IBS, point toward the possibility that SIBO is either the cause or the consequence of functional gastrointestinal disorders (FGIDs). More recently, new terms including “intestinal methanogen overgrowth” and “small intestinal fungal overgrowth” have been introduced to emphasize the contribution of methane production by archea and fungi in small intestinal dysbiosis. There is emerging data that targeted antimicrobial treatment of SIBO in patients with FD who simultaneously may or may not have IBS, results in symptom improvement and normalization of positive breath tests. However, the association between SIBO and FGIDs remains controversial, since widely accepted diagnostic tests for SIBO are lacking. Culture of jejunal fluid aspirate has been proposed as the “traditional gold standard” for establishing the diagnosis of SIBO. Utilizing jejunal fluid culture, the results can potentially be affected by cross contamination from oropharyngeal and luminal microbes, and there is controversy regarding the best cut off values for SIBO diagnosis. Thus, it is rarely used in routine clinical settings. These limitations have led to the development of breath tests, which when compared with the “traditional gold standard,” have sub-optimal sensitivity and specificity for SIBO diagnosis. With newer diagnostic approaches–based upon applications of the molecular techniques there is an opportunity to characterize the duodenal and colonic mucosa associated microbiome and associated gut microbiota dysbiosis in patients with various gastrointestinal and extraintestinal diseases. Furthermore, the role of confounders like psychological co-morbidities, medications, dietary practices, and environmental factors on the gastrointestinal microbiome in health and disease also needs to be explored.
Collapse
Affiliation(s)
- Ayesha Shah
- Faculty of Medicine and Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Newcastle, NSW, Australia
| | - Nicholas J. Talley
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Newcastle, NSW, Australia
- College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
| | - Gerald Holtmann
- Faculty of Medicine and Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Newcastle, NSW, Australia
- *Correspondence: Gerald Holtmann,
| |
Collapse
|
6
|
Affiliation(s)
- Ayesha Shah
- Faculty of Medicine and Faculty of Health and Behavioral Sciences, The University of Queensland, Brisbane, Australia. .,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia. .,AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Brisbane, Australia.
| | - Gerald Holtmann
- Faculty of Medicine and Faculty of Health and Behavioral Sciences, The University of Queensland, Brisbane, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia.,AGIRA (Australian Gastrointestinal Research Alliance) and the NHMRC Centre of Research Excellence in Digestive Health, Brisbane, Australia
| |
Collapse
|
7
|
Mohammed AD, Mohammed Z, Roland MM, Chatzistamou I, Jolly A, Schoettmer LM, Arroyo M, Kakar K, Tian Y, Patterson A, Nagarkatti M, Nagarkatti P, Kubinak JL. Defective humoral immunity disrupts bile acid homeostasis which promotes inflammatory disease of the small bowel. Nat Commun 2022; 13:525. [PMID: 35082296 PMCID: PMC8792037 DOI: 10.1038/s41467-022-28126-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 01/04/2022] [Indexed: 12/13/2022] Open
Abstract
Mucosal antibodies maintain gut homeostasis by promoting spatial segregation between host tissues and luminal microbes. Whether and how mucosal antibody responses influence gut health through modulation of microbiota composition is unclear. Here, we use a CD19-/- mouse model of antibody-deficiency to demonstrate that a relationship exists between dysbiosis, defects in bile acid homeostasis, and gluten-sensitive enteropathy of the small intestine. The gluten-sensitive small intestine enteropathy that develops in CD19-/- mice is associated with alterations to luminal bile acid composition in the SI, marked by significant reductions in the abundance of conjugated bile acids. Manipulation of bile acid availability, adoptive transfer of functional B cells, and ablation of bacterial bile salt hydrolase activity all influence the severity of small intestine enteropathy in CD19-/- mice. Collectively, results from our experiments support a model whereby mucosal humoral immune responses limit inflammatory disease of the small bowel by regulating bacterial BA metabolism.
Collapse
Affiliation(s)
- Ahmed Dawood Mohammed
- University of South Carolina School of Medicine Department of Pathology, Microbiology, Immunology 6439 Garners Ferry Rd., Columbia, SC, 29209, USA.,University of Baghdad School of Veterinary Medicine, Baghdad, Iraq
| | - Zahraa Mohammed
- University of South Carolina School of Medicine Department of Pathology, Microbiology, Immunology 6439 Garners Ferry Rd., Columbia, SC, 29209, USA.,Al-Mustansiriyah University School of Medicine Department of Microbiology, Baghdad, Iraq
| | - Mary M Roland
- University of South Carolina School of Medicine Department of Pathology, Microbiology, Immunology 6439 Garners Ferry Rd., Columbia, SC, 29209, USA
| | - Ioulia Chatzistamou
- University of South Carolina School of Medicine Department of Pathology, Microbiology, Immunology 6439 Garners Ferry Rd., Columbia, SC, 29209, USA
| | - Amy Jolly
- University of South Carolina School of Medicine Department of Pathology, Microbiology, Immunology 6439 Garners Ferry Rd., Columbia, SC, 29209, USA
| | - Lillian M Schoettmer
- University of South Carolina School of Medicine Department of Pathology, Microbiology, Immunology 6439 Garners Ferry Rd., Columbia, SC, 29209, USA
| | - Mireya Arroyo
- University of South Carolina School of Medicine Department of Pathology, Microbiology, Immunology 6439 Garners Ferry Rd., Columbia, SC, 29209, USA
| | - Khadija Kakar
- University of South Carolina School of Medicine Department of Pathology, Microbiology, Immunology 6439 Garners Ferry Rd., Columbia, SC, 29209, USA
| | - Yuan Tian
- Pennsylvania State University Department of Veterinary and Biomedical Sciences, State College, PA, USA
| | - Andrew Patterson
- Pennsylvania State University Department of Veterinary and Biomedical Sciences, State College, PA, USA
| | - Mitzi Nagarkatti
- University of South Carolina School of Medicine Department of Pathology, Microbiology, Immunology 6439 Garners Ferry Rd., Columbia, SC, 29209, USA
| | - Prakash Nagarkatti
- University of South Carolina School of Medicine Department of Pathology, Microbiology, Immunology 6439 Garners Ferry Rd., Columbia, SC, 29209, USA
| | - Jason L Kubinak
- University of South Carolina School of Medicine Department of Pathology, Microbiology, Immunology 6439 Garners Ferry Rd., Columbia, SC, 29209, USA.
