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The GI Tract – Clinical Insights from Stool, Urine and Blood

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1 The GI Tract – Clinical Insights from Stool, Urine and Blood
Presented by Terry Pollock, MS Clinical Educator Nutrition Specialist

2 Big hello to all of the Nutrition Geeks folks!
(The real me, at work last week…)

3 GI Health – What Is It? Absence of GI symptoms or illness
Normal/stable intestinal microbiota Effective digestion and absorption of foods Effective immune status Daily, “Type 4 or 5” bowel movements (TAP) General feeling of well-being Bischoff, S. Gut Health – a new objective in medicine? BMC Medicine 2011, 9:24 IBDQ, BDQ, IBSQofLQ – “most suitable assessment tool”

4 GI Health – Two Major Determinants
1-The GI Barrier Allergic disease Autoimmune disease Obesity, FLD/NASH Sepsis – ICU pts Malnutrition Infectious diarrhea IBD Celiac disease IBS Bischoff, S. BMC 2011, 9:24

5 GI Health – Two Major Determinants
2 – GI Microbiome IBD Celiac disease IBS Allergy Arthritis Obesity Bischoff, S. BMC 2011, 9:24

6 Testing the GI Barrier Lactulose/mannitol - urine
Hydrogen breath testing IgG4 – serum or bloodspot Histology (villus, crypt, etc) LPS – cell membrane antigen in G-bacteria Lactoferrin - stool Immunity – CBC, cytokines, sIgA We will revisit some of these as we proceed

7 Testing the GI Microbiome
Cell cultures, chemotaxis, phagocytosis Bacterial/fungal cultures and toxins measurements Metametrix: PCR – DNA-based identification/quantitation via GIfx test Metabonomics – metabolites of gut bacteria via Organix Dysbiosis test We will go in depth in just a moment

8 It Is Usually Not One or the Other!
The GI Barrier and the GI Microbiome Are Interrelated “significantly more variation in the gut microbiota of healthy volunteers than that of IBS patients” Codling C, et al, Dig Dis Sci, 2010 Feb;55(2):392

9 The GI Barrier and the GI Microbiome Are Interrelated
Host pathology Age Genes, receptors Diet Components Mode of birth Non-digestible CH2O, prebiotics Gut Microflora Maternal flora Gut mucosal pathology impacts gut flora, as recent research is indicating…Codling C et al, Dig Dis Sci 2010, p. 392 – IBS pts have less microbial diversity than healthy controls. Reason unclear…much more work needed. Probiotics Infant environment Antibiotics, drugs

10 Autoimmune Diseases Associated with Overgrowth of Specific Bacteria
GI microbes linking to autoimmune pathology: Klebsiella: Ankylosing Spondylitis Citrobacter & Klebsiella: Rheumatoid Arthritis Yersinia: Grave’s & Hashimoto’s Disease, Ulcerative Colitis Autoinflam, autoimmun dx associated with microbes

11 Irritable Bowel Syndrome (IBS)
The disease entity “closest to the borderline between gut health and disease” - Bischoff Symptoms – abdominal pain or tenderness, bloating, change in bowel habits; no other known organic cause Risk of developing IBS increases 6 fold after acute GI infection

12 Irritable Bowel Syndrome
IBS-like symptoms are associated with three intestinal protozoan parasites: Blastocystis hominis – prevalence averages 30% in IBS patients. Prevalence in non-IBS patients ~7% Giardia lamblia – exposed group IBS 46% versus controls IBS 14% (Wensaas, Epub, Sept 2011) Dientamoeba fragilis – not as much data available Blastocystis hominis

13 Irritable Bowel Syndrome
IBS incidence in Chronic Fatigue Syndrome patients is 51% Psychiatric disorders are found in 94% of IBS patients Whitehead WE et al, Gastroenterology 2002, p. 1140 Probiotics (VSL #3, L. rhamnosus, B. breve) improve IBS flatulence, distension and pain Collado MC et al. Current Drug Metabolism 2009, p 68

14 GI Health – What We Often See
Bloating Flatulence GERD Nausea Vomiting Heartburn Constipation Diarrhea Food sensitivities Incontinence Abdominal pain Loss of appetite Weight loss/gain Blood in stools Do not all originate in gut, but most seem to be remediated by optimizing gut function and support. May not all originate in gut, but seem to be remediated by optimizing gut function and support!

