Colonoscopic laxative instillation for the fecal-loaded colon: a case series

Context: Postoperative, critically ill, and elderly patients often have fecal loading or impaction. In a few such patients, disimpaction of fecalomas and colon cleansing are difficult. Bowel obstruction, megacolon, lower gastrointestinal bleeding, and gut perforation are complications that may ensue. Oral laxatives or enemas may only be partially effective. Surgical intervention may be needed for salvage or to treat complications. Series and Design: Fourteen hospitalized cases with defecation disorder due to fecal loading of the colon were enrolled for retrospective analysis. Colonoscopic instillation of mannitol and/or lactulose was undertaken as an intervention when the use of oral laxatives was either ineffective or unfeasible, and enema had yielded poor results. Results: Ten patients had satisfactory outcomes for fecal clearance, whereas four patients with poor or incomplete responses underwent repeat interventions or surgery. No significant complications were encountered due to this therapy. Conclusion: Colonoscopic instillation of mannitol or lactulose in fecal-loaded critically ill patients results in a safe and satisfactory fecal clearance. (AU)

Influencing Factors on Lactulose Breath Test Results / 대한소화기학회지

BACKGROUND/AIMS: This study aimed to identify the demographic and clinical factors associated with positive breath-test results and to assess the relationship between hydrogen and methane production in patients with suspected irritable bowel syndrome (IBS).METHODS: The demographic and clinical factors of 268 patients with suspected IBS, who had undergone a lactulose breath test, were analyzed.RESULTS: Of 268 patients included in this study, 143 (53.4%) were females. The median age and BMI of the patients was 58.0 years (range, 18.0–80.0 years) and 22.5 kg/m² (range, 14.4–34.3 kg/m²), respectively. A weak positive correlation was observed between the BMI and baseline hydrogen level (rho=0.134, p=0.031). Women were significantly more likely to show a ≥20 ppm increase in hydrogen within 90 min (early hydrogen increase, p=0.049), a ≥10 ppm increase in methane within 90 min (early methane increase, p=0.001), and a ≥10 ppm increase in methane between 90 min and 180 min (late methane increase, p=0.002) compared to men. The baseline hydrogen level was related to the baseline methane level (rho=0.592, p<0.001) and the maximal hydrogen level within 90 min was related to maximal methane level within 90 min (rho=0.721, p<0.001). Patients with an early hydrogen increase (43.8%) were more likely to show a positive result for an early methane increase compared to patients without an early increase in hydrogen (0%, p<0.001).CONCLUSIONS: Women were associated with high rates of positive lactulose breath-test results. In addition, methane production was correlated with hydrogen production.

The impact of small intestinal bacterial overgrowth on the growth of children and adolescents / Impacto do sobrecrescimento bacteriano no intestino delgado sobre o peso e a estatura de crianças e adolescentes

ABSTRACT Objective: To evaluate the association between small intestinal bacterial overgrowth (SIBO) and weight and height impairment in children and adolescents with gastroenterology diseases. Methods: Observational and retrospective study. All 162 patients aged less than 19 years old who underwent breath test in search of SIBO between 2011 and 2016 were studied. Breath test was collected after the intake of 10 grams of lactulose. The concentration of hydrogen and methane was measured for 180 minutes after the beginning of the test by 12i QuinTronMicroLyzer device. Results: SIBO was identified in 51 (31.5%) patients. There was no difference between the age of those with (mean=8.7y.o; 25th and 75th percentile: 4.6 and 11.3) and without (mean=7.9y.o 25th and 75th percentile: 4.8 and 12.2) SIBO (p=0.910). There was no association between gender and SIBO (male 26.3% vs. female 36.3%, p=1.00). A lower median of height-for-age Z score (mean=-1.32; 25th and 75th percentile: -2.12 and -0.08 vs. mean=-0.59; 25th and 75th percentile: -1.57 and 0.22; p=0.04) was demonstrated in children with SIBO when compared with children without it. There was no difference between the BMI-for-age Z score of patients with (mean=-0.48) and without SIBO (mean=-0.06) (p=0.106). The BMI of patients with SIBO (median=15.39) was lower than of those without it (median=16.06); however, the statistical analysis was not significant (p=0.052). The weight-for-age Z score was lower in patients with SIBO (mean=-0.96) than in those without SIBO (mean=-0.22) (p=0.02) Conclusions: Children and adolescents with SBIO associated with diseases of the gastrointestinal tract have lower weight and height values.