| |
Collapse
|
8
|
Ghoshal UC, Sachdeva S, Ghoshal U, Misra A, Puri AS, Pratap N, Shah A, Rahman MM, Gwee KA, Tan VPY, Ahmed T, Lee YY, Ramakrishna BS, Talukdar R, Rana SV, Sinha SK, Chen M, Kim N, Holtmann G. Asian-Pacific consensus on small intestinal bacterial overgrowth in gastrointestinal disorders: An initiative of the Indian Neurogastroenterology and Motility Association. Indian J Gastroenterol 2022; 41:483-507. [PMID: 36214973 PMCID: PMC9549446 DOI: 10.1007/s12664-022-01292-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/02/2022] [Indexed: 02/04/2023]
Abstract
In the clinical setting, small intestinal bacterial overgrowth (SIBO) is a frequent, but under-diagnosed entity. SIBO is linked to various gastrointestinal (GI) and non-GI disorders with potentially significant morbidity. The optimal management of SIBO is undefined while there is a lack of published consensus guidelines. Against this background, under the auspices of the Indian Neurogastroenterology and Motility Association (INMA), formerly known as the Indian Motility and Functional Diseases Association (IMFDA), experts from the Asian-Pacific region with extensive research and clinical experience in the field of gut dysbiosis including SIBO developed this evidence-based practice guideline for the management of SIBO utilizing a modified Delphi process based upon 37 consensus statements, involving an electronic voting process as well as face-to-face meetings and review of relevant supporting literature. These statements include 6 statements on definition and epidemiology; 11 on etiopathogenesis and pathophysiology; 5 on clinical manifestations, differential diagnosis, and predictors; and 15 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservations was 80% or higher, the statement was regarded as accepted. The members of the consensus team consider that this guideline would be valuable to inform clinical practice, teaching, and research on SIBO in the Asian-Pacific region as well as in other countries.
Collapse
Affiliation(s)
- Uday C. Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014 India
| | - Sanjeev Sachdeva
- Department of Gastroenterology, G B Pant Hospital, New Delhi, 110 002 India
| | - Ujjala Ghoshal
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014 India
| | - Asha Misra
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014 India
| | | | | | - Ayesha Shah
- University of Queensland, Faculty of Medicine, and Princess Alexandra Hospital, Department of Gastroenterology and Hepatology, Brisbane, Queensland, Australia
| | - M. Masudur Rahman
- Sheikh Russel National Gastroliver Institute and Hospital, Dhaka, Bangladesh
| | - Kok Ann Gwee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ,Stomach, Liver and Bowel Centre, Gleneagles Hospital, Singapore, Singapore
| | - Victoria P Y Tan
- Faculty of Medicine, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia ,GI Function and Motility Unit, Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - B S Ramakrishna
- SIMS Institute of Gastroenterology, Hepatology, and Transplantation, SRM Institutes for Medical Science, Chennai, 600 026 India
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, 500 082 India
| | - S V Rana
- Department of Biochemistry, All India Institute of Medical Sciences, Rishikesh, 249 203 India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012 India
| | - Minhu Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Nayoung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Gerald Holtmann
- University of Queensland, Faculty of Medicine, and Princess Alexandra Hospital, Department of Gastroenterology and Hepatology, Brisbane, Queensland, Australia
| |
Collapse
|
9
|
Montoro-Huguet MA, Belloc B, Domínguez-Cajal M. Small and Large Intestine (I): Malabsorption of Nutrients. Nutrients 2021; 13:1254. [PMID: 33920345 PMCID: PMC8070135 DOI: 10.3390/nu13041254] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 02/06/2023] Open
Abstract
Numerous disorders can alter the physiological mechanisms that guarantee proper digestion and absorption of nutrients (macro- and micronutrients), leading to a wide variety of symptoms and nutritional consequences. Malabsorption can be caused by many diseases of the small intestine, as well as by diseases of the pancreas, liver, biliary tract, and stomach. This article provides an overview of pathophysiologic mechanisms that lead to symptoms or complications of maldigestion (defined as the defective intraluminal hydrolysis of nutrients) or malabsorption (defined as defective mucosal absorption), as well as its clinical consequences, including both gastrointestinal symptoms and extraintestinal manifestations and/or laboratory abnormalities. The normal uptake of nutrients, vitamins, and minerals by the gastrointestinal tract (GI) requires several steps, each of which can be compromised in disease. This article will first describe the mechanisms that lead to poor assimilation of nutrients, and secondly discuss the symptoms and nutritional consequences of each specific disorder. The clinician must be aware that many malabsorptive disorders are manifested by subtle disorders, even without gastrointestinal symptoms (for example, anemia, osteoporosis, or infertility in celiac disease), so the index of suspicion must be high to recognize the underlying diseases in time.
Collapse
Affiliation(s)
- Miguel A. Montoro-Huguet
- Departamento de Medicina, Psiquiatría y Dermatología, Facultad de Ciencias de la Salud y del Deporte, University of Zaragoza, 50009 Zaragoza, Spain
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge de Huesca, 22004 Huesca, Spain; (B.B.); (M.D.-C.)
- Aragonese Institute of Health Sciences (IACS), 50009 Zaragoza, Spain
| | - Blanca Belloc
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge de Huesca, 22004 Huesca, Spain; (B.B.); (M.D.-C.)
- Aragonese Institute of Health Sciences (IACS), 50009 Zaragoza, Spain
| | - Manuel Domínguez-Cajal
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge de Huesca, 22004 Huesca, Spain; (B.B.); (M.D.-C.)
- Aragonese Institute of Health Sciences (IACS), 50009 Zaragoza, Spain
| |
Collapse
|
10
|
Wang FY, Chi CC. Rosacea, Germs, and Bowels: A Review on Gastrointestinal Comorbidities and Gut-Skin Axis of Rosacea. Adv Ther 2021; 38:1415-24. [PMID: 33507499 DOI: 10.1007/s12325-021-01624-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/12/2021] [Indexed: 12/16/2022]
Abstract
Rosacea is a chronic inflammatory disease with complicated pathophysiology that involves genetic and environmental elements and dysregulation of innate and adaptive immunity, neurovascular responses, microbiome colonization or infection, resulting in recurrent inflammation. Rosacea has been reported associated with various gastrointestinal diseases including inflammatory bowel disease, celiac disease, irritable bowel syndrome, gastroesophageal reflux disease, Helicobacter pylori (HP) infection, and small intestine bacterial overgrowth (SIBO). The link may involve common predisposing genetic, microbiota, and immunological factors, comprising the theory of the gut–skin axis. Although the evidence is still controversial, interestingly, medications for eradicating SIBO and HP provided an effective and prolonged therapeutic response in rosacea, and conventional therapy for which is usually disappointing because of frequent relapses. In this article, we review the current evidence and discuss probable mechanisms of the association between rosacea and gastrointestinal comorbidities.