15 GI Barrier Disorders Overview Ulcerative Colitis, Crohn’s
Selected Tests Case/Therapies We will talk about some GI barrier issues and see connections between microbes and these disease

16 The Importance of Mucosal Immunity
“The dominating part of the immune defense, even if flora is excluded, is localized in the gut—no less than 75% of the immune cells of the body are suggested to be found in the GI tract.” So much is immune-related…makes sense barrier d/o’s would have large immune component Bengmark S. Acute and "chronic" phase reaction--a mother of disease, Clin Nutr, Vol. 23, No. 6, pp , December 2004

17 Autoimmune/leaky gut/Celiac connection
Fasano A. Surprises from Celiac Disease. Scientific American, August 2009

18 Investigating the GI Barrier
Lactulose/mannitol - urine Hydrogen breath testing IgG4 – serum or bloodspot Histology (villus, crypt, etc) LPS – cell membrane antigen in Gram-bacteria Lactoferrin - stool Immunity – CBC, cytokines, sIgA

19 Hyperpermeable GI Barrier
11 out of 30 foods cause rxn – so not only food sensitivities, but leaky gut

20 Hyperpermeable GI Barrier
Lactulose/Mannitol Urine test for Leaky Gut – Lactulose molecule is larger and should not pass through to show up in urine. Mannitol should. Leaky Gut – both L and M are elevated in urine Malabsorption – both L and M are low in urine

21 Hyperpermeable GI Barrier
“Since the mucosal immune system is a central component of host defense, as a whole, any dysregulation and inflammatory reaction in the GI tissue results in intestinal barrier dysfunction and the entry of undigested dietary proteins into the circulation…. …The entry of dietary proteins in the circulation results in systemic immune response and the production of very high levels of IgG and IgA against dietary proteins and peptides. This systemic immune reaction against dietary proteins and peptides depends on the antigenic structure protein antigen, particulate antigens, polysaccharides, lipoproteins or enzymes and their molecular sizes, and of course, the genetic makeup of exposed individuals. One may produce IgG antibodies against dietary proteins, while others may produce IgA antibodies, or IgG and IgA antibodies against different dietary proteins and peptides.” Aristo Vojdani, PhD, immunologist, researcher Italics mine (TAP)

22 IBD - Ulcerative Colitis
Characteristics Any part of colon Diarrhea ~4X/d Mildly tender abdomen Fatigue Weight loss if severe case Increased oxidative stress Impaired colonic mucosal barrier -lesions very permeable Colon biopsy shows low copper/zinc

23 IBD - Ulcerative Colitis
Helpful Tests and Potential Findings GIfx stool analysis – H lactoferrin, H absorption markers Fatty acids – H arachidonic acid? OR mostly low fatty acids? 8OH-2DG, lipid peroxides – H in oxidative stress Inflammation markers – H crp, fibrinogen Lactulose/mannitol or IgG4 for permeability RBC elements – L zinc and copper Sometimes lip perox is low – if fats are low in malabsorption especially

24 IBD - Crohn’s Disease Characteristics:
Lower ileum usually, may occur at any locus Diarrhea ~4X/d (often twice as many) LRQ pain Bloody stool Fatigue Weight loss/anorexia Crohn’s pt’s small bowel bact markers in case coming up

25 IBD - Crohn’s Disease Helpful Tests and Potential Findings
GIfx stool analysis – H lactoferrin, malabsorption Organix Dysbiosis urine test – H bacterial markers Fatty acids – all L/L normal - malabsorption Fat-soluble vitamins – most L 8OH-2DG, lipid peroxides (oxid stress) - elevated Ferritin – low or sometimes very high! CBC – Low rbc’s, macrocytic cells, anemia

26 Russ - 48 yo m – Crohn’s History – Remicade Rx d/c– was not working
10 + bowel movements/d Hypothryroidism - on thyroid med Endoscopy showed Crohn’s-like inflammation Several antibiotics courses earlier  

27 Russ - 48 yo m – Crohn’s Labs - H lactoferrin, H calprotectin,
H leukocytes (original testing) Candida albicans neg Food sensitivities – IgG + buckwheat IgG4 mod/severe + to casein, milk

28 Russ - 48 yo m – Crohn’s disease
Supplements: DGL caps L-glutamine powder OTC Probiotics

29 Russ - 48 yo m – Crohn’s Borderline low anaerobes across the board.
Borderline low probiotics even though taking them. GIfx can show successful probiotics therapy

30 Russ - 48 yo m – Crohn’s “Low” total SCFA’s! Always look at number, not just at marker on the graph. Lactoferrin no longer H, but not where we see in non-IBD patients (1st Q), so pt is in remission or quiescence

31 Russ - 48 yo m – Crohn’s

32 Russ - 48 yo m – Crohn’s Clear SIBO! Moral of story – stool samples can’t offer much about small bowel bacterial overgrowth!

