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Title: Probiotics and Various States of Diarrhea


1
Probiotics and Various States of Diarrhea
  • By Lindsay Clapp-Hansen
  • Medical Nutrition Therapy
  • November 25, 2002

2
Probiotics
  • Microbes found in the food supply that enhance
    human health.
  • Criteria bacteria of human origin, able to
    adhere to the intestinal mucosa, have potential
    to colonize in the GI tract, can produce
    antimicrobial substances, stable against bile,
    HCl, and other acids, enzymes, and oxygen, and
    determined to be safe and effective.

3
Altered Disease States
  • Probiotics have been thought to improve or
    ameliorate a plethora of states, the most
    commonly reported upon are
  • Various states of diarrhea
  • Inflammatory Bowel Disease
  • H. Pylori Ulcers
  • Urinary Tract Infections
  • Vaginal Candida Overgrowth
  • Cancer of the Gastrointestinal (GI) Tract

4
What has Scientifically BasedResearch to Support
the Claims?
  • After reviewing a majority of the research and
    literature relative to probiotic use in humans,
    it is clear that diarrhea is the condition most
    beneficially treated by probiotic therapy. This
    can include diarrhea associated with antibiotics,
    travel, gastroenteritis, lactose intolerance, and
    Inflammatory Bowel Disease. These areas were
    reviewed.

5
Diarrhea Described
  • Diarrhea is frequent loose stools, along with an
    excessive loss of fluid and electrolytes (K Na
    especially), abdominal cramping, pain, and often
    presence of a fever.
  • It can be acute or chronic, and is secondary to
    an underlying disease or condition or pathogenic
    bacteria within the GI tract.

6
Types of Diarrhea
  1. Osmotica result of poorly absorbed nutrients
    that enter into the large intestine gt a
    solute-related osmotic shift
  2. Secretoryusually a result of bacterial or viral
    infections, which causes excessive secretion of
    electrolytes and water by the intestinal
    epithelium
  3. Exudative mucosal damage combined with a build
    up of blood, mucous, and plasma proteins in the
    colon
  4. Limited Contact Mucosalcaused by insufficient
    blending of chyme and decreased exposure to the
    intestinal epithelium

7
Antibiotic Associated Diarrhea
  • This is the most well studied area of probiotics,
    because antibiotic associated diarrhea is evident
    in 20 of all people on antibiotic therapy which
    provides a good sample.
  • Cause- by the antibiotic therapy destroying the
    normal, health-promoting gut flora as well as the
    pathogenic bacteria.
  • Result- the healthy bacteria that usually
    protects the GALT and the intestinal epithelium
    is not there, this enables pathogenic bacteria to
    bind to the available receptors

8
How Probiotics Aide in Decreased
Antibiotic-Associated Diarrhea
  • The probiotics promote increase production of the
    synergistic bacteria, thus increasing the
    quantity in the intestine decreasing the number
    of available receptor sites

9
Antibiotics Probiotics Tested
  • In 1989 the largest study on antibiotic-associated
    diarrhea and probiotic intervention was
    completed. This spurned more interest in the
    area.
  • Prospective, double-blind, placebo-controlled
    trial
  • N 180 hospital patients on antibiotics
  • Experimental Received S. boulardii in
    conjunction with antibiotics.
  • Results There was a 13 decrease in overall
    diarrhea symptoms when comparing the experimental
    to the control.

10
1999 Quantified Study Released
  • A study using clear dosage levels was published
    in 1999. It examined 119 children (2wks-12.8
    yrs) on antibiotics. Half were given a placebo
    and half a 2 1010 colony forming units of
    Lactobacillus GG twice a day. This was examined
    over a three month period. During this time
    careful stool frequency and consistency logs were
    maintained by the parents of subjects.

11
Results
  • There was a 11 decrease of diarrhea in the
    initial two weeks of probiotic therapy when
    comparing the experimental group to control.
  • By the third week, there was a 30 decrease
    difference between the two groups.