Collapse
|
11
|
Safi MAA, Jiman-Fatani AA, Saadah OI. Small intestinal bacterial overgrowth among patients with celiac disease unresponsive to a gluten free diet. Turk J Gastroenterol 2020; 31:767-774. [PMID: 33361039 DOI: 10.5152/tjg.2020.19627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS Little is known about the relationship between small intestinal bacterial overgrowth (SIBO) and celiac disease (CeD) in patients who are unresponsive to a gluten-free diet (GFD). This study aimed to determine the SIBO prevalence in patients with CeD who are unresponsive to a GFD. MATERIALS AND METHODS We conducted a case-control study from July 2012 to September 2014. We included 32 patients with CeD who were unresponsive to a GFD and 52 healthy age- and sex-matched controls. Demographic, clinical, and laboratory data were obtained from patients' medical records. Antitissue transglutaminase antibody determined by enzyme-linked immunosorbent assay was recorded, and lactulose hydrogen breath test (LHBT) was used to detect SIBO in all participants. Microbiological analysis, including jejunal aspirates obtained using upper endoscopy, was performed for only 20 patients with CeD. RESULTS A total of 10 (31%) of 32 patients with CeD and 4 (7.7%) of 52 controls tested positive for LHBT, with a statistically significant difference (p=0.007). Of 20 cultures, 3 (15%) were positive with no statistically significant correlation between the cultures and LHBT (p=0.05). In a subgroup analysis of children who were 18 years old or younger, 7/24 (29.2%) patients with CeD had a positive LHBT compared with 3/32 (9.4%) controls, but this difference was not statistically significant (p=0.08). CONCLUSION The prevalence of SIBO was 31% in unresponsive patients with CeD according to LHBT and 15% in the quantitative culture of the jejunal aspirate, which is comparable with the published Western literature.
Collapse
Affiliation(s)
- Mohammad-Ayman A Safi
- Department of Medical Microbiology and Parasitology, King Abdulaziz University Faculty of Medicine, Jeddah, Saudi Arabia
| | - Asif A Jiman-Fatani
- Department of Medical Microbiology and Parasitology, King Abdulaziz University Faculty of Medicine, Jeddah, Saudi Arabia
| | - Omar I Saadah
- Pediatric Gastroenterology Unit, Department of Pediatrics, King Abdulaziz University Faculty of Medicine, Jeddah, Saudi Arabia
| |
Collapse
|
12
|
Kucheryavyy YA, Andreev DN, Maev IV. [Prevalence of small bowel bacterial overgrowth in patients with functional dyspepsia: a meta-analysis]. TERAPEVT ARKH 2020; 92:53-58. [PMID: 33720574 DOI: 10.26442/00403660.2020.12.200433] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/07/2021] [Indexed: 12/12/2022]
Abstract
AIM Systematization of data on the frequency of detection of the syndrome of bacterial overgrowth in the small intestine (SIBO) in patients with functional dyspepsia (FD). MATERIALS AND METHODS MEDLINE/PubMed, EMBASE, Cochrane, Google Scholar, the Russian Science Citation Index (RSCI) through July 2020 were searched to identify studies evaluating the prevalence of SIBO in FD. In addition, a search for relevant abstracts was carried out in the electronic databases of the United European Gastroenterology Week (UEG), American College of Gastroenterology (ACG), International Conference on Nutrition and Food (ICNF). For the final analysis, publications were selected that used validated tests for the assessment of SIBO (hydrogen breath test using glucose or lactulose) with detailed descriptive statistics, allowing the resulting data to be included in the meta-analysis. RESULTS The final analysis included 7 studies with 1248 patients with FD. Overall pooled prevalence of SIBO in patients with FD was 34.73% (95% CI 24.80745.383). There was significant heterogeneity between the results (p0.0001; I2=89.91%). When excluded from the meta-analysis of a study in which the incidence of SIBO was studied in patients with refractory FD, the pooled prevalence was 38.98% (95% CI 28.96449.490). CONCLUSION This meta-analysis has demonstrated that SIBO is often associated with FD and is observed in about every third patient with this functional gastrointestinal tract disease.
Collapse
Affiliation(s)
- Y A Kucheryavyy
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - D N Andreev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - I V Maev
- Yevdokimov Moscow State University of Medicine and Dentistry
| |
Collapse
|
13
|
Liu Chen Kiow J, Bellila R, Therrien A, Sidani S, Bouin M. Predictors of Small Intestinal Bacterial Overgrowth in Symptomatic Patients Referred for Breath Testing. J Clin Med Res 2020; 12:655-661. [PMID: 33029272 PMCID: PMC7524565 DOI: 10.14740/jocmr4320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/03/2020] [Indexed: 11/11/2022] Open
Abstract
Background Indications for a breath test (BT) are well established in the symptomatic patient with risk factors predisposing them to small intestinal bacterial overgrowth (SIBO). Characteristics and the profile of this population are not well known. Our objective was to study the characteristics of patients undergoing a BT for SIBO and to identify factors associated with a positive BT. Methods Retrospective study was conducted from 2012 to 2016 at the neurogastroenterology unit of the Centre Hospitalier de l'Universite de Montreal (CHUM). All patients who completed a BT (lactulose and/or glucose) were included. Demographics and clinical factors were analyzed to identify predictors of positive BT. Type of antibiotic treatment and clinical response were compiled. Groups of patients with (SIBO+) and without SIBO (SIBO-) were also compared. Results A total of 136 patients were included in the study (mean age 51.2, range 20 - 80 years; 63% women), and SIBO was detected in 33.8% (n = 46). Both groups were similar in terms of age, body mass index, and gender. SIBO was significantly associated with the presence of abdominal pain (odds ratio (OR) = 4.78; P < 0.05), bloating (OR = 5.39; P < 0.05), smoking (OR = 6.66; P < 0.05), and anemia (OR = 4.08; P < 0.05). No association was identified with gender, age, obesity, and risk factors for SIBO. Antibiotics were used in 43% of patients with a positive BT, but clinical response was not significantly different in the subgroup that received antibiotics versus the subgroup that did not. Conclusions The prevalence of SIBO is high in symptomatic patients who underwent breath testing. Abdominal pain, bloating, smoking, and anemia are strongly associated with SIBO. Treatment of SIBO with antibiotics needs to be further investigated to better determine its efficacy on gastrointestinal symptoms.