RESUMO Objetivo: Avaliar a existência de associação entre sobrecrescimento bacteriano no intestino delgado (SBID) e comprometimento de peso e estatura em crianças e adolescentes com doenças do aparelho digestivo. Métodos: Estudo observacional e retrospectivo em ambulatório de gastroenterologia pediátrica. Foram incluídos todos os 162 pacientes com idade inferior a 19 anos que realizaram teste respiratório para pesquisa de SBID entre 2011 e 2016. O teste respiratório foi realizado após ingestão de dez gramas de lactulose. Foram determinadas as concentrações de hidrogênio e metano em aparelho 12i QuinTron MicroLyzer até 180 minutos após o início do teste respiratório. Resultados: SBID foi caracterizado em 51 (31,5%) dos 162 pacientes. Não houve diferença na idade das crianças com (mediana=8,7 anos; percentil 25-75: 4,6-11,3) e sem (mediana=7,9 anos; percentil 25-75: 4,8-12,2) SBID (p=0,910). Não se observou associação entre SBID e sexo (masculino 27,4% e feminino 36,6%; p=0,283). O escore Z da estatura-idade nos pacientes com SBID (mediana=-1,32; percentil 25-75: -2,12—0,08) foi menor (p=0,040) do que naqueles sem SBID (mediana=-0,59; percentil 25-75: -1,57-0,22). Na comparação do escore Z de índice de massa corpórea-idade não foi observada diferença entre os grupos com (média=-0,489±1,528) e sem (média=-0,067±1,532) SBID (p=0,106). Nos pacientes com menos de 10 anos de idade, o escore Z de peso-idade foi menor nos pacientes com SBID (média=-0,968±1,359) do que nos sem SBID (média=-0,223±1,584) (p=0,026). Conclusões: Crianças e adolescentes com SBID associado a doenças do trato gastrintestinal apresentam menores valores de peso e estatura.

Effect of polyethylene glycol versus lactulose on abdominal pain in children occult constipation: a randomized controlled study: un estudio controlado aleatorio / Efecto del polietilenglicol versus lactulosa sobre el dolor abdominal en el estreñimiento oculto en niños

Introduction and aim: Functional abdominal pain (FAP) is one of the major gastrointestinal complaints in childhood. Studies have reported occult constipation (OC) as one of the leading causes of abdominal pain. Recent researches have proposed laxatives as potent therapeutic targets for abdominal pain in patients with OC. However, no study has compared effect of poly ethylene glycol (PEG) and lactulose on occult constipation. Materials and methods: 51 patients aged 4 to 18 years with abdominal pain who had OC (defined as fecal impaction in abdominal X ray) were studied. Demographic and clinical data including age, sex, body weight, height, abdominal pain duration, abdominal pain rate and fecal odor were registered. They were randomly assigned to receive PEG (1gr/kg) or Lactulose (1cc/kg) for at least two weeks. All patients were reevaluated by pain measurement scale after at least two weeks of treatment. Results: It is indicated that the efficacy of PEG for reducing abdominal pain in OC was 48% while it was 37% for Lactulose. This study indicated that this efficacy is not affected significantly by sex and fecal odor, however this efficacy is influenced by age, body weight, abdominal pain duration and abdominal pain rate for both PEG and Lactulose. Conclusion: It could be concluded that PEG is a more efficient drug for treating abdominal pain in occult constipation than Lactulose and its optimum effect can be achieved in elder patients with more severe abdominal pain.

Introducción y objetivo: El dolor abdominal funcional (FAP) es una de las principales molestias gastrointestinales en la infancia. Los estudios han informado que el estreñimiento oculto (OC) es una de las principales causas de dolor abdominal. Investigaciones recientes han propuesto laxantes como objetivos terapéuticos potentes para el dolor abdominal en pacientes con OC. Sin embargo, ningún estudio ha comparado el efecto del polietilenglicol (PEG) y la lactulosa sobre el estreñimiento oculto. Materiales y métodos: Se estudiaron 51 pacientes de 4 a 18 años con dolor abdominal que tenían OC (definida como impactación fecal en rayos X abdominales). Se registraron datos demográficos y clínicos que incluyen edad, sexo, peso corporal, altura, duración del dolor abdominal, tasa de dolor abdominal y olor fecal. Fueron asignados aleatoriamente para recibir PEG (1 gr/kg) o lactulosa (1 cc/kg) durante al menos dos semanas. Todos los pacientes fueron reevaluados por la escala de medición del dolor después de al menos dos semanas de tratamiento. Resultados: Se indica que la eficacia de PEG para reducir el dolor abdominal en OC fue del 48% mientras que fue del 37% para la lactulosa. Este estudio indicó que esta eficacia no se ve afectada significativamente por el sexo y el olor fecal, sin embargo, esta eficacia está influenciada por la edad, el peso corporal, la duración del dolor abdominal y la tasa de dolor abdominal tanto para PEG como para lactulosa. Conclusión: Se podría concluir que el PEG es un fármaco más eficaz para tratar el dolor abdominal en el estreñimiento oculto que la lactulosa y que su efecto óptimo se puede lograr en pacientes mayores con dolor abdominal más severo.Palabras clave: dolor abdominal, estreñimiento oculto, polietilenglicol, lactulosa.