12
Confounds
  • The study in 1989 was lacking in clearly
    quantifiable values of probiotic dose.
  • The study that was completed in 1999 was a break
    through because there were standardized amounts
    of probiotics given. However, the age range of
    children does not enable a clear dose per weight
    determination to be made.
  • In all of the studies reviewed concerning
    antibiotic-related diarrhea, there were one or
    more of the following confounds lack of
    specific detail of amount and consistency of
    diarrhea and the quantity and viability of the
    probiotic strains administered. There leaves much
    to be researched.

13
Conclusion for Antibiotic Associated Diarrhea
  • There is a basis to believe that probiotics,
    through competitive exclusion by the enhancement
    of intestinal micro flora, are able to lessen the
    frequency and duration of diarrhea.
  • More needs to be done in order to create
    clinically applicable recommendations.

14
Travelers Diarrhea
  • It has been estimated that 20-50 of all people
    who travel are struck by diarrhea. The frequency
    and duration is associated with the destination
    and location of the traveler.
  • Cause it is presently unknown, but believed to
    be due to a change in ingested microbial content
    and stress. Pathogenic E. coli is usually
    protagonist.
  • Result unknown, however results in diarrhea.

15
Tested Probiotic Affect on Travelers Diarrhea
  • In 1993, a study was conducted that stated 47 of
    Americans traveling to Mexico were able to avoid
    Travelers diarrhea when a prophylactic dosage of
    Lactobacillus GG was administered daily.
  • This study was one of many, but is in accordance
    with the majority of published studies.

16
Traveler's Diarrhea Continued
  • Other trials conducted showed a HUGE range from
    gt50 reduction with the supplementation of
    probiotics to none at all.
  • However, in all of the studies that compared
    various ages, the outcome showed diminished
    diarrhea within the elderly population when
    taking a probiotic supplement. This shows that
    overall GALT and immune function are related to
    how a person will respond to microbes. This
    calls for studies to be conducted on the elderly
    to determine if probiotics could diminish nursing
    home GI-related distress.

17
Infectious Diarrhea
  • Infectious diarrhea can be induced by any
    pathogenic virus or bacteria. Rotaviral diarrhea
    will be covered here.
  • Rotavirus attacks the GI tracts of newborns and
    infants, and because of this it can be well
    isolated and studied in relation to probiotic
    dosing.
  • Rotavirus induces biphasic diarrhea, initially
    osmotic and then secretory.

18
What Probiotics Do to Combat Rotaviral Diarrhea
  1. Stabilize the intestinal micro flora thats been
    altered by rotavirus (through reproduction
    promotion)
  2. The above results in reduced gut permeability,
    which lowers the rate rotavirus can bind to the
    GALT and cause gastroenteritis
  3. Probiotics reduce the length of time rotavirus in
    the intestine (due to competitive exclusion)
  4. Probiotics increase the amount of IgA that the
    body produces to fight infection.

19
Key Study Rotavirus Probiotics
  • In 1997, a prospective, randomized,
    placebo-controlled trail was carried out to
    determine how Lactobacillus reuteri affected
    rotavirus.
  • Children between the ages of 6-36 months were
    brought into the study post admit for
    rotaviral-associated diarrhea
  • There were three groups placebo, 1 dose of 1010
    cfu, and 1 dose of 107 cfu. The treatment was
    given once daily for five days.

20
Results for Rotaviral Study
  • Results showed that the duration of diarrhea in
    the placebo group was 2.5 days in length as
    compared to 1.9 days with the 107 dose, and 1.5
    with the 1010 dose.
  • Additionally, stool cultures show that there was
    significant probiotic colonization in the GI
    tract in both test groups.
  • This study, as well as others, shows that there
    is a clear correlation between oral
    administration of a probiotic strain and
    diminished rotaviral diarrhea.
  • More must be researched to establish a clinically
    meaningful therapy.

21
Lactose Intolerance
  • Lactose intolerance presents in 70-100 of adults
    worldwide.
  • Probiotics function as a lactase isomer. When
    probiotics deteriorate, they produce
    B-D-galactosidase from the cell wall. This is an
    isomer of lactase which then destroys ingested
    lactose.

22
B-D-Galactosidase
  • In order for the B-D-galactosidase to appear in
    the GI tract, the probiotic must be ingested in a
    viable state, and then breakdown.
  • This means that frozen yogurt and pasteurized
    yogurt are not as effective as fresh yogurt,
    because they do not produce the
    B-D-Galactosidase.

