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Use of Probiotics in Gastrointestinal Disorders
What to Recommend?
Elizabeth C. Verna, MD, MSc; Susan Lucak, MD
Authors and Disclosures
Ther Adv Gastroenterol. 2010;3(5):307-319. © 2010 Sage Publications, Inc.
Abstract and Introduction
Abstract
Perturbation of bacterial microflora of the gastrointestinal (GI) tract may play an important role in the pathophysiology of some GI disorders. Probiotics have been used as a treatment modality for over a century. They may restore normal bacterial microflora and effect the functioning of the GI tract by a variety of mechanisms. Probiotics are not currently regulated and only few randomized controlled trials exist investigating their efficacy in different GI disorders. They are available in a variety of formulations and delivery systems making interpretation and comparison of studies even more difficult. The efficacy of probiotics, either as a single strain or a combination of probiotics, has been tested in antibiotic-associated diarrhea, Clostridium difficile colitis, infectious diarrhea, ulcerative colitis, Crohn's disease, pouchitis, and irritable bowel syndrome, among other disorders. Results of the studies are reviewed in this article and recommendations for probiotic use in these disorders are made. Although probiotics appear to be generally safe in an outpatient setting, the situation may be different in immunocompromised, hospitalized patients who may be at a greater risk of developing probiotic sepsis. No studies exist addressing the issue of safety specifically. Many questions regarding use of probiotics in GI disorders remain to be answered in future studies, such as most optimal doses, duration of treatment, physiological and immunological effects, efficacy of specific probiotics in specific disease states, and safety in debilitated patients.
Introduction
Probiotics are being used with increasing frequency as a treatment for several medical conditions, such as allergic diseases (atopic dermatitis, possibly allergic rhinitis), bacterial vaginosis, urinary tract infections, and prevention of dental caries or respiratory infections. Probiotics are used as a treatment for a variety of gastrointestinal (GI) disorders. In this review, the historical perspectives, proposed mechanisms of action, formulations and delivery systems, safety, and specific GI disorders for which probiotics have been used are discussed.
Historical Perspectives
Probiotics have been used therapeutically for many centuries in different parts of the world for their contribution to longevity and digestive health. The World Health Organization has defined probiotics as 'live organisms which when administered in adequate amounts confer a health benefit on the host'. Categories of probiotics in use today include: bacteria such as lactic-acid bacteria (LAB) and Escherichia coli strains (such as E. coli Nissle 1917), as well as yeast species including most prominently Saccharomyces boulardii among others (Table 1). Prebiotics such as lactulose, inulin, psyllium, and other oligosaccharides (found in onions, garlic, asparagus, leeks, artichoke, bananas, tomatoes, wheat, oats, soy beans, and other plants) are nondigestible food ingredients that stimulate the growth or activity of bacteria in the GI tract which are beneficial to the health of the body [Grajek et al. 2005]. Synbiotics are a combination of a prebiotic and a probiotic, such as inulin and Lactobacillus rhamnosus GG or Bifidobacter longum. Antibiotics, in contrast, are compounds that kill or inhibit the growth of bacteria.
Probably the first person of Western medicine to publish on the topic of probiotics in the early 20th century was the Russian Nobel Prize winner Ilya Metchnikoff, when he described longevity in people in Eastern Europe who lived largely on milk fermented by LAB. He theorized that proteolytic microbes in the colon produced toxic substances responsible for the aging process and proposed that consumption of fermented milk would coat the colon with LABs, decreasing intestinal pH, suppressing proteolytic bacteria and thus leading to slowing of the aging process [Gordon, 2008]. Metchnikoff and his followers ingested milk fermented with this 'Bulgarian Bacillus' and reported health benefits [Vaughan, 1965].
In 1917, during World War I, Alfred Nissle isolated a strain of E. coli from the feces of a soldier who did not develop enterocolitis during a severe outbreak of shigellosis. Nissle used the E. coli strain with considerable success in acute cases of infectious intestinal diseases such as salmonellosis and shigellosis [Nissle, 1959]. E. coli Nissle 1917 is still in use today and is one of the few examples of a non-LAB probiotic.
Researchers and clinicians have studied and used probiotics in a variety of medical conditions. In the last decade, over 5000 articles were published in the medical literature. Furthermore, the use of probiotics has surged dramatically as a result of direct-to-consumer marketing as probiotics are not regulated.
