Probiotics in Clinical Use


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Probiotics in Clinical Use

  1. 1. Mrs Anita Jatana Chief Dietitian Batra Hospital
  2. 2. GUT HEALTH 70% of our immune system is located in the gut. Keeping it healthy is the key to good health. The average human body consists of about 10¹³ (10,000,000,000,000 or ten trillion) cells, has about ten times that number of microorganisms and about 500-1000 different bacterial species in the gut. The metabolic activity performed by these bacteria is equal to that of a virtual organ making the gut bacteria termed as a “Forgotten organ”.
  3. 3. INTESTINAL FLORA (A BALANCED ECOSYSTEM)Potentially Harmful Bacteria Pseudomonas Potentially Helpful Bacteria • Diarrhea/constipation Proteus • Infections • Inhibition of exogeneous and/or • Production of Toxins harmful bacteria Staphylococci • Stimulation of immune functions • Aid in digestion and/or absorption Clostridia • Synthesis of vitamins Enterococci E. coli Lactobacilli Streptococci Eubacteria Bifidobacteria Bacteroides From: Gibson GR. J Nutrition 1995; 125:1401-1412.
  4. 4. A closer look at our intestinal bacteria Lactobacillus E. coli StaphylococcusBifidobacterium Bacteroides C. perfringens
  5. 5. Adult Microbiota: A Complex Ecosystem Esophagus No own microbiota Microbes from food and oral cavity Stomach Duodenum 104 CFU/g Candida albicans 500 - 1000 103-104 CFU/g Bacteroides Helicobacter pylori Lactobacillus species Candida albicans Streptococcus Lactobacillus Streptococcus Jejunum 105-107 CFU/g Colon Bacteroides 1010-1011 CFU/g Candida albicans Bacteroides Lactobacillus Bacillus Streptococcus Bifidobacterium Clostridium Ileum Enterococcus 107-108 CFU/g Eubacterium Bacteroides Fusobacterium ClostridiumPeptostreptococcus Enterobacteriaceae Ruminococcus Enterococcus Streptococcus Lactobacillus Veillonella
  6. 6. The Mucosal surface of the GI tract forms an important organ of host defense. Anaerobic bacteria influence gut physiology & health by exerting a number of activities including:- Barrier protection against colonization of pathogens; Regulation of Intestinal transit; Deconjugation of bile acids and promotion of enterohepatic circulation; Degradation and digestion of some undigested carbohydrates; Improvement of lactose intolerance; Limitation of bacterial translocation and thus dissemination of bacteria in the peripheral organs; Production of vitamins and growth factors for host intestinal cells; Maturation and stimulation of the gut immune system.
  7. 7. Studies show that intestinal flora remains quite stable despite the variation in the ingested micro organisms in food. Factors influencing the balance of intestinal bacteria flora adversely are :- Congenital or acquired immuno-deficiencies. Illness Intestinal motility disorders Digestive stasis Parenteral nutrition Antibiotic treatment These can act by inhibiting certain commensal bacterial strains and by making the normal flora unable to act as barrier. This may promote the growth of potentially pathogenic germs ( eg. Clostridium difficle, Klebsiella oxytoca).
  8. 8. Potential beneficial effects of colonic foodsmediated by the human large gut microbiota Alleviate the symptoms of lactose malabsorption Boost natural resistance to infectious disease of the intestinal tract Neutralize certain toxins Suppress cancer Supply SCFA as energy substrates Lower serum lipids Affect hormonal regulation Aid digestion Produce vitamins Stimulate gastrointestinal immunity
  9. 9. Inflammatory Bowel Disease [Mitsuyama K et al 2008, J Clin Biochem Nutr 43 (Suppl.1):78-81] An open label preliminary trial conducted on 10 patients with mildly to moderately active Ulcerative Colitis (UC) Intervention: LcS (8x1010 CFU/day) in addition to conventional therapy daily for 8 weeks Significantly better clinical activity index score seen after LcS treatment as compared with pre-treatment and control group CONLUSION: LcS effectively treats UC at least in part through the inhibition of interleukin-6 signalling
  10. 10. Inflammatory Bowel Disorders [Sang et al, 2010 World of Gastroenterol 16:(15)1908-1915] Meta-analysis of thirteen randomized controlled studies - seven studies evaluated the remission rate and eight studies estimated the recurrence rate, two studies evaluated both remission and recurrence rate. Compared with the non probiotic group, the remission rate for ulcerative colitis patients who received probiotics was better. In the mild to moderate group who received probiotics compared to the group who did not receive probiotics, the recurrence rate was less. CONCLUSION: Probiotic treatment was more effective than placebo in maintaining remission in ulcerative colitis.