Caracterização fisico-química de produto curado seco de carne ovina elaborado com lactulose como prebiótico / Physicochemical characterization of dry-cured lamb with lactulose as prebiotic

O objetivo desse trabalho foi acompanhar as alterações nas características físico-químicas de produto curado dessecado de carne ovina adicionado de lactulose ao longo de sua elaboração (0, 7, 21 e 30 dias). Foram necessários 30 dias para que os produtos perdessem cerca de 40% de peso. A umidade foi afetada (P<0,05) apenas pelo tempo de processamento, atingindo valores finais de 47,60%. Em relação ao pH, houve efeito significativo (p<0,05) nos tempos e nos tratamentos analisados ao longo do processo. A presença de lactulose não afetou na produção de ácido lático e nem na Atividade de água. Foi possível desenvolver e caracterizar um produto de carne ovina adicionado de Prebiótico com as mesmas características em relação tratamento controle atendendo a legislação Brasileira.

Bowel Wall Thickness, Elasticity, Intestinal Permeability, and Inflammatory Cytokines in Patients with Cirrhosis and Ascites / 대한내과학회지

BACKGROUND/AIMS: Previous studies have reported that endotoxemia is associated with pathogenesis and complications in cirrhosis. Endotoxin stimulates the secretion of inflammatory cytokines, which contributes to the development of complications. In addition, endotoxin easily invades the gut barrier system because of the increased intestinal permeability due to portal hypertensive enteropathy. In this report, we explored changes in cytokine levels and intestinal permeability and measured the thickness and elasticity of the bowel wall using ultrasonography in cirrhotic patients.METHODS: We enrolled 40 patients with cirrhosis classified as Child-Pugh B or C and 20 healthy volunteers. Abdominal ultrasonography examinations were used to evaluate bowel wall parameters in the ascending colon and terminal ileum. Intestinal permeability was measured using dual sugar absorption tests with lactulose and mannitol. Levels of tumor necrosis factor (TNF)-α and IL-10 were determined from blood samples. We compared these outcomes between cirrhotic patients and healthy controls and between Child-Pugh B and C patients. In addition, we explored the correlation between cytokine levels, intestinal permeability ratio, and bowel wall parameters in cirrhotic patients.RESULTS: In cirrhotic patients, the ascending colon wall elasticity decreased (20.4 vs. 10.9 kPa, p = 0.048) and the terminal ileum wall thickness increased (4.2 vs. 1.9 mm, p < 0.001). The intestinal permeability ratio and levels of the cytokines TNF-α and IL-10 increased (0.219 vs. 0.017, p < 0.001; 22.47 vs. 13.48 pg/mL, p < 0.001; and 14.91 vs. 8.57 pg/mL, p = 0.019, respectively) in cirrhotic patients. However, there were no significant differences between Child-Pugh classes and no significant correlations between bowel wall parameters and intestinal permeability or cytokine levels.CONCLUSIONS: Ultrasonography revealed bowel wall thickening and decreases in elasticity; in addition, intestinal permeability and cytokine levels increased in cirrhotic patients compared with healthy controls.

Nationwide Survey for Application of ROME IV Criteria and Clinical Practice for Functional Constipation in Children

BACKGROUND: This study aimed to investigate the awareness and application of ROME IV criteria for functional constipation (FC) in real-world practices and assessed differences between pediatric gastroenterologists (PGs) and general pediatricians. METHODS: A total of 239 (47.8%) out of 500 nationwide pediatricians answered a questionnaire for diagnosis and management of pediatric FC; 60 were PGs (75% of total PGs in Korea). RESULTS: A total of 16.6% of pediatricians were aware of the exact ROME IV criteria. Perianal examination and digital rectal examination were practiced less, with a higher tendency among PGs (P 6 months (63.8%) than 1-year were lactulose (59.1%), followed by polyethylene glycol (PEG) 4000 (17.7%), and probiotics (11.8%). Prescription priority significantly differed between PGs and general pediatricians; lactulose or PEG 4000 were most commonly prescribed by PGs (89.7%), and lactulose or probiotics (75.7%) were prescribed by general pediatricians (P < 0.001). For patients aged < 1-year, lactulose (41.6%) and changing formula (31.7%) were commonly prescribed. Most participants recommended diet modification, and PGs more frequently used defecation diary (P = 0.002). CONCLUSION: Discrepancies between actual practice and Rome IV criteria and between PGs and general pediatricians were observed. This survey may help construct practice guidelines and educational programs for pediatric FC.

Double blinded randomized clinical trial to assess the effectiveness of several preparations for colonoscopy / Ensaio clínico randomizado duplo cego para avaliar a eficácia de várias preparações para colonoscopia

ABSTRACT Introduction: Colonoscopy is the screening gold standard to investigate several conditions in the colon. The excellence of preparation is a determining factor for a quality colonoscopy. Objective: Compare the quality of colon preparations for colonoscopy with different kinds of laxative medications in a public hospital of Belo Horizonte, Brazil. Method: A prospective double blind randomized clinical trial was conducted from June 2016 to March 2017. A total of 117 Patients were randomised in four groups to receive a type of preparation (Sodium picosulfate, Mannitol, Lactitol, Lactulose). The patients answered a questionnaire and peripheral blood samples were collected before and after the preparation.The quality of the cleansing was accessed according to the Boston Bowel Preparation Scale. Results: 99.1% of patients have taken the recommended dose and 79.5% reported a good tolerability. Endoscopists performed complete colonoscopy in 89.7%, with an polipectomy rate of 47%. The total effectiveness rate of the solutions were 88%. There were no statistically significant differences between groups (p = 0.271). Regarding the laboratory parameters, differences were seen in the pre- and post-test values of sodium, chlorine and creatinine but without exceeding reference values. Conclusion: The four preparations were effective for colon cleansing, with good acceptance, differing only as for costs.

