Probiotics and Various States of Diarrhea

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Probiotics and Various States of Diarrhea

• By Lindsay Clapp-Hansen
• Medical Nutrition Therapy
• November 25, 2002

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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.

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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

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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.

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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.

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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

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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

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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• 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.

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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

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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.

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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

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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.

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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.

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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.