  11. 11. Probiotics useful in Celiac Disease Probiotics have shown promise for treating autoimmune and allergic disorders by altering intestinal microbiota composition and fermentation derived metabolite, thereby regulating epithelial cell barrier function and modulating immune response. (Licciardi PV et al 2010, Gut Pathol 2-24) Dietary changes include probiotics/prebiotics may help alleviate the severity of celiac disease for some patients. Differing intestinal bacteria in celiac patients could influence inflammation to varying degrees. This suggests that manipulating the intestinal microbiota with dietary strategies such as probiotics and prebiotics, could improve the quality of life for celiac patients, as well as patients with associated diseases such as type 1 diabetes and other autoimmune disorders. (Rossi M et al 2010 Journal of Leukocyte Biology 87:749 -751)
  12. 12. CASE 1 (Age- 2yrs) Celiac DiseasePATIENT HISTORY c/o loose stool ( 7-8 times) with vomiting on and off ( 2 months) and 1 episode of blood in stool. c/o abdominal distension Less oral intake History of wt loss- 3-4kg in 2months. Feeding history- home based soft diet + milk. On examination stomach distended Bs (positive) Liver spleen not palpable.
  13. 13. Biochemical investigations Urea 9.0 Creatinine 0.2 Protein 6.8 Albumin 3.2 SGOT 34 SGPT 44 Sodium 135 Potassium 4.3 Haemoglobin 7.6
  14. 14. INVESTIGATIONS Ultrasound- liver normal- gaseous distention of stomach Endoscopy- pale mucosa seen of duodenal folds Blood test- anti tissue tranglutaminase antibody ( tTG) positive Duodenal biopsy report- partial villous atrophy with intraepithelial lymphocytosis, possibility of coeliac disease. Stool report - fat globules positive - reducing substance negative
  15. 15. Endoscopic findingsEsophagus: pale mucosaStomach: pale mucosa seenDuodenum: duodenal folds scalloping seenImpression: celiac disease,biopsy took.
  16. 16. DIETARY MANAGEMENT Patient was put on a lactose and gluten free diet. Probiotics (LcS) was introduced 1/day Frequency of stools decreased to 5/day and decreased stomach distension On 3rd day- frequency of stools was 3 and semiformed. Patient was discharged with instructions of gluten free diet with probiotics (LcS) once a day.
  17. 17. CASE 2 77 year -male HISTORY: Carcinoma prostate Post b/l orchidectomy on radical Radiation and has completed 18 radiations. Diabetes 25 yrs CAD with CABG
  18. 18. Symptoms Patient Admitted With Loose motions, vomiting, 2 day Blackstools ++ Poor oral intake
  19. 19. MEDICATION Injection raciper 40mg IVBD Emset 8mg IVBD Pantocid Metrogyl Monocef 2gm
  20. 20. INVESTIGATIONS Endoscopy- antral gastritis Colonoscopy- seen upto desending colon diffuse erythma with multiple ulcers in rectum Radiation proctitis Bone scan –no mets. SPSA- markedly elevated
  21. 21. DIETARY MANAGEMENT 19/3/2012- patient on clear liquid diet frequency of stool 6-8/day 20/3/2012-patient was on full liquid diet probiotic (LcS) introduced – 1BD frequency of stools 4-5/day 21/3/2012-patient was on soft diet frequency of stools decreased to 2 but the stools were formed.
  22. 22. CASE 3 age:58yrs male Ulcerative Colitis General Information Age : 58yr Wt: 72kg Ht: 175cm BMI: 23.51kg/msq BP: 130/90
  23. 23. HISTORY h/o Diabetes Complain of bleeding per rectum. Increased frequency of stools with mucosa since 1-1/2 months. There was no history of fever. Also developed osteoporosis. Patient was on steroids since 22yrs.
  24. 24. MEDICATION Medication on admission 1. Inj. Pantocid 2. N. Saline 3. Metrogyl 4. Inj. Forzid 5. Efcorlin 50ml/6hrly
  25. 25. INVESTIGATIONS Colonoscopy: Seen upto Caecum. Showed diffused mucosal ulceration with erosion. Chronic proctosigmoidotis and ulcerative colitis.
  26. 26. DIETARY MANAGEMENT DIET: The patient was kept on Bland soft – Lactose free diet 2 probiotics (LcS) were introduced per day. On third day frequency of stools reduced to 3 from initial 5 Stools were formed. Patient was discharged after a week on a diabetic lactose free with instructions to continue probiotics (LcS) BD.
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