33 Russ - 48 yo m – Crohn’s Bacterial action on polyphenols, tyrosine, unabsorbed phenylalanine HPA – intestinal pathology Hippurate common in urine, but VH hippurate (from H bacterial benzoate) calls for more glycine to conjugate it in liver…. Still no sign of Candida

34 Russ – Crohn’s – follow-up
4 months later follow-up: Mainly 3- 4 bm’s per day. Feels “not well, but much better” Added in interim: Red yeast rice, vit D, vit C, milk thistle, Vit E, zinc carnosine, professional probiotic Needs to support colonic bacteria: I further recommended Biotagen, Therbiotic Complete, curcumin, anti-infl diet changes, no dairy!

35 GI Microbiome Disorders
Overview Testing Microbial Therapy

36 “It is today generally accepted that intestinal flora [are] deeply involved
In the pathogenesis of human inflammatory bowel diseases (IBDs). Although the exact presence of unwanted or lack of specific crucial bacteria are not yet known. Westerners lack, to a large extent, important immunomodulatory and fibre-fermenting lactic acid bacteria (LAB), bacteria which are present in all with a more primitive rural lifestyle”. Bifidobacter in colon Bengmark S. Bioecological control of inflammatory bowel disease. Clin Nutr, 26, 2007, p

37 Gut Microbiome Factoids
There are ~1000 species of microbes in the human intestinal tract - totaling over 4 lbs There are 10 times the number of microbial cells as human cells in the body (90% of DNA in our body is bacterial!!) Metabolic activity of our gut bugs rivals that of the liver

38 Colonization Resistance
Normal GI microbiota: provides a natural defense mechanism against invading pathogens prevents overgrowth of opportunistic microorganisms provides colonization resistance in a variety of ways, including: occupying adhesion sites producing antimicrobial agents

39 Testing the GI Microbiome
Cell cultures, chemotaxis, phagocytosis Bacterial/fungal cultures and toxins measurements Metametrix: PCR – DNA-based identification/quantitation via GIfx test Metabonomics – metabolites of gut bacteria via Organix Dysbiosis test

40 Obese mice on the same diet as lean mice demonstrate higher increase in body fat, indicating the microbial community seems to affect the amount of energy extracted from the diet. Germ-free mice inoculated with microbiota from obese mice increased in adiposity over germ- free mice inoculated from lean mice while on the same diet. Ley R, Turnbaugh P, Klein S, Gordon J, Human Gut Microbes, Nature, V444, December 21/28, 2006

41 Mechanism of “Fat Bugs” Effect
á CHO-Degrading Enzymes Increased blood lipids â Fasting-Induced Adipose Factor Increased adipocyte storage â AMP-Activated Protein Kinase Reduced energy for muscular activity

42 Sacchromyces boulardii as Therapy
Antibiotic-Associated Diarrhea: N = 466 children, 1-15 yrs of age Azithromycin alone 11.4% diarrhea + S. boulardii 5.5% diarrhea Sulfactam-ampicillin 25.6% diarrhea + S. boulardii 5.7% diarrhea Erdeve O, J Trop Pediatr 2004, p 234

43 Lactobacillus in Antibiotic-Associated Diarrhea
10 studies – total of 1862 patients, 6 studies were patients >18 yrs (a meta-analysis) Risk ratio of developing AAD was significantly lower when Lactobacillus was given, compared to placebo Kale-Pradham PB. Pharmacotherapy, 2010, p. 119.

44 SHEILA - 33 yo f - constipation
History: Constipation Belching, gas Mild depression Fatigue B12 deficient Vitamin D deficient Iron deficient On GF diet for ~ 1 year Antibiotics 2 months for tooth infection

45 SHEILA - 33 yr old female On antibiotics 2 months earlier for tooth infection Lowest value is for Fusobacteria; this genus is often found in infections of mouth (abx tx?)

46 SHEILA - 33 yo f Fungal overgrowths are common after antibiotic treatments +4 is our highest rating Observation – anti-fungal botanicals usually bring TU fungi down

47 SHEILA - 33 yo f VERY LOW Short Chain Fatty Acids are consistent with constipation (and often diarrhea too). More about SCFA’s just up GF diets effectively lower AGA sIgA.