Collapse
Affiliation(s)
- Jeremy Liu Chen Kiow
- Department of Gastroenterology, Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, QC, Canada
| | - Ratiba Bellila
- Department of Gastroenterology, Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, QC, Canada
| | - Amelie Therrien
- Department of Gastroenterology, Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, QC, Canada
| | - Sacha Sidani
- Department of Gastroenterology, Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, QC, Canada
| | - Mickael Bouin
- Department of Gastroenterology, Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, QC, Canada
| |
Collapse
|
14
|
El Kurdi B, Babar S, El Iskandarani M, Bataineh A, Lerch MM, Young M, Singh VP. Factors That Affect Prevalence of Small Intestinal Bacterial Overgrowth in Chronic Pancreatitis: A Systematic Review, Meta-Analysis, and Meta-Regression. Clin Transl Gastroenterol 2019; 10:e00072. [PMID: 31517648 DOI: 10.14309/ctg.0000000000000072] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Small intestinal bacterial overgrowth (SIBO) can complicate chronic pancreatitis (CP) and interfere with management. Its predisposing factors in CP and treatment response are unknown. In this review, we evaluated factors affecting disease burden. METHODS A computerized search of PubMed and EMBASE databases from inception through May 2019 was done for studies correlating SIBO with CP. Studies were screened, and relevant data were extracted and analyzed. Pooled prevalence, odds ratio (OR), and meta-regression were performed using the random effects model as classically described by Borenstein et al. (2009). SIBO's relation to diabetes mellitus (DM), pancreatic exocrine insufficiency (PEI), narcotic use, and proton-pump inhibitor use was investigated. Treatment response was pooled across studies. P value < 0.05 was considered significant. RESULTS In 13 studies containing 518 patients with CP, SIBO prevalence was 38.6% (95% confidence interval [CI] 25.5-53.5). OR for SIBO in CP vs controls was 5.58 (95% CI 2.26-13.75). Meta-regression showed that PEI and the diagnostic test used were able to explain 54% and 43% of the variance in SIBO prevalence across studies, respectively. DM and PEI were associated with increased SIBO in CP with OR (2.1, 95% CI 1.2-3.5) and OR (2.5, 95% CI 1.3-4.8), respectively. Symptomatic improvement was reported in 76% of patients after SIBO treatment. DISCUSSION SIBO complicates 38% of CP with OR of 5.58 indicating a predisposition for this condition. PEI correlates with SIBO in CP and might play a role in pathophysiology. DM and PEI are associated with increased SIBO in CP. Treatment of SIBO may lead to symptomatic improvement.
Collapse
|
15
|
Losurdo G, Salvatore D'Abramo F, Indellicati G, Lillo C, Ierardi E, Di Leo A. The Influence of Small Intestinal Bacterial Overgrowth in Digestive and Extra-Intestinal Disorders. Int J Mol Sci 2020; 21:E3531. [PMID: 32429454 DOI: 10.3390/ijms21103531] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 02/07/2023] Open
Abstract
Small intestinal bacterial overgrowth (SIBO) is a condition hallmarked by an increase in the concentration of colonic-type bacteria in the small bowel. Watery diarrhea, bloating, abdominal pain and distension are the most common clinical manifestations. Additionally, malnutrition and vitamin (B12, D, A, and E) as well as minerals (iron and calcium) deficiency may be present. SIBO may mask or worsen the history of some diseases (celiac disease, irritable bowel disease), may be more common in some extra-intestinal disorders (scleroderma, obesity), or could even represent a pathogenetic link with some diseases, in which a perturbation of intestinal microbiota may be involved. On these bases, we performed a review to explore the multiple links between SIBO and digestive and extra-intestinal diseases.
Collapse
|
16
|
Affiliation(s)
| | - Gal Winter
- School of Science and Technology, University of New England , Armidale, Australia
| |
Collapse
|
17
|
Shah A, Talley NJ, Jones M, Kendall BJ, Koloski N, Walker MM, Morrison M, Holtmann GJ. Small Intestinal Bacterial Overgrowth in Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis of Case-Control Studies. Am J Gastroenterol 2020; 115:190-201. [PMID: 31913194 DOI: 10.14309/ajg.0000000000000504] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION We conducted a systematic review and meta-analysis to compare the prevalence of small intestinal bacterial overgrowth (SIBO) in patients with irritable bowel syndrome (IBS) and controls. METHODS Electronic databases were searched up to December 2018 for studies reporting SIBO prevalence in patients with IBS. Prevalence rates, odds ratios (ORs), and 95% confidence intervals (CIs) of SIBO in patients with IBS and controls were calculated. RESULTS We included 25 studies with 3,192 patients with IBS and 3,320 controls. SIBO prevalence in patients with IBS was significantly increased compared with controls (OR = 3.7, 95% CI 2.3-6.0). In studies using only healthy controls, the OR for SIBO in patients with IBS was 4.9 (95% CI 2.8-8.6). With breath testing, SIBO prevalence in patients with IBS was 35.5% (95% CI 33.6-37.4) vs 29.7% (95% CI 27.6-31.8) in controls. Culture-based studies yielded a SIBO prevalence of 13.9% (95% CI 11.5-16.4) in patients with IBS and 5.0% (95% CI 3.9-6.2) in controls with a cutoff value of 10 colony-forming units per milliliter vs 33.5% (95% CI 30.1-36.9) in patients with IBS and 8.2% (95% CI 6.8-9.6) in controls with a cutoff value of 10 colony-forming unit per milliliter, respectively. SIBO prevalence diagnosed by lactulose breath test is much greater in both patients with IBS (3.6-fold) and controls (7.6-fold) compared with glucose breath test. Similar difference is seen when lactulose breath test is compared with culture methods. OR for SIBO in patients with IBS-diarrhea compared with IBS-constipation was 1.86 (95% CI 1.83-2.8). Methane-positive breath tests were significantly more prevalent in IBS-constipation compared with IBS-diarrhea (OR = 2.3, 95% CI 1.2-4.2). In patients with IBS, proton pump inhibitor was not associated with SIBO (OR = 0.8, 95% CI 0.5-1.5, P = 0.55). DISCUSSION This systematic review and meta-analysis suggests a link between IBS and SIBO. However, the overall quality of the evidence is low. This is mainly due to substantial "clinical heterogeneity" due to lack of uniform selection criteria for cases and controls and limited sensitivity and specificity of the available diagnostic tests.
