A Low FODMAP Diet Supplemented with L-Tryptophan Reduces the Symptoms of Functional Constipation in Elderly Patients.

(1) Background: The elderly suffer from functional constipation (FC), whose causes are not fully known, but nutritional factors may play a role. The aim of the present study was to assess the effect of a low FODMAP diet supplemented with L-tryptophan (TRP) on its metabolism and symptoms of functional constipation in elderly patients. (2) Methods: This study included 40 people without abdominal complaints (Group I, controls) and 60 patients with FC, diagnosed according to the Rome IV Criteria (Group II). Two groups were randomly selected: Group IIA (n = 30) was qualified for administration of the low FODMAP diet, and the diet of patients of Group IIB (n = 30) was supplemented with 1000 mg TRP per day. The severity of abdominal symptoms was assessed with an abdominal pain index ranging from 1 to 7 points (S-score). The concentration of TRP and its metabolites, 5-hydroxyindoleacetic acid (5-HIAA), kynurenine (KYN), and 3-indoxyl sulfate (3-IS) in urine were determined using the LC-MS/MS method. (3) Results: In Group II, 5-HIAA concentration in urine was lower, and KYN and 3-IS concentrations were higher than in the control group. A negative correlation was found between the S-score and urinary concentration of 5-HIAA (p < 0.001), and 3-IS concentration was positively correlated with the S-score. However, the correlation between the S-score and 3-IS concentration was negative (p < 0.01). After a dietary intervention, 5-HIAA concentration increased in both groups, and the severity of symptoms decreased, but the decrease was more pronounced in Group IIB. (4) Conclusion: A low FODMAP diet supplemented with L-tryptophan has beneficial effects in elderly patients suffering from functional constipation.

The Variability of Tryptophan Metabolism in Patients with Mixed Type of Irritable Bowel Syndrome.

Patients with a mixed type of irritable bowel syndrome (IBS-M) experience constipation and diarrhea, which alternate between weeks or months. The pathogenesis of this syndrome is still little understood. The aim of the study was mainly to evaluate the urinary excretion of selected tryptophan (TRP) metabolites during the constipation and diarrhea periods of this syndrome. In 36 patients with IBS-M and 36 healthy people, serum serotonin level was measured by ELISA and urinary levels of 5-hydroxyindoleacetic acid (5-HIAA), kynurenine (KYN) and indican (3-IS) were determined using the LC-MS/MS method. The levels of all above metabolites were higher in the patient group, and increased significantly during the diarrheal period of IBS-M. In particular, the changes concerned 5-HIAA (3.67 ± 0.86 vs. 4.59 ± 0.95 mg/gCr, p < 0.001) and 3-IS (80.2 ± 17.4 vs. 93.7 ± 25.1 mg/g/Cr, p < 0.001). These changes coexisted with gut microbiome changes, assessed using hydrogen-methane and ammonia breath tests. In conclusion, the variability of TRP metabolism and the gut microbiome may cause the alternation of IBS-M symptoms.

A Reduced Tryptophan Diet in Patients with Diarrhoea-Predominant Irritable Bowel Syndrome Improves Their Abdominal Symptoms and Their Quality of Life through Reduction of Serotonin Levels and Its Urinary Metabolites.