48 SHEILA – 33 yo f Trend persists:
H nml trigs plus H nml Absorption markers – LCFA’s, Total fat and cholesterol This trend correlates with gluten sensitivity

49 SHEILA – 33 yo f Treatments Suggested: Prebiotic supplements
Anti-fungal diet Sacchromyces boulardii mg/cap = 3 billion CFU’s - 1 bid with meals Increase water intake Follow-up: Added psyllium on her own – after 5 weeks has better BM’s and less gas!

50 Short Chain Fatty Acids
Derived from microbial fermentation of undigested carbohydrate (fiber) that reaches the colon Act as “physiological ligands” of FFA receptors 2 and 3, which are expressed in immune, endocrine and fat cells, to name a few Increase colonic and hepatic blood flow Increase solubility of Ca++ Increase absorption in the small intestine

51 Short Chain Fatty Acids
Major SCFA’s studied are acetate, butyrate and propionate Low SCFA’s on stool testing mean more prebiotic soluble fiber is needed…and more bacteria to process them are needed also! Bacteroides species, etc can change SCFA profile (MacFarlane, 1996). Prebiotics can increase Bacteroides.

52 Short Chain Fatty Acids
Food sources of soluble fiber: Legumes Oats, rye, barley, chia Broccoli, carrots, asparagus, Jerusalem artichoke Sweet potatoes, onions, leeks Prunes/plums, bananas, apple/pear flesh, berries Psyllium husks

53 HENRY - 60 year old male, hx “chronic GI problems”, no GERD, big tummy (loves beer)
Labs: (non-MMX) H serum anti-gliadin antibodies Several other IgA-mediated markers H 4 of 6 autoimmune markers positive (Cyrex Labs, Phoenix, AZ) Very new case I’ll follow

54 HENRY - 60 yo male Lower levels of predominant bacteria
Higher Bifidobacter associated with less weight gain…

55 HENRY - 60 yo male, hx chronic GI problems
No GERD, but is this level of Hp a problem? This +2 Sacch may be brewer’s yeast Observation – chronic Blastocystis is concurrent with IBS symptoms in some people

56 HENRY 60 yo male, hx chronic GI problems
Nml lactoferrin, rather than >3rd Q, is a good finding! If lactoferrin H, IBD likely When LOW sIgA, anti-gliadin sIgA may be ‘false negative’; H lactoferrin – can distinguish IBD from IBS Henry’s blood tests showed H AGA, so he has gluten sensitivity

57 HENRY - 60 yo m, hx chronic GI problems
Digestion issues – H Putrefactive SCFA’s (protein) Malabsorption of LCFA’s (VH marker) Observation – pattern of H or H nml trigs with one or more Absorption markers H often is associated with gluten sensitivity. Persists long after GF diet is started.

58 HENRY - 60 yo m, hx chronic GI problems
GF diet, learn to like GF beer Digestive enzymes with trial of HCl Pre- and probiotics daily Experiment with new foods providing prebiotic substrate (replacing gluten foods)

59 General Gut-Healing “Go To’s”
Biotagen – prebiotic powder containing inulin, oligofructose, beta-glucan and Larch arabinogalactan Ther-Biotic Complete probiotic (7 Lactobacilli, 4 Bifidobacteria and Streptococcus thermophilus) Theralac (5 Lactobacilli with two prebiotics) Zinc carnosine – 50 mg bid L-glutamine – 1-35 g/d Curcumin – 50 mg (Meriva) 2-6/d DGL – mg/d powder

60 GI Health - Insights Addenda

61 An Ecological Perspective
The effects of the GI microflora are not mediated by a single species but rather by relationships among many. Therefore, characterization of the global composition is critical to understanding the effects of the microbiota on the host. From digestion, immune function to neurotransmitter production to correlation w/ certain diseases…. Listen to what the gut has to say…..

62 Intestinal Transit Time
Many clinicians consider Types 4 and 5 to be in the “normal” or ideal range

63 GI Complications in Eating D/O
Esophageal spasm/tearing Gastric dilation Acute pancreatitis Motility issues Nutritional deficiencies – esp. Zn, Mg, B’s, EFA’s, calories, protein, vitamin K Low serotonin in bulimia/anorexia – available tryptophan prioritized to make vital protein!

64 Urine Organix Toxicity Markers

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