RESUMO Introdução: a colonoscopia é o padrão ouro de triagem para pesquisa de várias doenças colônicas. A excelência de preparação é um fator determinante para uma colonoscopia de qualidade. Objetivo: Comparar a qualidade das preparações do cólon para colonoscopia com diferentes tipos de medicamentos laxantes em um hospital público de Belo Horizonte, Brasil. Método: Foi realizado um ensaio clínico randomizado duplo cego prospectivo de junho de 2016 a março de 2017. Um total de 117 pacientes foi randomizado em quatro grupos para receber um tipo de preparação (picossulfato sódico, manitol, lacticol, lactulose). Os pacientes responderam a um questionário e amostras de sangue periférico foram coletadas antes e depois da preparação. A qualidade da limpeza foi acessada de acordo com a Boston Bowel Preparation Scale. Resultados: 99,1% dos pacientes tomaram a dose recomendada e 79,5% relataram boa tolerabilidade. Os endoscopistas realizaram colonoscopia completa em 89,7%, com taxa de polipectomia de 47%. A taxa de eficácia total das soluções foi de 88%. Não houve diferenças estatisticamente significantes entre os grupos (p = 0,271). Em relação aos parâmetros laboratoriais, foram observadas diferenças nos valores pré e pós-teste de sódio, cloro e creatinina, mas sem exceder os valores de referência. Conclusão: As quatro preparações foram eficazes para limpeza do cólon, com boa aceitação, diferindo apenas quanto aos custos.

Intestinal fructose malabsorption is associated with increased lactulose fermentation in the intestinal lumen / Má absorção intestinal de frutose associa-se com maior fermentação de lactulose na luz intestinal

Abstract Objective: To study fructose malabsorption in children and adolescents with abdominal pain associated with functional gastrointestinal disorders. As an additional objective, the association between intestinal fructose malabsorption and food intake, including the estimated fructose consumption, weight, height, and lactulose fermentability were also studied. Methods: The study included 31 patients with abdominal pain (11 with functional dyspepsia, 10 with irritable bowel syndrome, and 10 with functional abdominal pain). The hydrogen breath test was used to investigate fructose malabsorption and lactulose fermentation in the intestinal lumen. Food consumption was assessed by food registry. Weight and height were measured. Results: Fructose malabsorption was characterized in 21 (67.7%) patients (nine with irritable bowel syndrome, seven with functional abdominal pain, and five with functional dyspepsia). Intolerance after fructose administration was observed in six (28.6%) of the 21 patients with fructose malabsorption. Fructose malabsorption was associated with higher (p < 0.05) hydrogen production after lactulose ingestion, higher (p < 0.05) energy and carbohydrate consumption, and higher (p < 0.05) body mass index z-score value for age. Median estimates of daily fructose intake by patients with and without fructose malabsorption were, respectively, 16.1 and 10.5 g/day (p = 0.087). Conclusion: Fructose malabsorption is associated with increased lactulose fermentability in the intestinal lumen. Body mass index was higher in patients with fructose malabsorption.

Resumo Objetivo: Pesquisar a má absorção de frutose em crianças e adolescentes com dor abdominal associada com distúrbios funcionais gastrintestinais. Como objetivo adicional, estudou-se a relação entre a má absorção intestinal de frutose e a ingestão alimentar, inclusive a estimativa de consumo de frutose, o peso e a estatura dos pacientes e a capacidade de fermentação de lactulose. Métodos: Foram incluídos 31 pacientes com dor abdominal (11 com dispepsia funcional, 10 com síndrome do intestino irritável e 10 com dor abdominal funcional). O teste de hidrogênio no ar expirado foi usado para pesquisar a má absorção de frutose e a fermentação de lactulose na luz intestinal. O consumo alimentar foi avaliado por registro alimentar. Foram mensurados também o peso e a estatura dos pacientes. Resultados: Má absorção de frutose foi caracterizada em 21 (67,7%) pacientes (nove com síndrome do intestino irritável, sete com dor abdominal funcional e cinco com dispepsia funcional). Intolerância após administração de frutose foi observada em seis (28,6%) dos 21 pacientes com má absorção de frutose. Má absorção de frutose associou-se com maior produção de hidrogênio após ingestão de lactulose (p < 0,05), maior consumo de energia e carboidratos (p < 0,05) e maior valor de escore z de IMC para a idade (p < 0,05). As medianas da estimativa de ingestão diária de frutose pelos pacientes com e sem má absorção de frutose foram, respectivamente, 16,1 e 10,5 g/dia (p = 0,087). Conclusão: Má absorção de frutose associa-se com maior capacidade de fermentação de lactulose na luz intestinal. O índice de massa corporal foi maior nos pacientes com má absorção de frutose.