(1). An essential component of any treatment for patients with irritable bowel syndrome (IBS) is an adequate diet. Currently, a low FODMAP diet is recommended as a first-line therapy, but it does not relieve abdominal discomfort in all patients, and alternative nutritional treatment is required. The purpose of this study was to evaluate the effect of a tryptophan-lowering diet (TRP) on abdominal and mental symptoms in patients with irritable bowel syndrome with predominant diarrhea (IBS-D). (2). The study included 40 patients with IBS-D, and 40 healthy subjects served as a baseline for IBS-D patients, after excluding comorbidities. The TRP intake was calculated using the nutritional calculator. The severity of abdominal symptoms was assessed using the gastrointestinal symptom rating scale (GSRS-IBS). Mental state was assessed using the Hamilton anxiety rating scale (HAM-A), the Hamilton depression rating scale (HAM-D), and the insomnia severity index (ISI). The serum levels of serotonin and melatonin and the urinary excretion of their metabolites 5-hydroxyindoleacetic acid (5-HIAA) and 6-sulfatoxymelatonin (aMT6) were determined by the ELISA method. The severity of symptoms and laboratory data were analyzed before and after a 12 week diet with tryptophan restricted to a daily dose 10 mg per kilogram body weight. (3). Compared to the control group, patients with IBS-D had a higher serum level of serotonin (198.2 ± 38.1 vs. 142.3 ± 36.4 ng/mL; p < 0.001) but a similar level of melatonin (8.6 ± 1.1 vs. 9.4 ± 3.0 pg/mL; p > 0.05). The urinary excretion of 5-HIAA was also higher in patients with IBS-D patients (7.7 ± 1.5 vs. 6.0 ± 1.7 mg/24 h; p < 0.001). After nutritional treatment, both the serum serotonin level and the urinary 5-HIAA excretion significantly decreased (p < 0.001). The severity of the abdominal symptoms and anxiety also decreased, while the HAM-D score and the ISI score remained unchanged (4). Lowering the dietary intake of tryptophan may reduce abdominal complaints and does not alter the mental state of IBS-D patients.

Altered Tryptophan Metabolism on the Kynurenine Pathway in Depressive Patients with Small Intestinal Bacterial Overgrowth.

The causes of depression are diverse and are still not fully understood. Recently, an increasing role is attributed to nutritional and inflammatory factors. The aim of this study was to evaluate selected metabolites of the tryptophan kynurenine pathway in depressive patients with small intestinal bacterial overgrowth (SIBO). The study involved 40 healthy people (controls) and 40 patients with predominant small intestinal bacterial overgrowth (SIBO-D). The lactulose hydrogen breath test (LHBT) was performed to diagnose SIBO. The severity of symptoms was assessed using the Gastrointestinal Symptom Rating Scale (GSRS-IBS) and the Hamilton Depression Rating Scale (HAM-D). The concentration of tryptophan (TRP), kynurenine (KYN), kynurenic acid (KYNA), and quinolinic acid (QA) in urine was determined using an LC-MS/MS method, before and after cyclic treatment with an antibiotic drug, rifaximin, for three months. The number of intraepithelial lymphocytes (IELs) in the duodenum and small intestinal mucosa, fecal calprotectin (FC) and serum level of C-reactive protein (CRP) were also determined. In patients with SIBO, a higher level of KYN and QA were found as compared to the control group. These two groups also differed in KYN/TRP (higher in SIBO) and KYNA/KYN ratios (lower in SIBO). A positive correlation was found between HAM-D and the number of IELs and the level of FC. Treatment with rifaximin improves the kynurenic pathway, as well as abdominal and mental complaints. Therefore, small intestinal bacterial overgrowth can be a cause of abdominal symptoms, but also mental disorders.

Altered tryptophan metabolism in patients with recurrent functional abdominal pain.

The causes of functional abdominal pain are still unclear. The role of food factors in their pathogenesis has been assessed by many researches, but the obtained results are varied. AIM: The aim of present study was to evaluate metabolism of tryptophan, which is substrate for serotonin synthesis and other bioactive compounds, in patients with recurrent functional abdominal pain. MATERIALS AND METHODS: Thirty patients with recurrent abdominal pain and 30 healthy subjects were enrolled in this study. Urinary levels of tryptophan (TRP), 5-hydroxyindoleacetic acid(5-HIAA), L-kynurenine (KYN), xanthurenic acid(XA), and quinolinic acid(QA) were determined by liquid chromatography with tandem mass spectrometry (LC-MS/MS), and related to creatinine level (mg/gCr), during active phase(day with acute pain), and silence period, which recommended optimalisation of tryptophan intake. RESULTS: 5-HIAA/TRP ratio and KYN/TRP ratio as well as QA level s were significantly higher in patients compared to control group (p<0.001). After reducing TRP consumption, the above results improved, in particular, the level of QA decreased from 6.88±1.04 mg/Cr to 4,32±0.97 mg/gCr (p<0.001). CONCLUSIONS: Altered tryptophan metabolism may affect locally-andcentrally mediated recurrent functional abdominal pain.