Collapse
|
18
|
Losurdo G, Leandro G, Ierardi E, Perri F, Barone M, Principi M, Di Leo A. Breath Tests for the Non-invasive Diagnosis of Small Intestinal Bacterial Overgrowth: A Systematic Review With Meta-analysis. J Neurogastroenterol Motil 2020; 26:16-28. [PMID: 31743632 PMCID: PMC6955189 DOI: 10.5056/jnm19113] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/29/2019] [Accepted: 09/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND/AIMS Small intestinal bacterial overgrowth (SIBO) diagnosis is usually based on non-invasive breath tests (BTs), namely lactulose BT (LBT) and glucose BT (GBT). However, divergent opinions and problems of parameter standardization are still controversial aspects. We aim to perform a meta-analysis to analyze diagnostic performance of LBT/GBT for SIBO diagnosis. METHODS We searched in main literature databases articles in which SIBO diagnosis was achieved by LBT/GBT in comparison to jejunal aspirate culture (reference gold standard). We calculated pooled sensitivity, specificity, positive, and negative likelihood ratios and diagnostic odd ratios. Summary receiver operating characteristic curves were drawn and pooled areas under the curve were calculated. RESULTS We selected 14 studies. Pooled sensitivity of LBT and GBT was 42.0% and 54.5%, respectively. Pooled specificity of LBT and GBT was 70.6% and 83.2%, respectively. When delta over baseline cut-off > 20 H2 parts per million (ppm) was used, GBT sensitivity and specificity were 47.3% and 80.9%; when the cutoff was other than and lower than > 20 ppm, sensitivity and specificity were 61.7% and 86.0%. In patients with abdominal surgery history, pooled GBT sensitivity and specificity gave the impression of having a better performance (81.7% and 78.8%) compared to subjects without any SIBO predisposing condition (sensitivity = 40.6% and specificity = 84.0%). CONCLUSIONS GBT seems to work better than LBT. A cut-off of delta H2 expired other than and lower than > 20 ppm shows a slightly better result than > 20 ppm. BTs demonstrate the best effectiveness in patients with surgical reconstructions of gastrointestinal tract.
Collapse
Affiliation(s)
- Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro”, Piazza Giulio Cesare, Bari,
Italy
| | - Gioacchino Leandro
- Gastroenterology Unit, National Institute of Research for Gastroenterology “Saverio De Bellis”, Castellana Grotte, Bari,
Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro”, Piazza Giulio Cesare, Bari,
Italy
| | - Francesco Perri
- Digestive Endoscopy Unit, National Institute of Research “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Foggia,
Italy
| | - Michele Barone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro”, Piazza Giulio Cesare, Bari,
Italy
| | - Mariabeatrice Principi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro”, Piazza Giulio Cesare, Bari,
Italy
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro”, Piazza Giulio Cesare, Bari,
Italy
- Correspondence: Alfredo Di Leo, MD, PhD, Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy, Tel: +39-080-559-3452, Fax: +39-080-559-3088, E-mail:
| |
Collapse
|
19
|
Chetcuti Zammit S, Sanders DS, Sidhu R. Coeliac disease: older patients have the most extensive small bowel involvement on capsule endoscopy. Eur J Gastroenterol Hepatol 2019; 31:1496-1501. [PMID: 31464789 DOI: 10.1097/meg.0000000000001503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The relation between symptomatology, serology and findings on small bowel capsule endoscopy (SBCE) in patients with coeliac disease (CD) remains unclear. Clarifying such associations will help to determine whether symptoms and serology can predict severity and extent of disease on SBCE. METHODS Patients with newly diagnosed CD were recruited. Information on SBCE was recorded. Signs and symptoms at presentation, serological markers and histological classification of the disease in the duodenum were noted. RESULTS Sixty patients with newly diagnosed CD (mean age: 44.9 years, SD: ±17.4, 17-76) were included in this study. Older patients (P = 0.025) and patients presenting with iron deficiency anaemia had more extensive small bowel (SB) involvement (25.7% vs. 13.5%; P = 0.026). Those with weight loss were more likely to have SB involvement beyond the duodenum (37.5% vs. 5.8%; P = 0.027). Patients presenting with iron deficiency anaemia (53.5 vs. 42.4 years; P = 0.038) and weight loss (60.5 vs. 42.4 years; P = 0.009) were significantly older at diagnosis. Serum albumin was lower in those patients diagnosed later on in life (Pearson correlation -0.0361; P = 0.007). There was no significant association between anti-tissue transglutaminase antibody (P = 0.396) and extent of affected SB mucosa. Patients with more severe Marsh scores on histology from the duodenal bulb had more extensive SB involvement (P = 0.017). CONCLUSIONS This is the largest study on the use of SBCE in newly diagnosed CD. Older patients are likely to have more extensive disease on SBCE at diagnosis. Symptoms and serology had no impact on the findings on SBCE apart from weight loss and iron deficiency anaemia.
Collapse
|
20
|
Ryabkova VA, Churilov LP, Shoenfeld Y. Neuroimmunology: What Role for Autoimmunity, Neuroinflammation, and Small Fiber Neuropathy in Fibromyalgia, Chronic Fatigue Syndrome, and Adverse Events after Human Papillomavirus Vaccination? Int J Mol Sci 2019; 20:E5164. [PMID: 31635218 PMCID: PMC6834318 DOI: 10.3390/ijms20205164] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/26/2019] [Accepted: 10/16/2019] [Indexed: 02/06/2023] Open
Abstract
Fibromyalgia is a disorder characterized by chronic widespread pain and non-pain symptoms, such as fatigue, dysautonomia, and cognitive and sleep disturbances. Its pathogenesis and treatment continue to be the subject of debate. We highlight the role of three mechanisms-autoimmunity, neuroinflammation, and small fiber neuropathy-in the pathogenesis of the disease. These mechanisms are shown to be closely interlinked (also on a molecular level), and the review considers the implementation of this relationship in the search for therapeutic options. We also pay attention to chronic fatigue syndrome, which overlaps with fibromyalgia, and propose a concept of "autoimmune hypothalamopathy" for its pathogenesis. Finally, we analyze the molecular mechanisms underlying the neuroinflammatory background in the development of adverse events following HPV vaccination and suggesting neuroinflammation, which could exacerbate the development of symptoms following HPV vaccination (though this is hotly debated), as a model for fibromyalgia pathogenesis.
Collapse
Affiliation(s)
- Varvara A Ryabkova
- Laboratory of the Mosaic of Autoimmunity, Saint Petersburg State University, Saint-Petersburg 199034, Russian Federation.
| | - Leonid P Churilov
- Laboratory of the Mosaic of Autoimmunity, Saint Petersburg State University, Saint-Petersburg 199034, Russian Federation.
- Saint Petersburg Research Institute of Phthisiopulmonology; Saint-Petersburg 191036, Russian Federation.
| | - Yehuda Shoenfeld
- Laboratory of the Mosaic of Autoimmunity, Saint Petersburg State University, Saint-Petersburg 199034, Russian Federation.