El impacto del tratamiento de la encefalopatía hepática mínima en el pronóstico a largo plazo / The impact of minimal hepatic encephalopathy treatment in long-term prognosis

La encefalopatía hepática mínima (EHm) afecta del 30% al 50% de los pacientes cirróticos. Su detección es esencial por su relación con la encefalopatía hepática clínica, la alteración de la habilidad para conducir, el mayor riesgo de caídas, la alteración de la calidad de vida, la progresión más acelerada de la cirrosis y la supervivencia. A pesar de la información fidedigna de su relevancia clínica, pronóstica y social, la detección de EHm no está generalizada en la práctica clínica. El espectro de la encefalopatía hepática engloba diversas alteraciones de las funciones cerebrales, por lo que se requiere realizar más de un test para su diagnóstico. Además, las alteraciones iniciales difieren de un paciente a otro. Esto ha dificultado el desarrollo de una estrategia diagnóstica universal. Como resultado, no disponemos de datos suficientes para generar recomendaciones basadas en la evidencia del impacto del tratamiento de la EHm en la calidad de vida y la supervivencia, así como de su rentabilidad. Por lo tanto, las guías clínicas actuales sugieren que se evalúe la EHm cuando se afecta la calidad de vida de los pacientes, ya que no se conocen las consecuencias del tamizaje. Las terapias reductoras de amonio se consideran la piedra angular del tratamiento de la EHm. Los disacáridos no absorbibles, la rifaximina y, más recientemente, los probióticos, han mostrado efectos beneficiosos. Se necesitan más ensayos controlados con placebo para evaluar la eficacia, seguridad y rentabilidad de los regímenes de tratamiento disponibles para evaluar el impacto del tratamiento de la EHm en el pronóstico a largo plazo de estos pacientes.

Minimal hepatic encephalopathy (MHE) affects up to 30-50% of cirrhotic patients. The detection of MHE is essential because of its relationship with overt hepatic encephalopathy, impairment of motor vehicle driving abilities, higher risk of falls, quality of life impairment, faster cirrhosis progression and survival. Despite the robust evidence regarding its clinical, prognostic and social relevance, MHE testing is not widespread in routine clinical care. Hepatic encephalopathy spectrum covers various alterations in complex brain functions, requiring more than one test to be quantified. In addition, initial disturbances differ from one patient to another. All this has made it difficult to develop a universal diagnostic strategy. As a consequence, there is a lack of available robust data in the literature to generate evidence-based recommendations related to the impact of MHE treatment on quality of life and survival of these patients, as well as on cost-effectiveness. Therefore, current clinical guidelines suggest MHE testing only when patients have problems with their quality of life, since consequences of the screening procedure are still unclear. Ammonia lowering therapies have been considered the cornerstone of MHE treatment. Beneficial effects of non-absorbable disaccharides (lactulose or lactitol), rifaximin and more recently, probiotics have been reported. Further placebo-controlled trials are needed to assess the efficacy, safety, and cost-effectiveness of available treatment regimes to evaluate the impact of MHE treatment on the long-term prognosis of these patients.

Minimal Hepatic Encephalopathy in Cirrhosis- How Long to Treat?

Abstract: Introduction. Minimal hepatic encephalopathy (MHE) can reverse after short-term treatment. However, relapse rate of MHE after stopping treatment has not been studied so far. We aimed to evaluate long-term (9 months) efficacy of a short-term (3 months) treatment of MHE with lactulose/rifaximin, for maintenance of remission from MHE. Material and methods. In this prospective study, consecutive patients with cirrhosis and MHE were treated with lactulose/rifaximin for 3 months. After treatment, they were followed up for 6 months. Psychometric testing for diagnosis of MHE was performed at baseline, 3 months and 9 months. Results. Of the 527 patients screened, 351 were found eligible and tested for MHE. Out of these, 112 (31.9%) patients had MHE (mean age 55.3 years; 75% males). They were randomized to receive Rifaximin (n = 57; 1,200 mg/day) or Lactulose (n = 55; 30-120 mL/day) for three months. At 3 months, 73.7% (42/57) patients in Rifaximin group experienced MHE reversal compared to 69.1% (38/55) in Lactulose group (p = 0.677). Six months after stopping treatment, 47.6% (20/42) in rifaximin group and 42.1% (16/38) patients in lactulose group experienced MHE relapse (p = 0.274). The overt hepatic encephalopathy development rate (7.1% vs. 7.9%) and mortality rate (0.23% vs. 0%) were similar in both groups. The Child-Turcotte-Pugh score and model for end stage liver disease (MELD) scores of patients who had MHE relapse were higher compared to those who didn’t. On multivariate regression analysis, MELD score was an independent predictor of MHE relapse. Conclusion. Of the patients who became MHE negative after short-term (3 months) treatment with rifaximin/lactulose, almost 50% had a relapse of MHE at 6 months follow-up.