23
Yogurt Conundrum
  • So why is pasteurized yogurt tolerated?
  • One study states that is it the decreased
    intestinal transit time, which means that the
    lactose spends less time as an undigested
    molecule within the large intestine. If the
    lactase were to spend a longer period of time in
    the large intestine, fermentation and osmotic
    diarrhea would result.
  • Other studies state that pasteurized yogurt
    causes a delay in gastric emptying and orocecal
    transit time, because the probiotics and organic
    acids they produce result in a lower osmotic load.

24
So now what?
  • There must be more research on how non-viable
    (aka pasteurized) probiotics alter the lactose
    intolerants GI tract that makes the person able
    to consume lactose-containing yogurt.
  • Over and over again the B-D-galactosidase has
    been seen to break down lactose, so non-heat
    treated yogurt is acceptable.
  • Overall, the viable probiotics have been seen to
    have a positive effect on lactose intolerant
    consumption of dairy. Additionally, there is
    some manner in which non-viable microbes are
    aiding in the acceptability of lactose in the
    intolerant individual.

25
Inflammatory Bowel Syndrome
  • IBD includes both Crohns and ulcerative colitis.
    The cause of these disease states are unknown,
    but it is believed to be due to genetics and
    immunlogic deficiencies. These disease states
    present when there is an imbalance in the gut
    micro flora.
  • The current method of treating IDB flare ups is
    with antibiotics.

26
  • In 1997, a double-blind study was conducted that
    examined a probiotic (non-pathogenic E. coli) and
    an antibiotic (mesalazine).
  • The study included 120 adults, with inactive
    colitis. They were divided into the two test
    groups. Over a three moth period, they were asked
    to assess the frequency, intensity, and an
    overall health assessment.
  • Results The results were not clinically
    significant, the E. coli group had a 16 rate of
    controlled flare up, where as the mesalazine had
    an 11 rate.

27
Not Clinically Significant, but Still Significant
  • Although the 11 vs. 16 is not clinically
    different, this shows that the probiotic was
    nearly as effective as the antibiotic.
  • Because IBD patients are immunosuppressed, the
    reduction in antibiotic associated diarrhea would
    improve the overall quality of life.
  • By taking the probiotic therapy instead of the
    antibiotic, there would be commensal bacterial
    growth within the intestine, which would act as a
    barrier against ingested pathogens and promote
    the production of IgA immune response within the
    gut

28
IBD Probiotics
  • Although it seems that probiotics could at some
    point be an alternative therapy for IBD, it is
    not possible now, because standardized doses must
    be determined. More research must be done to
    determine if antibiotic-associated diarrhea in
    the IBD patient can be significantly reduced.
  • After reviewing the literature, the consensus is
    that probiotics as a supplement are not altering
    IBD significantly.

29
Probiotic Research Overall
  • The studies that have been completed are limiting
    because there are not standardized amounts, there
    is a large variation in the strain used for
    experimentation, the viability of the microbes
    are not tested pre-experimentation.
  • More must be done so that this potentially
    beneficial supplement can be used in practice

30
Conclusion
  • Probiotics are able to decrease the
    length/incidence of antibiotic-induced diarrhea
    through competitive exclusion.
  • Probiotics were seen to decrease the severity and
    length of travelers diarrhea, especially among
    the elderly.
  • Rotaviral-associated diarrhea cases were
    positively altered when oral probiotics were
    administered.

31
Conclusion
  • Lactose intolerance and probiotics is still
    controversial. Viable probiotics clearly have a
    positive function. Pasteurized probiotics are an
    unknown area at present.
  • IBD is likely not significantly altered through
    probiotic supplementation, however probiotics
    could potentially be used instead of antibiotics
    to control flare-ups, which may decrease the
    incidence of antibiotic-associated diarrhea.

32
Areas of Research
  • The correlation between probiotic therapy and
    increased production of IgA.
  • Determining the best strains and the quantities
    that are needed to support intestinal health
    promotion.
  • Research that has minimal confounds so that it
    will be honored by the scientific community.
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