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, affiliated to Tel-Aviv University School of Medicine, Tel-Hashomer 52621, Israel.
| |
Collapse
|
21
|
Cichewicz AB, Mearns ES, Taylor A, Boulanger T, Gerber M, Leffler DA, Drahos J, Sanders DS, Thomas Craig KJ, Lebwohl B. Diagnosis and Treatment Patterns in Celiac Disease. Dig Dis Sci 2019; 64:2095-106. [PMID: 30820708 DOI: 10.1007/s10620-019-05528-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/08/2019] [Indexed: 02/07/2023]
Abstract
Celiac disease (CD) is an immune-mediated gastrointestinal (GI) disorder driven by innate and adaptive immune responses to gluten. Presentation of CD has changed over time, with non-GI symptoms, such as anemia and osteoporosis, presenting more commonly. With improved screening and diagnostic methods, the reported prevalence of CD has increased globally, and there is considerable global variation in diagnostic and treatment practices. The objective of this study was to describe the current state of CD diagnosis and treatment patterns. A targeted review of literature from MEDLINE, Embase, the Cochrane Library, and screening of relevant conference abstracts was performed. The generally recommended diagnostic approach is GI endoscopy with small bowel biopsy; however, in selected patients, biopsy may be avoided and diagnosis based on positive serology and clinical symptoms. Diagnosis often is delayed; the average diagnostic delay after symptom onset is highly variable and can last up to 12 years. Barriers to accurate and timely diagnosis include atypical presentation, lack of physician awareness about current diagnostic criteria, misdiagnosis, and limited access to specialists. Currently, strict adherence to a gluten-free diet (GFD) is the only recommended treatment, which is not successful in all patients. Only one-third of patients are monitored regularly following diagnosis. Unmet needs for CD include improvements in the accuracy and timeliness of diagnosis, and the development of treatments for both refractory CD and GFD nonresponsive CD. Further research should investigate the impact of education about gluten-free eating and the availability of gluten-free foods support adherence and improve outcomes in patients with CD.
Collapse
|
22
|
Abstract
Levothyroxine, a largely prescribed drug with a narrow therapeutic index, is often a lifelong treatment. The therapeutic efficacy of T4 may be marred by behavioral, pharmacologic, and pathologic issues acting as interfering factors. Despite a continuous search for an optimal T4 treatment, a significant number of patients fail to show a complete chemical and/or clinical response to this reference dose of T4. Gastrointestinal malabsorption of oral T4 represents an emerging cause of refractory hypothyroidism and may be more frequent than previously reputed. In this review, we examine the pharmacologic features of T4 preparations and their linkage with the intestinal absorption of the hormone. We have stressed the major biochemical and pharmacologic characteristics of T4 and its interaction with the putative transporter at the intestinal level. We have examined the interfering role of nutrients, foods, and drugs on T4 absorption at the gastric and intestinal levels. The impact of gastrointestinal disorders on T4 treatment efficacy has been also analyzed, in keeping with the site of action and the interfering mechanisms. Based on the evidence obtained from the literature, we also propose a schematic diagnostic workup for the most frequent and often hidden gastrointestinal diseases impairing T4 absorption.
Collapse
Affiliation(s)
- Camilla Virili
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Giulia Santaguida
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.,Endocrinology Unit, AUSL Latina, Latina, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Policlinico Universitario G. Martino, Messina, Italy.,Master Program on Childhood, Adolescent and Women's Endocrine Health, University of Messina, Policlinico Universitario G. Martino, Messina, Italy.,Interdepartmental Program of Molecular and Clinical Endocrinology, and Women's Endocrine Health, University Hospital, Policlinico Universitario G. Martino, Messina, Italy
| | - Marco Centanni
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy.,Endocrinology Unit, AUSL Latina, Latina, Italy
| |
Collapse
|
23
|
Abstract
PURPOSE OF REVIEW To critically review recent (past 3 years) literature on the definition, diagnosis, and management of small intestinal bacterial overgrowth (SIBO). RECENT FINDINGS While various series continue to illustrate the occurrence of SIBO in disease states where well-known risk factors for its occurrence are present (hypochlorhydria, disorders of intestinal structure or motor function, pancreatic insufficiency, and chronic liver disease, for example), the current challenge is in defining the limits of SIBO. Is SIBO truly common among those with "functional" gastrointestinal symptoms where there is no evidence of maldigestion or malabsorption; the original hallmarks of SIBO? Our attempts to address this question continue to be hampered by the limitations of our diagnostic tool kit. There is hope-the application of modern molecular techniques to the study of the small intestinal microbiome, together with some innovative sampling techniques, such as real-time intestinal gas sampling, may soon allow us to truly define the spectrum of SIBO. SIBO, once removed from its original confines as a cause of malabsorption syndrome, has proven to be an elusive and moving target. Only the most rigorous studies employing validated methodologies will finally corral this mysterious entity.
Collapse
Affiliation(s)
- Eamonn M M Quigley
- Lynda K and David M Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital, Weill Cornell Medical College, Houston, TX, USA.
- Houston Methodist Gastroenterology Associates, 6550 Fannin St, SM 1201, Houston, TX, 77030, USA.
| |
Collapse
|
24
|
Avelar Rodriguez D, Ryan PM, Toro Monjaraz EM, Ramirez Mayans JA, Quigley EM. Small Intestinal Bacterial Overgrowth in Children: A State-Of-The-Art Review. Front Pediatr 2019; 7:363. [PMID: 31552207 PMCID: PMC6737284 DOI: 10.3389/fped.2019.00363] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/20/2019] [Indexed: 12/11/2022] Open
Abstract
Small intestinal bacterial overgrowth (SIBO) is a heterogenous and poorly understood entity characterised by an excessive growth of select microorganisms within the small intestine. This excessive bacterial biomass, in turn, disrupts host physiology in a myriad of ways, leading to gastrointestinal and non-gastrointestinal symptoms and complications. SIBO is a common cause of non-specific gastrointestinal symptoms in children, such as chronic abdominal pain, abdominal distention, diarrhoea, and flatulence, amongst others. In addition, it has recently been implicated in the pathophysiology of stunting, a disease that affects millions of children worldwide. Risk factors such as acid-suppressive therapies, alterations in gastrointestinal motility and anatomy, as well as impoverished conditions, have been shown to predispose children to SIBO. SIBO can be diagnosed via culture-dependant or culture-independent approaches. SIBO's epidemiology is limited due to the lack of uniformity and consensus of its diagnostic criteria, as well as the paucity of literature available. Antibiotics remain the first-line treatment option for SIBO, although emerging modalities such as probiotics and diet manipulation could also have a role. Herein, we present a state-of-the-art-review which aims to comprehensively outline the most current information on SIBO in children, with particular emphasis on the gut microbiota.