Obesity Is Inversely Related to Hydrogen-Producing Small Intestinal Bacterial Overgrowth in Non-Constipation Irritable Bowel Syndrome

There have been inconsistent findings on the association of obesity and non-constipation irritable bowel syndrome (IBS). Small intestinal bacterial overgrowth (SIBO) with hydrogen (H₂) gas forming-microflora causes non-constipation IBS. But, the effect of H₂ producing SIBO on obesity in non-constipation IBS patients has not been studied yet. The aim of this study was to investigate the association between obesity and SIBO in non-constipation IBS patients. We reviewed the charts of patients who showed IBS symptoms along with the documented results of their lactulose hydrogen breath test (LHBT) for SIBO. Multivariate models were used to assess the association between obesity and SIBO. Four-hundred fifty-eight patients were retrospectively included in the study. Of the 485 IBS patients, 158 (30.7%) subjects had positive results for LHBT. Subjects without SIBO showed significantly higher levels of body mass index (24.8 vs. 23.3; P < 0.001) and waist circumference (86.5 vs. 82.7; P < 0.001) as compared to subjects with SIBO. In multivariate analysis, the odds ratios of SIBO were 0.396 (P = 0.018) for obesity and 0.482 (P = 0.021) for abdominal obesity. This is the first human study to demonstrate that obesity is inversely related to SIBO with H2 gas production in non-constipation IBS patients.

Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge between Functional Organic Dichotomy

The pathogenesis of irritable bowel syndrome (IBS), once thought to be largely psychogenic in origin, is now understood to be multifactorial. One of the reasons for this paradigm shift is the realization that gut dysbiosis, including small intestinal bacterial overgrowth (SIBO), causes IBS symptoms. Between 4% and 78% of patients with IBS and 1% and 40% of controls have SIBO; such wide variations in prevalence might result from population differences, IBS diagnostic criteria, and, most importantly, methods to diagnose SIBO. Although quantitative jejunal aspirate culture is considered the gold standard for the diagnosis of SIBO, noninvasive hydrogen breath tests have been popular. Although the glucose hydrogen breath test is highly specific, its sensitivity is low; in contrast, the early-peak criteria in the lactulose hydrogen breath test are highly nonspecific. Female gender, older age, diarrhea-predominant IBS, bloating and flatulence, proton pump inhibitor and narcotic intake, and low hemoglobin are associated with SIBO among IBS patients. Several therapeutic trials targeting gut microbes using antibiotics and probiotics have further demonstrated that not all symptoms in patients with IBS originate in the brain but rather in the gut, providing support for the micro-organic basis of IBS. A recent proof-of-concept study showing the high frequency of symptom improvement in patients with IBS with SIBO further supports this hypothesis.

Rhubarb Monomers Protect Intestinal Mucosal Barrier in Sepsis via Junction Proteins / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Leakage of the intestinal mucosal barrier may cause translocation of bacteria, then leading to multiorgan failure. This study hypothesized that rhubarb monomers might protect the gut mucosal barrier in sepsis through junction proteins.</p><p><b>METHODS</b>Healthy male Sprague-Dawley rats (weighing 230-250 g) under anesthesia and sedation were subjected to cecal ligation and perforation (CLP). After surgical preparation, rats were randomly assigned to eight groups (n = 6 or 8 each group): sham group (Group A: normal saline gavage); sepsis group (Group B: normal saline gavage); Group C (intraperitoneally, dexamethasone 0.5 mg/kg) immediately after CLP surgery; and rhubarb monomer (100 mg/kg in normal saline)-treated groups (Group D: rhein; Group E: emodin; Group F: 3,8-dihydroxy-1-methyl-anthraquinone-2-carboxylic acid; Group G: 1-O-caffeoyl-2-(4-hydroxy-O-cinnamoyl)-D-glucose; and Group H: daucosterol linoleate). Animals were sacrificed after 24 h. Intestinal histology, lactulose, mannitol concentrations were measured, and zonula occludens (ZO)-1, occludin and claudin-5 transcription (polymerase chain reaction), translation (by Western blot analysis), and expression (by immunohistochemistry) were also measured.</p><p><b>RESULTS</b>Intestinal histology revealed injury to intestinal mucosal villi induced by sepsis in Group B, compared with Group A. Compared with Group A (0.17 ± 0.41), the pathological scores in Groups B (2.83 ± 0.41, P < 0.001), C (1.83 ± 0.41, P < 0.001), D (2.00 ± 0.63, P < 0.001), E (1.83 ± 0.41, P < 0.001), F (1.83 ± 0.75, P < 0.001), G (2.17 ± 0.41, P < 0.001),and H (1.83 ± 0.41, P < 0.001) were significantly increased. Lactulose/mannitol (L/M) ratio in Group B (0.046 ± 0.003) was significantly higher than in Group A (0.013 ± 0.001, P< 0.001) while L/M ratios in Groups C (0.028 ± 0.002, P< 0.001), D (0.029 ± 0.003, P< 0.001), E (0.026 ± 0.003, P< 0.001), F (0.027 ± 0.003, P< 0.001), G (0.030 ± 0.005, P< 0.001), and H (0.026 ± 0.002, P< 0.001) were significantly lower than that in Group B. ZO-1, occludin and claudin-5 transcription, translation, and expression in Group B were significantly lower than that in Group A (P < 0.001), but they were significantly higher in Groups C, D, E, F, G, and H than those in Group B (P < 0.05).</p><p><b>CONCLUSION</b>Rhubarb monomer treatment ameliorated mucosal damage in sepsis via enhanced transcription, translation, and expression of junction proteins.</p>

