United States Guidelines for Diverticulitis Treatment.

Guidelines for diverticular disease management were last supported and published by the American Gastroenterology Association and the American College of Gastroenterology 2 decades ago. Guidelines have been published in other countries and by some societies. These guidelines are suggested as United States of America guidelines. In reality, they are what is practiced in Connecticut at Yale New Haven hospitals. The epidemiology and pathophysiology is described. This is still considered a dietary fiber-deficiency disease that results in high intracolonic pressure with resultant outpocketing of diverticula in the weakest point of the colon at the sites of vascular penetration with developing elastin deposition in the colon wall. The age and gender distribution is described. They are most common in the sigmoid. The guidelines of management are described according to accepted classification of the disease at all stages from onset, to early formation, to mild disease, to complicated disease, to rare specific states. The outcomes and mortality are discussed.

Recommendations for Probiotic Use--2015 Update: Proceedings and Consensus Opinion.

This paper describes the consensus opinion of the participants in the 4th Triennial Yale/Harvard Workshop on Probiotic Recommendations. The recommendations update those of the first 3 meetings that were published in 2006, 2008, and 2011. Recommendations for the use of probiotics in necrotizing enterocolitis, childhood diarrhea, inflammatory bowel disease, irritable bowel syndrome and Clostridium difficile diarrhea are reviewed. In addition, we have added recommendations for liver disease for the first time. As in previous publications, the recommendations are given as A, B, or C ratings.

Prebiotics, probiotics and digestive health.

PURPOSE OF REVIEW: The human gastrointestinal lumen is inhabited by a wide variety of microbiota. Our understanding of the intestinal microbiota and its full consequences on gastrointestinal health is still evolving. However, it is well accepted that altered colonic flora drives the pathogenesis of many disorders and diseases as seen in antibiotic-associated diarrhea and Clostridium difficile infection. Recent works published in the area of probiotics are reviewed here. RECENT FINDINGS: Alterations in colonic microbiota, or dysbiosis, are now implicated in irritable bowel syndrome and inflammatory bowel diseases. Probiotics and prebiotics are evolving treatment options that are targeted at restoring nonpathogenic digestive flora. There has been great interest in the role of these therapies in treatment of many diseases including childhood diarrhea, antibiotic-associated diarrhea, Clostridium difficile infection, irritable bowel syndrome, and inflammatory bowel disease. SUMMARY: Trials of probiotics have been shown to be helpful in some of these, not in others, and more work is needed in others. We review recent work done in these areas.

Intestinal microecology in health and wellness.

Intestinal microecology consists of 4 components-the luminal gastrointestinal tract, secretions of the tract, the epithelium, nutrients and foods that enter the tract, and the microbatome or microflora. This ecosystem is very dynamic. It is not possible to define a normal flora as it varies with geography, diet, and the dynamics of the microecology. A normal flora exists in a healthy human. The life cycle of the intestinal microbatome will vary with geography and feeding. Dysbiosis may occur in disease. At the present time, the flora is best determined from older biochemical techniques and newer genetic bacteriologic studies, but much more research is needed to define the makeup of the microbatome as it varies with diet and geography.

Recommendations for probiotic use-2011 update.

This study describes the consensus opinion of the participants of the third Yale Workshop on probiotic use. There were 10 experts participating. The recommendations update those of the first 2 meetings that were published in 2005 and 2008. The workshop presentations and papers in this supplement relate to the involvement of normal microbiota involved in intestinal microecology, how the microbes interact with the intestine to affect our immunologic responses, the stability and natural history of probiotic organisms, and the role of the intestinal microbatome with regard to affecting cardiac risk factors and obesity. Recommendations for the use of probiotics in necrotizing enterocolitis, childhood diarrhea, inflammatory bowel disease, irritable bowel syndrome, and Clostridium difficile diarrhea are reviewed. As in previous publications, the recommendations are given as A, B, or C ratings. The recent positive experiences with bacteriotherapy (fecal microbiome transplant) are also discussed in detail and a positive recommendation is made for use in severe resistant C. difficile diarrhea.

The effect of probiotics on host metabolism: the microbiota and fermentation.

When probiotics are ingested, they become part of the intestinal microflora. Their most important documented effects seem to be 3-fold in supporting or stimulating the immune process and being helpful in treating or affecting the process of infection; affecting luminal pathophysiology that has been shown in many animal experiments; and their role on fermentation of nutrients. Although there is understanding of the role of the microflora on the fermentation process, the effective clinical role is not yet completely understood or shown. The fermentation process consists of the action of bacterial enzymes from the microflora or probiotic organisms on nutrients. The carbohydrate nutrients are the main source of nutrients for the bacterial flora. Although protein and fats may be metabolized by the fermentation process, they are less well understood. Soluble fiber is the main food for probiotic and microbiota organisms. In addition, prebiotic substances are very effective in being metabolized by the organisms. Strains of both Lactobacillus and Bifidobacterium species are effective as lactic acid producing organisms. Their main product is short-chain fatty acids. Butyric, acetic, and propionic are readily produced and either absorbed into the portal circulation or excreted in the stool. Butyrate is the main fuel for colonocytes, whereas acetic and propionic acid are an integral part of cholesterol synthesis. The affect on lipid metabolism by various probiotic organisms and probiotics is discussed. There are some preliminary studies on the importance of the microbiota and the potential importance of probiotic organisms added to this microbiota in lipid metabolism. However, the obvious importance and details of probiotic influence need to be evaluated in future studies.

Diverticular disease and diverticulitis.

Diverticular disease is one of the most prevalent medical conditions to affect Western populations. Symptomatic diverticular disease can range from mild, low-level symptomatology similar to that seen in irritable bowel syndrome to acute bouts of diverticulitis complicated by abscess or frank perforation. This review discusses the epidemiology, pathophysiology, clinical presentation, and management of the spectrum of diverticular disease, including mention of recent advances in the treatment of chronic diverticular disease with aminosalicyclates and probiotics.

Symptom severity and disease activity indices for diverticulitis.

There are no controlled studies evaluating symptoms of diverticular disease or diverticulitis. Monitoring symptoms are reported repeatedly in research studies but yet an evaluation of the significance of recording these symptoms in a controlled study does not exist. The older literature was reviewed. The literature largely classifies the disease in stages, which are reviewed in this paper. Symptomatic uncomplicated diverticular disease and its evolution and the present literature on this are discussed.

Recommendations for probiotic use--2008.

Recommendations for the clinical use of probiotics were published after a Yale University Workshop in 2005. A similar workshop was held in 2007, and the recommendations were updated and extended into other areas. The recommendations are graded into an "A," "B," "C" or no category based on the expert's opinion and review by the workshop participants. An "A" recommendation is made for acute childhood diarrhea, prevention of antibiotic-associated diarrhea, preventing and maintaining remission in pouchitis, and in an immune response for the treatment and prevention of atopic eczema associated with cow's milk allergy. The group maintained several "B" recommendations in other areas of treating inflammatory bowel disease and irritable bowel syndrome. Although there are significant studies in the "B" group, most "B" recommendations did not reach an "A" level because of some negative studies or a limited number of studies. Many reports in the "C" recommendations were significant but fell short of receiving stronger ratings because of the size of reported patient studies, and also the factors that limited categories to the "B" rating.