Collapse
Affiliation(s)
- David Avelar Rodriguez
- Pediatric Gastroenterology and Nutrition Unit, National Institute of Pediatrics, Mexico City, Mexico
| | | | | | | | - Eamonn Martin Quigley
- Lynda K. and David M. Underwood Center for Digestive Disorders, Houston Methodist Hospital, Houston, TX, United States
| |
Collapse
|
25
|
Cristofori F, Indrio F, Miniello VL, De Angelis M, Francavilla R. Probiotics in Celiac Disease. Nutrients 2018; 10:E1824. [PMID: 30477107 DOI: 10.3390/nu10121824] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/06/2018] [Accepted: 11/15/2018] [Indexed: 02/06/2023] Open
Abstract
Recently, the interest in the human microbiome and its interplay with the host has exploded and provided new insights on its role in conferring host protection and regulating host physiology, including the correct development of immunity. However, in the presence of microbial imbalance and particular genetic settings, the microbiome may contribute to the dysfunction of host metabolism and physiology, leading to pathogenesis and/or the progression of several diseases. Celiac disease (CD) is a chronic autoimmune enteropathy triggered by dietary gluten exposure in genetically predisposed individuals. Despite ascertaining that gluten is the trigger in CD, evidence has indicated that intestinal microbiota is somehow involved in the pathogenesis, progression, and clinical presentation of CD. Indeed, several studies have reported imbalances in the intestinal microbiota of patients with CD that are mainly characterized by an increased abundance of Bacteroides spp. and a decrease in Bifidobacterium spp. The evidence that some of these microbial imbalances still persist in spite of a strict gluten-free diet and that celiac patients suffering from persistent gastrointestinal symptoms have a desert gut microbiota composition further support its close link with CD. All of this evidence gives rise to the hypothesis that probiotics might play a role in this condition. In this review, we describe the recent scientific evidences linking the gut microbiota in CD, starting from the possible role of microbes in CD pathogenesis, the attempt to define a microbial signature of disease, the effect of a gluten-free diet and host genetic assets regarding microbial composition to end in the exploration of the proof of concept of probiotic use in animal models to the most recent clinical application of selected probiotic strains.
Collapse
|
26
|
Berry N, Basha J, Varma N, Varma S, Prasad KK, Vaiphei K, Dhaka N, Sinha SK, Kochhar R. Anemia in celiac disease is multifactorial in etiology: A prospective study from India. JGH Open 2018; 2:196-200. [PMID: 30483589 PMCID: PMC6207013 DOI: 10.1002/jgh3.12073] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/06/2018] [Accepted: 06/23/2018] [Indexed: 12/16/2022]
Abstract
Background and Aims Anemia is one of the most common extraintestinal manifestations of celiac disease (CD), with iron deficiency anemia (IDA) being the predominant cause. However, anemia in CD can have varied etiologies, including mixed nutritional deficiency. We aimed to study the prevalence and etiology of anemia in CD in a north Indian population. Methods In this prospective observational study, consecutive patients with documented CD between January 2012 and December 2013 were included, and all patients underwent detailed clinical assessment; hematological investigations including iron profile, serum folate, and vitamin B12 levels; and esophageoduodenoscopy with duodenal biopsies for histopathological examination. Prevalence of anemia and different deficiencies were calculated, and a correlation between hematological parameters and histological findings was found. Results Of the 103 patients studied, anemia was detected in 96 patients, giving a prevalence of 93.2% with a baseline hemoglobin of 8.94 ± 2.54 g/dL. Overall, iron deficiency was seen in 84 (81.5%) patients, followed by vitamin B12 deficiency in 14 (13.6%) and folate deficiency in 11 (10.7%) patients; 17 (16.5%) patients had anemia due to mixed nutritional deficiencies, and 4 (3.9%) patients had anemia of chronic disease. The mean hemoglobin and median ferritin levels were significantly lower in patients with severe villous atrophy compared to those with mild atrophy. Conclusion Anemia in patients with CD is multifactorial. Even though iron deficiency is the most common cause, other nutrient deficiencies should always be explored.
Collapse
Affiliation(s)
- Neha Berry
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Jahangeer Basha
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Neelam Varma
- Department of Hematopathology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Subhash Varma
- Department of Medicine Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Kaushal Kishor Prasad
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Kim Vaiphei
- Department of Histopathology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Narendra Dhaka
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Saroj K Sinha
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Rakesh Kochhar
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| |
Collapse
|
27
|
Hatton GB, Madla CM, Rabbie SC, Basit AW. All disease begins in the gut: Influence of gastrointestinal disorders and surgery on oral drug performance. Int J Pharm 2018; 548:408-422. [PMID: 29969711 DOI: 10.1016/j.ijpharm.2018.06.054] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/23/2018] [Accepted: 06/25/2018] [Indexed: 02/07/2023]
Abstract
The term "disease" conjures a plethora of graphic imagery for many, and the use of drugs to combat symptoms and treat underlying pathology is at the core of modern medicine. However, the effects of the various gastrointestinal diseases, infections, co-morbidities and the impact of gastrointestinal surgery on the pharmacokinetic and pharmacodynamic behaviour of drugs have been largely overlooked. The better elucidation of disease pathology and the role of underlying cellular and molecular mechanisms have increased our knowledge as far as diagnoses and prognoses are concerned. In addition, the recent advances in our understanding of the intestinal microbiome have linked the composition and function of gut microbiota to disease predisposition and development. This knowledge, however, applies less so in the context of drug absorption and distribution for orally administered dosage forms. Here, we revisit and re-evaluate the influence of a portfolio of gastrointestinal diseases and surgical effects on the functionality of the gastrointestinal tract, their implications for drug delivery and attempt to uncover significant links for clinical practice.
Collapse
Affiliation(s)
- Grace B Hatton
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - Christine M Madla
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - Sarit C Rabbie
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - Abdul W Basit
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom.
| |
Collapse
|
28
|
Effinger A, O'Driscoll CM, McAllister M, Fotaki N. Impact of gastrointestinal disease states on oral drug absorption – implications for formulation design – a PEARRL review. J Pharm Pharmacol 2018; 71:674-698. [DOI: 10.1111/jphp.12928] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/16/2018] [Indexed: 12/18/2022]
Abstract
Abstract
Objectives
Drug product performance in patients with gastrointestinal (GI) diseases can be altered compared to healthy subjects due to pathophysiological changes. In this review, relevant differences in patients with inflammatory bowel diseases, coeliac disease, irritable bowel syndrome and short bowel syndrome are discussed and possible in vitro and in silico tools to predict drug product performance in this patient population are assessed.