What to Recommend?
Elizabeth C. Verna, MD, MSc; Susan Lucak, MD
Authors and Disclosures
Ther Adv Gastroenterol. 2010;3(5):307-319. © 2010 Sage Publications, Inc.
Abstract and Introduction
Abstract
Perturbation of bacterial microflora of the gastrointestinal (GI) tract may play an important role in the pathophysiology of some GI disorders. Probiotics have been used as a treatment modality for over a century. They may restore normal bacterial microflora and effect the functioning of the GI tract by a variety of mechanisms. Probiotics are not currently regulated and only few randomized controlled trials exist investigating their efficacy in different GI disorders. They are available in a variety of formulations and delivery systems making interpretation and comparison of studies even more difficult. The efficacy of probiotics, either as a single strain or a combination of probiotics, has been tested in antibiotic-associated diarrhea, Clostridium difficile colitis, infectious diarrhea, ulcerative colitis, Crohn's disease, pouchitis, and irritable bowel syndrome, among other disorders. Results of the studies are reviewed in this article and recommendations for probiotic use in these disorders are made. Although probiotics appear to be generally safe in an outpatient setting, the situation may be different in immunocompromised, hospitalized patients who may be at a greater risk of developing probiotic sepsis. No studies exist addressing the issue of safety specifically. Many questions regarding use of probiotics in GI disorders remain to be answered in future studies, such as most optimal doses, duration of treatment, physiological and immunological effects, efficacy of specific probiotics in specific disease states, and safety in debilitated patients.
Introduction
Probiotics are being used with increasing frequency as a treatment for several medical conditions, such as allergic diseases (atopic dermatitis, possibly allergic rhinitis), bacterial vaginosis, urinary tract infections, and prevention of dental caries or respiratory infections. Probiotics are used as a treatment for a variety of gastrointestinal (GI) disorders. In this review, the historical perspectives, proposed mechanisms of action, formulations and delivery systems, safety, and specific GI disorders for which probiotics have been used are discussed.
Historical Perspectives
Probiotics have been used therapeutically for many centuries in different parts of the world for their contribution to longevity and digestive health. The World Health Organization has defined probiotics as 'live organisms which when administered in adequate amounts confer a health benefit on the host'. Categories of probiotics in use today include: bacteria such as lactic-acid bacteria (LAB) and Escherichia coli strains (such as E. coli Nissle 1917), as well as yeast species including most prominently Saccharomyces boulardii among others (Table 1). Prebiotics such as lactulose, inulin, psyllium, and other oligosaccharides (found in onions, garlic, asparagus, leeks, artichoke, bananas, tomatoes, wheat, oats, soy beans, and other plants) are nondigestible food ingredients that stimulate the growth or activity of bacteria in the GI tract which are beneficial to the health of the body [Grajek et al. 2005]. Synbiotics are a combination of a prebiotic and a probiotic, such as inulin and Lactobacillus rhamnosus GG or Bifidobacter longum. Antibiotics, in contrast, are compounds that kill or inhibit the growth of bacteria.
Probably the first person of Western medicine to publish on the topic of probiotics in the early 20th century was the Russian Nobel Prize winner Ilya Metchnikoff, when he described longevity in people in Eastern Europe who lived largely on milk fermented by LAB. He theorized that proteolytic microbes in the colon produced toxic substances responsible for the aging process and proposed that consumption of fermented milk would coat the colon with LABs, decreasing intestinal pH, suppressing proteolytic bacteria and thus leading to slowing of the aging process [Gordon, 2008]. Metchnikoff and his followers ingested milk fermented with this 'Bulgarian Bacillus' and reported health benefits [Vaughan, 1965].
In 1917, during World War I, Alfred Nissle isolated a strain of E. coli from the feces of a soldier who did not develop enterocolitis during a severe outbreak of shigellosis. Nissle used the E. coli strain with considerable success in acute cases of infectious intestinal diseases such as salmonellosis and shigellosis [Nissle, 1959]. E. coli Nissle 1917 is still in use today and is one of the few examples of a non-LAB probiotic.
Researchers and clinicians have studied and used probiotics in a variety of medical conditions. In the last decade, over 5000 articles were published in the medical literature. Furthermore, the use of probiotics has surged dramatically as a result of direct-to-consumer marketing as probiotics are not regulated.
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