The clinical value of breath ammonia determination in patients with irritable bowel syndrome.

Gastrointestinal tract is the major source of ammonia (NH3). NH3 is produced by bacterial hydrolysis of urea as well as by bacterial protein deamination. The intensity of this process depends on protein intake and the amount of gut bacteria. AIM: The aim of the study was to assess the level of the fasting breath ammonia in patients with irritable bowel syndrome (IBS) in relation to the results of lactulose hydrogen breath test (LHBT) and to clinical form of this syndrome before and after 14-days rifaximin treatment at daily dose of 1200 mg. MATERIALS AND METHODS: The study was conducted in 120 subjects, including 40 healthy people (Controls, group I), 40 patients with IBS and predominant diarrhea (group II, IBS-D), and 40 patients with IBS and predominant constipation (group III, IBS-C). The lactulose breath test (LHBT) and ammonia breath test (ABT) were performed. Diagnosis of IBS was based on Rome IV Criteria. The severity of abdominal symptoms was assessed using the Gastrointestinal Symptom Rating Scale (GSRS-IBS). RESULTS: The basic level of ammonia in expired air in control group I was 5.2 ± 1.6 ppm, in group II - 20.8 ± 5.1 ppm (p< 0.001), and in group III - 10.4 ± 3.2 ppm (p< 0.001). Positive correlation was found between breath ammonia level and the results of LHBT in both groups with IBS. After 14-days rifaximin treatment at daily dose of 1200 mg the results of LHBT and breath ammonia significantly decreased in both groups. At the same time abdominal ailments subsided or significantly reduced. CONCLUSIONS: The determination of breath ammonia may be useful as biomarker of dysbiosis in patients with irritable bowel syndrome, especially in questionable results of hydrogen breath test.

The value of melatonin supplementation in postmenopausal women with Helicobacter pylori-associated dyspepsia.

BACKGROUND: Dyspeptic syndrome is particularly common in postmenopausal women in the form of epigastric pain. The aim of the study was to assess the role of melatonin in chronic dyspepsia in this group of women, and examine the role of Helicobacter infection. METHODS: The study comprised 152 subjects including 30 healthy women (Group I), 60 women with asymptomatic H.pylori infection (Group II), and 64 women with H. pylori infection with chronic dyspepsia (Group III). Endoscopic examination was performed, as well as histological assessment of gastric end duodenal mucosa, urease breath test (UBT-13C), and immunoenzymatic assessment of serum 17-ß-estradiol, follicle stimulating hormone and melatonin, and urinary 6-sulfatoxymelatonin. In Group III, 14-day antibacterial treatment was introduced with pantoprazole, amoxicillin and levofloxacin followed a six-month treatment with placebo in 32 women (Group IIIa), and melatonin 1 mg/morning and 3 mg/at bedtime in the other 32 women (Group IIIb). RESULTS: No significant differences were found between serum level of female hormone. Serum melatonin levels were similar between Group I (12.5 ± 2.72 pg/ml) and Group II (10.5 ± 3.73 pg/ml; p > 0,05). The level was significantly lower in Group III (5.72 ± 1.42 pg/ml; p < 0.001). Eradication of H.pylori was obtained in 75.0% women in Group IIIa, and in 84.3% in Group IIIb (p > 0.05). After six months, dyspeptic symptoms resolved in 43.7% patients in Group IIIa and 84.3% in Group IIIb (p < 0.001). CONCLUSION: Melatonin supplementation is useful in treating H. pylori-associated dyspepsia, particularly in postmenopausal women with lower levels of this hormone. TRIAL REGISTRATION: NCT04352062, date of registration: 15.04.2020.