Key findings
Drug product performance was altered in patients with GI diseases compared to healthy subjects, as assessed in a limited number of studies for some drugs. Underlying causes can be observed pathophysiological alterations such as the differences in GI transit time, the composition of the GI fluids and GI permeability. Additionally, alterations in the abundance of metabolising enzymes and transporter systems were observed. The effect of the GI diseases on each parameter is not always evident as it may depend on the location and the state of the disease. The impact of the pathophysiological change on drug bioavailability depends on the physicochemical characteristics of the drug, the pharmaceutical formulation and drug metabolism. In vitro and in silico methods to predict drug product performance in patients with GI diseases are currently limited but could be a useful tool to improve drug therapy.
Summary
Development of suitable in vitro dissolution and in silico models for patients with GI diseases can improve their drug therapy. The likeliness of the models to provide accurate predictions depends on the knowledge of pathophysiological alterations, and thus, further assessment of physiological differences is essential.
Collapse
Affiliation(s)
- Angela Effinger
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | | | | | - Nikoletta Fotaki
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| |
Collapse
|
29
|
Losurdo G, Cubisino R, Barone M, Principi M, Leandro G, Ierardi E, Di Leo A. Probiotic monotherapy and Helicobacter pylori eradication: A systematic review with pooled-data analysis. World J Gastroenterol 2018; 24:139-149. [PMID: 29358890 PMCID: PMC5757118 DOI: 10.3748/wjg.v24.i1.139] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 11/13/2017] [Accepted: 11/21/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To define probiotic monotherapy effect on Helicobacter pylori (H. pylori) status by performing a systematic review.
METHODS Methods of analysis and inclusion criteria were based on PRISMA recommendations. Relevant publications were identified by searching PubMed, MEDLINE, Science Direct, and EMBASE. The end-point was to estimate eradication rate and urea breath test delta value before and after probiotic monotherapy across all studies and, overall, with a pooled data analysis. Adverse events of probiotic therapy were evaluated. The data were expressed as proportions/percentages, and 95%CIs were calculated. For continuous variables, we evaluated the weighted mean difference. Odd ratios (ORs) were calculated according to the Peto method for the comparison of eradication rates between probiotics and placebo.
RESULTS Eleven studies were selected. Probiotics eradicated H. pylori in 50 out of 403 cases. The mean weighted eradication rate was 14% (95%CI: 2%-25%, P = 0.02). Lactobacilli eradicated the bacterium in 30 out of 235 patients, with a mean weighted rate of 16% (95%CI: 1%-31%). Saccharomyces boulardii achieved eradication in 6 out of 63 patients, with a pooled eradication rate of 12% (95%CI: 0%-29%). Multistrain combinations were effective in 14 out of 105 patients, with a pooled eradication rate of 14% (95%CI: 0%-43%). In the comparison of probiotics vs placebo, we found an OR of 7.91 in favor of probiotics (95%CI: 2.97-21.05, P < 0.001). Probiotics induced a mean reduction in delta values higher than placebo (8.61% with a 95%CI: 5.88-11.34, vs 0.19% for placebo, P < 0.001). Finally, no significant difference in adverse events was found between probiotics and placebo (OR = 1, 95%CI: 0.06-18.08).
CONCLUSION Probiotics alone show a minimal effect on H. pylori clearance, thus suggesting a likely direct role.
Collapse
Affiliation(s)
- Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro”, Piazza Giulio Cesare, Bari 70124, Italy
| | - Rossella Cubisino
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro”, Piazza Giulio Cesare, Bari 70124, Italy
| | - Michele Barone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro”, Piazza Giulio Cesare, Bari 70124, Italy
| | - Mariabeatrice Principi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro”, Piazza Giulio Cesare, Bari 70124, Italy
| | - Gioacchino Leandro
- National Institute of Gastroenterology, “S De Bellis” Research Hospital, Via Turi, Castellana Grotte (BA) 70013, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro”, Piazza Giulio Cesare, Bari 70124, Italy
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro”, Piazza Giulio Cesare, Bari 70124, Italy
| |
Collapse
|
30
|
Ierardi E, Losurdo G, Iannone A, Piscitelli D, Amoruso A, Barone M, Principi M, Pisani A, Di Leo A. Lymphocytic duodenitis or microscopic enteritis and gluten-related conditions: what needs to be explored? Ann Gastroenterol 2017; 30:380-392. [PMID: 28655974 PMCID: PMC5479990 DOI: 10.20524/aog.2017.0165] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 05/10/2017] [Indexed: 02/07/2023] Open
Abstract
Microscopic enteritis (ME) is characterized by abnormal infiltration of intraepithelial lymphocytes in intestinal mucosa. It was described as duodenal lymphocytosis or lymphocytic duodenitis until the dedicated Consensus Conference of 2015. ME represents a common feature of several gluten-mediated and non-gluten related diseases; therefore, it is an umbrella term embracing several conditions. The most frequent causes of ME are gluten-related disorders (celiac disease, non-celiac gluten sensitivity, wheat allergy), Helicobacter pylori infection and drug-related damages. Less frequently, ME may be secondary to inflammatory bowel disease, some autoimmune conditions, immunoglobulin deficiencies, blood malignancies, infections and irritable bowel syndrome. Therefore, the differential diagnosis of ME may be challenging. The diagnosis of ME needs to be driven by predominant symptoms and patient history. However, it is often difficult to achieve an immediate identification of the underlying condition, and a broad variety of diagnostic tests may be required. Ultimately, long-term surveillance is needed for a final diagnosis in many cases, since a hidden or quiescent condition may be disclosed after a period of latency. In any case, strict collaboration between the clinician and the pathologist is pivotal. The treatment of ME should be personalized, depending on the underlying disease. For gluten-related conditions (celiac disease, gluten sensitivity, wheat allergy, dermatitis herpetiformis), a gluten-free diet may be proposed. For other conditions, a targeted etiologic treatment is necessary. In conclusion, ME represents a novel entity that is attracting increasing interest. The growing epidemiologic trend confirms that it will become a common condition in clinical practice.
Collapse
Affiliation(s)
- Enzo Ierardi
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
- Correspondence to: Prof. Enzo Ierardi, Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, Piazza Giulio Cesare, Bari, University of Bari, Italy, Tel.: +39 080 5594033, Fax: +39 080 5593088, e-mail:
| | - Giuseppe Losurdo
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Andrea Iannone
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Domenico Piscitelli
- Section of Pathology (Domenico Piscitelli), Department of Emergency and Organ Transplantation, AOU Policlinico, Piazza Giulio Cesare, Bari, University of Bari, Italy
| | - Annacinzia Amoruso
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Michele Barone
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Mariabeatrice Principi
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Antonio Pisani
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Alfredo Di Leo
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| |
Collapse
|