Serial Frozen Fecal Microbiota Transplantation in the Treatment of Chronic Intestinal Pseudo-obstruction: A Preliminary Study

BACKGROUND/AIMS: Chronic intestinal pseudo-obstruction (CIPO) is a serious, life-threatening motility disorder that is often related to bacterial overgrowth. Fecal microbiota transplantation (FMT) results in restoration of the normal intestinal microbial community structure. We investigated the efficacy of FMT in the treatment of CIPO patients. METHODS: Nine patients (age 18–53 years) with CIPO were enrolled in this prospective, open-label study. Patients received FMT for 6 consecutive days through nasojejunal (NJ) tubes and were followed up for 8 weeks after treatment. We evaluated the rate of clinical improvement and remission, feeding tolerance of enteral nutrition, and CT imaging scores of intestinal obstructions. Lactulose hydrogen breath tests were performed before FMT and 8 weeks after FMT to evaluate for the presence small intestinal bacterial overgrowth (SIBO). RESULTS: FMT significantly alleviated bloating symptoms, and symptoms of pain were relieved 2 weeks after FMT. Enteral nutrition administered through a NJ tube after FMT was well-tolerated by 66.7% (6/9) of patients. CT scores of intestinal obstructions were significantly reduced after FMT (P = 0.014). SIBO was eliminated in 71.0% (5/7) of patients. CONCLUSIONS: This pilot study demonstrated the safety of using FMT. FMT may relieve symptoms in selected patients with CIPO. FMT may also improve patient tolerance of enteral nutrition delivered via a NJ tube.

Eficacia y seguridad de rifaximina alfa en pacientes con encefalopatia hepatica refractaria al uso de lactulosa / Efficacy and safety of rifaximin alfa in patients with hepatic encephalopathy refractory to the use of lactulose

INTRODUCCIÓN: Antecedentes: El presente dictamen responde a la solicitud de evaluación del uso del petitorio de Rifaximina alfa en pacientes con encefalopatia hepática refractaria al uso de lactulosa. Aspectos Generales: Se estima que aproximadamente 5.5 millones de personas en los Estados Unidos sufren de cirrosis hepática, una causa de movilidad y mortalidad tanto en este país como en el mundo. La encefalopatia hepática o encefalopatía portosistemica constituye una complicación de la cirrosis hepática y falla de la función neuropsiquiátrica asociada con falla en la función hepática. A pesar que la condición es frecuentemente diagnosticada aún no existe un claro entendimiento de la patogénesis. Sin embargo, se estipula que se puede deber a un incremiento en las concentraciones de amoniaco en vista que el higado ya no es capaz de eliminar las toxinas de la sangre causando así toxicidad en el cerebro. Puede presentarse como episodios agudos o crónicamente a largo plazo. Tecnología Sanitaria de Interés: La Rifaximina alfa es un agente antimicrobiano con un amplio espectro de acción sobre Bacterias Gram-positivas y Gram- negativas, tanto aerobias como anaerobais. La característica de Rifaximina alfa es su forma polimorfa alfa y su escasa absorción en el tracto gastrointestinal (inferior a 1%), lo cual favorece la concentración del fármaco en el intestino y sobre todo, en las heces en forma activa. METODOLOGÍA: Estrategia de Búsqueda: Se llevó a cabo una búsqueda sistemática de la literatura con respecto a la eficacia y seguridad de Rifaximina alfa para el tratamiento de pacientes con encefalopatía hepática con resistencia (falla) al tratamiento estándar con lactulosa. La búsqueda se inicio revisando la información sobre el uso del medicamento de acuerdo con entidades reguladoras com la Food and Drug Administration (FDA), la European Medicines Agency (EMA) y la Dirección General de Medicamentos y Drogas (DIGEMID). Posteriomente se buscaron Guías de Práctica Clínica a través de los metabuscadores: Translating Research into Practice (TRIPDATABASE), National Library of Medicine (Pubmed-Medline), The National Guuideline of Clearinghouse, y Health Systems Evidence. Finalmente. se realizó una búsqueda dentro de la información generada por grupos internacionales que realizan revisiones sistemáticas, evaluación de tecnologías sanitarias y guías de práctica clínica. RESULTADOS: Sinopsis de la Evidencia: En la presente sinopsis se describe la evidencia disponible que sustenta la eficacia y seguridad de Rifaximina alfa para el tratamiento de pacientes con encefalopatia hgepática refractarios al tratamiento estándar con lactulosa. CONCLUSIONES: A la fecha, no se ha evaluado la eficacia y seguridad de Rifazimina alfa como monoterapia ni en pacientes refractarios a lactulosa, por lo que la evidencia encontrada responde la pregunta PICO de manera indirecta. Actualmente no existe alternativa de tratamiento a lactulosa en el Petitorio Farmacológico de EsSalud, por lo que es necesario contar con una alternativa de tratamiento para así evitar el deterioro de la calidad de vida del paciente, dadas las limitaciones en las funciones cognitiva y psicomotriz a la que la enfermedad conlleva. El Instituto de Evaluacioón de Tecnologías en Salud e Investigación-IETSI, aprueba el uso de Rifaximina alfa en pacientes con encefalopatía hepática refractaria al uso de lactulosa. El presente Dicatamen Preliminar tiene una vigencia de dos años a partir de su fecha de publicación.

