Introduction

Disease-associated alterations of the intestinal microbiota composition, known as dysbiosis, have been well described. Duodenal mucosal biopsies occasionally demonstrate the presence of adherent bacteria in the epithelium. However, there is a lack of universally accepted and applied gold standard for investigating the association with various diseases such as small intestinal bacterial overgrowth (SIBO), close relationships with obesity, cirrhosis, IBS, etc.

Aims & Methods

Aim: This retrospective study evaluated the spectrum of such bacteria after the cultivation of tissue samples that were obtained at routine endoscopy of 81 patients indicated to examination for different reasons.
Methods: Biopsies were taken using sterilized standard endoscopic biopsy forceps. Two pieces of tissue were obtained without the removal of forceps from the third and fourth part of the duodenum and the same way from the antrum of the stomach. One of the samples was placed into a 10% glucose solution for microbial cultivation, the other was placed into a 10% formaldehyde solution for histological examination. In 22 patients SIBO testing by breath test and stool cultivation was performed.

Results

Overall 81 biopsy specimens from the duodenum and 45 from the antrum of the stomach were cultivated. In the duodenum, bacterial overgrowth was found in 64,19% of patients and it was negative in 35,80% of cases, while in the antrum of the stomach, the presence of bacteria was found in 48,88% and was negative in 51,11% of patients. The agreement with the same genera (E. coli) in antrum and duodenum was only in 9 patients (25%). E. coli was present in 19,7% of specimens from duodenum followed by present Pseudomonas aeruginosa (17,24%) and Enterobacter cloacae (12,34%). While in antrum E. coli was present in 17,77% of specimens, Klebsiella species and Enterobacter cloacae were present in 8,88% of cases respectively. 22 patients were examined by lactulose-hydrogen breath testing for SIBO with 60% positivity. There were 18,1% positively tested patients for SIBO, but the duodenal and antral cultivation was negative. Stool cultivation did not reveal any pathogens except E. coli. When the bacteria were cultivated, we performed MIC testing for antibiotics. Overall resistance was found for ampicillin in 88,4% of all pathogens and ampicillin + sulbactam 61,5% respectively in following percentages, E. coli: 52,9%, Klebsiella spp.: 100%, Enterobacter: 69,2%, Proteus mirabilis: 100%, Enterococcus: 33% were resistant for ampicillin.

Conclusion

Cultivation of mucosal biopsy specimens seems to be useful for the identification of patients with bacterial overgrowth in the upper part of the GI tract. There is a need to stress the elucidation of their role in the pathogenesis of different chronic illnesses.

Introduction

Patients with Hypermobile Ehlers Danlos Syndrome (hEDS) have a high prevalence of Disorders of Gut-Brain Interaction (DGBI) and pose complex nutritional challenges in gastroenterology clinic. Despite this, little is known regarding nutrient intake and adequacy in hEDS.

Aims & Methods

Our aim was to assess nutrient intake and adequacy of patients with hEDS, as well as to determine which factors, including co-existent DGBI, are associated with poor intake. We conducted a cross sectional survey of patients with hEDS from two tertiary neurogastroenterology clinics as well as the Ehlers-Danlos Support UK. Inclusion criteria were adults with hEDS, exclusion criteria were those currently or previously using artificial nutrition. Patients completed the validated semi-quantitative Scottish Collaboration Group Food Frequency Questionnaire (FFQ) alongside questionnaires characterising: demographics, DGBIs (Rome IV), gastrointestinal, mood, somatic and autonomic symptoms, past history of eating disorders and screen for Avoidant Restrictive Food Intake Disorder (ARFID) using the Nine Item Avoidant-Restrictive Scale (NIAS). Nutrient intake was calculated from the FFQ and nutrient adequacy was calculated by comparison with UK daily reference values (DRVs) for age and sex. Unpaired t-tests were performed to compare nutrient intakes among patients with and without comorbidities, including the most common DGBIs.

Results

425 participants were included in the final analysis (mean: 41 years, 96% female). Only 48.5% reported BMI in the normal range, whereas 5.2% were underweight (BMI <18.5 kg/m²)and46.4% were overweight/obese (BMI >25 kg/m²). Only one third met their estimated average requirements (EAR) for energy (kcal/d). The majority met their reference nutrient intake (RNI) for protein (87.3%) and fat (72.5%), in contrast to only 21.2% for carbohydrate. Fibre intakes were very low (AOAC mean 23.7g/day (SD: 12.7) with only 24.7% meeting the RNI of 30 g/d. More than 58% of participants met/exceeded their DRV for micronutrients (zinc, magnesium, copper, manganese and selenium) and >95% for vitamins. Patients with functional nausea (n=157) were less likely to meet their protein requirements compared to those without (82.2% vs. 90.3%, p=0.015) and also had lower intakes for sodium (p=0.02), magnesium (p=0.02), calcium (p=0.01), zinc (p=0.002), selenium (p=0.03), folic acid (p=0.02) and vitamin C (p=0.05). Patients with previous eating disorders were less likely to meet nutrient requirements for thiamine (p=0.01) and vitamin B12 (p=0.04). Patients with ARFID (n=110) were less likely to meet requirements for all nutrients (except fat, calcium, vitamin D, vitamin B12) compared to patients without.