Usefulness of the hydrogen breath test in patients with functional dyspepsia.

INTRODUCTION: The pathogenesis of functional dyspepsia is complex and not well understood. Therefore, in this disease there should be considered involvement of different pathogenic factors, including intestinal bacteria. AIM: To evaluate the results of the hydrogen breath test in relation to the clinical picture of functional dyspepsia. MATERIAL AND METHODS: The study included 40 healthy subjects (group I), 72 patients with postprandial distress syndrome (PDS, group II), and 84 patients with epigastric pain syndrome (EPS, group III). The diagnosis of functional dyspepsia was based on Rome Criteria IV. The urea breath test (13C-UBT) and lactulose hydrogen breath test (LHBT) were performed in all subjects. Patients with a positive urea breath test were excluded from the study. Patients with a positive LHBT test were assigned to antibiotic therapy (1200 mg daily for 14 days). Before treatment and 6 weeks after the end of antibiotic therapy the LHBT was performed, and severity of dyspeptic symptoms was assessed using a 10-points visual analogue scale. RESULTS: A positive LHBT test was found in 35 (48.6%) patients in the group with PDS, and in 40 (47.6%) patients with EPS (p > 0.05). A positive correlation between the results of the LHBT test and severity of dyspeptic symptoms was found in both group (p < 0.001). After treatment with rifaximin the mean LHBT result and the index of severity of dyspeptic complaints were significantly decreased (p < 0.001). CONCLUSIONS: Quantitative and/or qualitative changes in the gut microbiota may be the cause of functional dyspepsia.

[Zaburzenia czynnosciowe przewodu pokarmowego u osób z przerostem bakteryjnym jelita cienkiego]. / Functional disorders of gastrointestinal tract in subjects with small intestinal bacterial overgrowth.

Small intestinal bacterial overgrowth (SIBO) is a frequent cause of chronic abdominal complaining. AIM: The aim of this study was to assess the prevalence of the functional disorders in this group patients. MATERIALS AND METHODS: The study was conducted in a group of 426 subjects, aged 22-65, including 294 women and 132 men with intestinal functional diseases, as defined in Rome IV Criteria. Small intestinal bacterial overgrowth was evaluated using the Gastrolyzer (Bedfont), assuming an increase of hydrogen concentration in the breath samples over 20 ppm in relation to the baseline value within 90 minutes after consumption of 10 g lactulose (LHBT test). In 185 subjects (group I) results of this test was negative, and in 241 patients (group II) was positive. RESULTS: On the whole the prevalence of functional disorders are similar in both groups (p > 0,05). However, in the group with a positive LHBT score, the diarrheal form of the irritable bowel syndrome was more often diagnosed (21,1% vs 28,2%; OR -1,47, 95% Cl - 0,94-2,31) as well as functional diarrhea (22,1% vs 17,8%; OR - 1,22; Cl 95% - 0,78-1,92). Less differences were determined in evaluation of the constipation and bloatedness. CONCLUSIONS: The LHBT is useful in the diagnosis of functional disorders of the gastrointestinal tract.

Changes in the lipid profile of patients with asymptomatic and symptomatic helicobacter pylori infection.