Efficacy of lactulose in the prophylaxis of hepatic encephalopathy in cirrhotic patients presenting gastrointestinal bleeding / Eficácia da lactulose na profilaxia de encefalopatia hepática em pacientes cirróticos apresentando hemorragia digestiva

SUMMARY Introduction: Hepatic encephalopathy (HE) is a bad prognostic factor in patients with liver cirrhosis and its incidence is associated with several triggering factors being the most prevalent gastrointestinal bleeding. Lactulose, despite its questionable efficacy in the literature, is considered a first line treatment in patients with HE. Objective: To evaluate the effectiveness of lactulose in preventing HE in cirrhotic patients with gastrointestinal bleeding. Method: A systematic review of the literature using the Medline scientific database. Only randomized controlled clinical trials evaluating the efficacy of lactulose for HE prophylaxis in cirrhotic patients with gastrointestinal bleeding were included. Results: The incidence of HE in the intervention group was 7%, while the control group was 26% (p=0.01). There was no significant difference in the incidence of mortality in the group treated with lactulose compared to the group that was not treated (p=0.48). Conclusion: Administering lactulose to cirrhotic patients with upper gastrointestinal bleeding reduces the incidence of hepatic encephalopathy.

RSUMO Introdução: encefalopatia hepática (EH) é fator de mau prognóstico no paciente com cirrose hepática e sua incidência está associada a vários fatores desencadeantes, sendo a hemorragia digestiva o mais prevalente. A lactulose, apesar de apresentar eficácia discutível na literatura, é considerada tratamento de primeira linha em pacientes com EH. Objetivo: avaliar a eficácia da lactulose na prevenção de EH em pacientes cirróticos apresentando hemorragia digestiva. Método: realizou-se revisão sistemática da literatura pela base de dados Medline. Foram incluídos apenas ensaios clínicos controlados e randomizados que avaliaram a eficácia da lactulose na profilaxia de EH em pacientes cirróticos com hemorragia digestiva. Resultados: a incidência de EH no grupo intervenção foi de 7% enquanto no grupo controle foi de 26% (p=0,01). Não houve diferença significante na incidência de mortalidade entre o grupo que recebeu lactulose e o que não recebeu (p=0,48). Conclusão: a administração de lactulose em pacientes cirróticos apresentando hemorragia digestiva alta diminui a incidência de encefalopatia hepática.

Hyperammonemic hepatic encephalopathy management through L-ornithin-L-aspartate administration in dogs

Seventeen dogs were treated with L-ornithin-L-aspartate (LOLA; experimental group). Three dogs were treated with lactulose recognized therapy (control group). Following LOLA administration, 15 dogs experienced a significant decrease in ammonia level (p 0.05). These results suggest that LOLA is an effective drug to treat hyperammonemia in veterinary medicine.

Correlation between Colon Transit Time Test Value and Initial Maintenance Dose of Laxative in Children with Chronic Functional Constipation / 대한소아소화기영양학회지

PURPOSE: To evaluate the correlation between colon transit time (CTT) test value and initial maintenance dose of polyethylene glycol (PEG) 4000 or lactulose. METHODS: Of 415 children with chronic functional constipation, 190 were enrolled based on exclusion criteria using the CTT test, defecation diary, and clinical chart. The CTT test was performed with prior disimpaction. The laxative dose for maintenance was determined on the basis of the defecation diary and clinical chart. The Shapiro-Wilk test and Pearson's and Spearman's correlations were used for statistical analysis. RESULTS: The overall group median value and interquartile range of the CTT test was 43.8 (31.8) hours. The average PEG 4000 dose for maintenance in the overall group was 0.68±0.18 g/kg/d; according to age, the dose was 0.73±0.16 g/kg/d (<8 years), 0.53±0.12 g/kg/d (8 to <12 years), and 0.36±0.05 g/kg/d (12 to 15 years). The dose of lactulose was 1.99±0.43 mL/kg/d (<8 years) or 1.26±0.25 mL/kg/d (8 to <12 years). There was no significant correlation between CTT test value and initial dose of laxative, irrespective of the subgroup (encopresis, abnormal CTT test subtype) for either laxative. Even in the largest group (overall, n=109, younger than 8 years and on PEG 4000), the correlation was weak (Pearson's correlation coefficient [R]=0.268, p=0.005). Within the abnormal transit group, subgroup (n=73, younger than 8 years and on PEG 4000) correlation was weak (R=0.267, p=0.022). CONCLUSION: CTT test value cannot predict the initial maintenance dose of PEG 4000 or lactulose with linear correlation.