Conclusion

Patients with hEDS are rarely underweight and tend to consume high protein, high fat diets that are low in fibre. Functional nausea is the single most important DGBI impacting nutrient intake, as well as previous eating disorders and disordered eating (ARFID). These factors should be considered by clinicians and dietitians when assessing nutrient intake in this complex patient group.

Disclosure

RT, AF and QA have received a grant from EDS-UK to conduct this study. AF undergoes consulting work for Abbvie.
KW has received research funding from Almond Board of California, Danone, International Nut & Dried Fruit Council, and has a patent for volatile organic compounds in the detection and management of IBS.
QA undergoes consulting work for Takeda Pharmacueticals, and Classado Biosciences Ltd.

Introduction

Recent years have seen a significant increase in randomized controlled trials (RCT) published on the efficacy of probiotics on irritable bowel syndrome (IBS), which several reviews have tried to comprehensively review. Two recent trials, Yang et al. 2024¹ and Chen et al. 2023² report the safety and efficacy of probiotics for IBS, which seems to reflect prevailing favorable view of this therapeutic option by most reviews conducted. Yet, despite efforts in this field, major organizations have not changed their stance in this and make no assertive recommendation for probiotics in afflicted patients^3,4. While further investigations are required, two challenges are faced: (1) repeated reviews have been undertaken in this field, resulting in a "multiplicity problem", (2) traditional meta-analytic techniques may also fail to provide a conclusive answer on the sufficiency of evidence, particularly when the data are sparse, and the risk of type I and type II errors is significant. This indicates a need for.

Aims & Methods

This study aims to evaluate the efficacy of probiotics in alleviating symptoms of IBS and improve quality of life through a timely implemented trial sequential analysis (TSA) and rigorously evaluate the evidence for recommendations on future studies. Medline, Embase, Web of Science, and Cochrane were screened for randomized controlled trials (RCTs) comparing probiotics to placebo in adult patients with IBS. Primary outcomes included IBS Symptom Severity Score (IBS-SSS) and IBS Quality of Life (IBS-QOL) scores comparing probiotics and placebo groups. Traditional pairwise meta-analysis conducted in restricted maximum likelihood was conducted, with subsequent TSA . Study quality was graded according to risk-of-bias 2 (ROB-2) and certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results

42 studies were included. Overall, probiotics demonstrated non-significant improvements in IBS-SSS (MD: -27.64; 95% CI: -56.90 to 1.63; p=0.06) and IBS-QOL (MD: 1.33; 95% CI: -3.65 to 6.30; p=0.59). TSA was conducted on IBS-SSS demonstrated current evidence has not reached the required information size. The representative cumulative Z-curve demonstrated neither futility, benefit nor detrimental effect, indicating the need for further trials. Assessment with ROB-2 indicates high quality amongst most trials included in this study. GRADE evaluation of the evidence demonstrated low certainty of existing evidence.

Table 1: GRADE Evaluation

No. of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Probiotics	Placebo	Relative (95% CI)	Absolute (95% CI)	Certainty
Probiotics effectively reduces a patient's IBS-SSS score
24	randomised trials	not seriousa	very seriousb	not serious	very seriousc	publication bias strongly suspectedd	2237	1599	-	MD 27.64 lower (56.9 lower to 1.63 higher)	⨁◯◯◯ Very lowa,b,c,d
Probiotics effectively reduces a patient's IBS-QOL score
24	randomised trials	not seriousa	very seriousb	not serious	not seriouse	publication bias strongly suspectedd	2292	1712	-	MD 1.33 higher (3.65 lower to 6.3 higher)	⨁◯◯◯ Very lowa,b,d,e

CI: confidence interval; MD: mean difference

Two contributing factors to the low certainty of current evidence include: (1) Inconsistency of existing trials – there exists high level of heterogeneity as detected by statistical analysis through I² and Cochran Q amongst studies; (2) Suspected publication bias through inspection of a funnel plot, though Egger’s regression did not demonstrate statistical significance.

Conclusion

Existing evidence is insufficient to make conclusive recommendations regarding the role probiotics should play in the management of IBS in symptoms and QOL. Given the persistent heterogeneity and potential publication bias, future research should focus on standardizing probiotic interventions and clarifying their clinical utility to truly advance the field.

References

1. Yang R, Jiang J, Ouyang J, Zhao Y, Xi B. Efficacy and safety of probiotics in irritable bowel syndrome: a systematic review and meta-analysis. Clinical Nutrition ESPEN. 2024;
2. Chen M, Yuan L, Xie C-R, et al. Probiotics for the management of irritable bowel syndrome: a systematic review and three-level meta-analysis. International Journal of Surgery. 2023;109(11):3631-3647.
3. Su GL, Ko CW, Bercik P, et al. AGA Clinical Practice Guidelines on the Role of Probiotics in the Management of Gastrointestinal Disorders. Gastroenterology. 2020;159(2):697-705. doi:10.1053/j.gastro.2020.05.059
4. McKenzie Y, Thompson J, Gulia P, Lomer M. British Dietetic Association systematic review of systematic reviews and evidence‐based practice guidelines for the use of probiotics in the management of irritable bowel syndrome in adults (2016 update). Journal of Human Nutrition and Dietetics. 2016;29(5):576-592.
5. Lacy BE, Pimentel M, Brenner DM, et al. ACG clinical guideline: management of irritable bowel syndrome. Official journal of the American College of Gastroenterology| ACG. 2021;116(1):17-44.

Disclosure

All authors of the manuscript do not have a conflict of interest to declare.