OBJECTIVE: Introduction: Helicobacterpylori ( H. pylori) infection often coexists with coronary artery disease, but the causal relationship is not clear as yet. The aim: to assess the lipidogram of patients with asymptomatic and symptomatic H. pylori infection. PATIENTS AND METHODS: Material and methods: The study included 30 healthy subjects (group I), 40 patients with asymptomatic (group II) and 40 with symptomatic (group III) H. pylori infection. The diagnosis of infection was based on the results of the urea breath test (13C-UBT) and the concentration of specific IgG antibodies. Serum concentration of: total cholesterol (TC), low density lipoprotein (LDL) fraction, high density lipoprotein fraction (HDL), non-HDL cholesterol (TC-LDL) and triglycerides (TG) were tested. RESULTS: Results:Mean total cholesterol concentration was in group I-170,1±14,9 mg/dl, in group II - 173,0±13,1 mg/dl (>0,05), in group III - 192,9±20,1 mg/dl (<0,001). The concentration of LDL fraction was in group I - 111,6±12,5 mg/dl, in group II - 130,2±13,1 mg/dl (<0,001) and in group III-151,3±14,6 mg/dl (<0,001). The concentration of HDL fraction was in group I - 55,1±7,1 mg/dl, in group II-40,7±6,4 mg/dl (<0,001), in group III-40,0±4,9 mg/dl (<0,001). The concentration of non-HDL (TC-HDL) was in group I - 114,5±12,4 mg/dl, in group II - 132,2±13,8 mg/dl (<0,001), in group III - 152,8±15,6 mg/dl (<0,001). Triglycerides were in group I-133,3±24,2 mg/dl, in group II - 132,1±23,4 mg/dl (>0.05), in group III - 154,75±17,2 mg/dl (<0,001).Moreover, in group III a positive correlation was demonstrated between total cholesterol, LDL, HDL, triglycerides, non-HDL cholesterol and 13C-UBT. CONCLUSION: Conclusion: In H.pylori-infected patients there are observed changes in the lipidogram, particularly adverse ones in the proportion of LDL to HDL.

[The number of intraepithelial lymphocytes in digestive tract in patients with IgG-dependent intolerance of cereal products]. / Liczba limfocytów sródnablonkowych w przewodzie pokarmowym u osób z IgG-zalezna nietolerancja pokarmowa.

Abnormal reaction of food antigens cause a variety disorders of gastrointestinal tract. It is not clear why exactly the same products provoke diarrhea or constipation. AIM: The aim of this study was to assess the number of intraepithelial lymphocytes (IEL) in different parts of gastrointestinal tract in patients with specific IgG antibodies against wheat and secale products. MATERIALS AND METHODS: The study was performed in 36 healthy subjects(group I) and in 70 patients with diarrhea predominant (group II, n=38) or with constipation (group III, n=32). The level of specific IgG antibodies in blood were determined using Food Detective tests (Cambridge Diagnostics). The biopsy material obtained from duodenum, jejunum as well as from right and left colon was used for routine hematoxylin-eosin staining. RESULTS: In group II compared to control group the number of IEL was statistical higher in all part of gastrointestinal tract. Furthermore, in 9 patients (23.6%) in duodenum exceed 30/100 enterocytes, and in colon mucosa exceed 25/100 (21.0%) enterocytes. In patients with constipation (group III) the number of IEL was similar to healthy subjects. CONCLUSIONS: Food intolerance of cereal products may cause immuneinflammatory changes in digestive tract comparable to celiakia and lymphocytic colitis.

The Diagnosis of Sigmoid Liposarcoma in a Young Male with Metabolic Syndrome.

The clinical picture and risk factors are decisive in differential diagnosis. It was proved that patients with metabolic syndrome have increased incidence of malignant tumours. The visceral adipose tissue releases active proteins that promote oncogenesis. We are presenting a case of 34-year-old male with metabolic syndrome suffering from pain in left iliac fossa with accompanying variable stool pattern. At first, the sigmoid diverticulosis was suspected. Patient's condition after the treatment has improved. The ambulatory, partial colonoscopy revealed a cauliflower-like, balloting, wide-base growth in the sigmoid that narrowed its lumen. The biopsy did not reveal atypical growth characteristics. Because of tumour type and enlarged regional lymph nodes seen in abdomen CT scan, the segmental colon resection and end-to-end anastomosis was performed in the area of sigmoid-rectal junction. Macroscopically, there were no visible metastases in the operation field. The surgery and postoperative period ran without any complications. On histopathological examination, the removed tumour was a well differentiated liposarcoma (WDL) stemming unusually from adipose tissue of colonic submucosa in an obese male. WDL is a hard to diagnose tumour, especially in early stages of its growth. In the presented case, the tumour was completely resected.