Small intestinal bacterial overgrowth syndrome

Human intestinal microbiota create a complex polymi-crobial ecology. This is characterised by its high population density, wide diversity and complexity of interaction. Any dysbalance of this complex intestinal microbiome, both qualitative and quantitative, might have serious health consequence for a macro-organism, including small intestinal bacterial overgrowth syndrome (SIBO).SIBO is defined as an increase in the number and/or alteration in the type of bacteria in the upper gastro-intestinal tract. There are several endogenous defence mechanisms for preventing bacterial overgrowth: gastric acid secretion, intestinal motility, intact ileo-caecal valve, immunoglobulins within intestinal secretion and bacte-riostatic properties of pancreatic and biliary secretion. Aetiology of SIBO is usually complex, associated with disorders of protective antibacterial mechanisms (e.g. achlorhydria, pancreatic exocrine insuff iciency, immuno-deficiency syndromes), anatomical abnormalities (e.g. small intestinal obstruction, diverticula, f istulae, surgical blind loop, previous ileo-caecal resections) and/or motility disorders (e.g. scleroderma, autonomic neuropathy in diabetes mellitus, post-radiation enteropathy, small intestinal pseudo-obstruction). In some patients more than one factor may be involved. Symptoms related to SIBO are bloating, diarrhoea, malabsorption, weight loss and malnutrition. The gold standard for diagnosing SIBO is still microbial investigation of jejunal aspirates. Noninvasive hydrogen and methane breath tests are most commonly used for the diagnosis of SIBO using glucose or lactulose. Therapy for SIBO must be com-plex, addressing all causes, symptoms and complica-tions, and fully individualised. It should include treatment of the underlying disease, nutritional support and cyclical gastro-intestinal selective antibiotics. Prognosis is usually serious, determined mostly by the underlying disease that led to SIBO.

Peutz-Jeghers syndrome:Diagnostic and therapeutic approach

Peutz-Jeghers syndrome （P3S） is an inherited, autosomal dominant disorder distinguished by hamartomatous polyps in the gastrointestinal tract and pigmented mucocutaneous lesions. Prevalence of PJS is estimated from 1 in 8300 to 1 in 280000 individuals. PJS predisposes sufferers to various malignancies （gastrointestinal, pancreatic, lung, breast, uterine, ovarian and testicular tumors）. Bleeding, obstruction and intussusception are common complications in patients with P3S. Double balloon enteroscopy （DBE） allows examination and treatment of the small bowel. Polypectomy using DBE may obviate the need for repeated urgent operations and small bowel resection that leads to short bowel syndrome. Prophylaxis and polypectomy of the entire small bowel is the gold standard in PJS patients. Intraoperative enteroscopy （IOE） was the only possibility for endoscopic treatment of patients with PJS before the DBE era. Both DBE and IOE facilitate exploration and treatment of the small intestine. DBE is less invasive and more convenient for the patient. Both procedures are generally safe and useful. An overall recommendation for PJS patients includes not only gastrointestinal multiple polyp resolution, but also regular lifelong cancer screening （colonoscopy, upper endoscopy, computed tomography, magnetic resonance imaging or ultrasound of the pancreas, chest X-ray, mammography and pelvic examination with ultrasound in women, and testicular examination in men）. Although the incidence of PJS is low, it is important for clinicians to recognize these disorders to prevent morbidity and mortality in these patients, and to perform presymptomatic testing in the first-degree relatives of PJS patients.

Double balloon enteroscopy and acute pancreatitis

Double balloon enteroscopy(DBE)is a new technique, first published and introduced into clinical practice in 2001 by Yamamoto,the inventor of this outstanding method.DBE allows complete visualization,biopsy and treatment of the small bowel.Nowadays,we have some experience of this method for evaluation of the complica- tion rate.Severe complications are described in 1%-1.7% of patients.Acute pancreatitis is a rare complication of the investigation.The incidence of acute pancreatitis after diagnostic DBE is 0.3%in most studies.More than 50 cases of acute pancreatitis have been described in the literature so far.On the contrary,hyperamylasemia after DBE seems to be a rather common condition.Association with acute pancreatitis is supposed to be possible,but not obligatory.The causal mechanism of post-DBE acute pancreatitis is uncertain,and there are several theories in the literature.The most probable cause seems to be a mechanical straining of the endoscope with over-tube on the pancreas or in the papillary area.

Buried bumper syndrome:A complication of percutaneousendoscopic gastrostomy

Percutaneous endoscopic gastrostomy(PEG) is a widely used method of nutrition delivery for patients with longterm insufficiency of oral intake. The PEG complication rate varies from 0.4% to 22.5% of cases, with minor complications being three times more frequent. Buried bumper syndrome(BBS) is a severe complication of this method, in which the internal fixation device migrates alongside the tract of the stoma outside the stomach. Excessive compression of tissue between the external and internal fixation device of the gastrostomy tube is considered the main etiological factor leading to BBS. Incidence of BBS is estimated at around 1%(0.3%-2.4%). Inability to insert, loss of patency and leakage around the PEG tube are considered to be a typical symptomatic triad. Gastroscopy is indicated in all cases in which BBS is suspected. The depth of disc migration in relation to the lamina muscularis propria of the stomach is critical for further therapy and can be estimated by endoscopic or transabdominal ultrasound. BBS can be complicated by gastrointestinal bleeding, perforation, peritonitis, intra-abdominal and abdominal wall abscesses, or phlegmon, and these complications can lead to fatal outcomes. The most important preventive measure is adequate positioning of the external bolster. A conservative approach should be applied only in patients with high operative risk and dismal prognosis. Choice of the method of release is based on the type of the PEG set and depth of disc migration. A disc retained inside the stomach and completely covered by the overgrowing tissue can be released using some type of endoscopic dissection technique(needle knife, argon plasma coagulation, or papillotome through the cannula). Proper patient selection and dissection of the overgrowing tissue are the major determinants for successful endoscopic therapy. A disc localized out of the stomach(lamina muscularis propria) should be treated by a surgeon.

Blood pressure and stature in Helicobacter pylori positive and negative persons

To evaluate vital signs and body indices in Helicobacter pylori (H. pylori) positive and negative persons. A total of 22 centres entered the study. They were spread over the whole country, corresponding well to the geographical distribution of the Czech population. A total of 1818 subjects (aged 5-98 years) took part in the study, randomly selected out of 38147 subjects. H. pylori infection was investigated by means of a 13C-urea breath test. Data on height, weight, systolic and diastolic blood pressure and heart rate were collected at the clinics of general practitioners. The overall prevalence of H. pylori infection was 30.4% (402/1321) in adults (≥ 18 year-old) and 5.2% (26/497) in children and adolescents (≤ 17 year-old). Once adjusted for age and gender, only a difference in body mass index remained statistically significant with H. pylori positive adults showing an increase of 0.6 kg/m2 in body mass index. Once adjusted for age and gender, we found a difference in height between H. pylori positive and H. pylori negative children and adolescents. On further adjustment for place of residence, this difference became statistically significant, with H. pylori positive children and adolescents being on average 3.5 cm shorter. H. pylori positive adults were significantly older compared to H. pylori negative subjects. Once adjusted for age and gender, H. pylori infection had no impact on body weight, body mass index and vital signs either in adults or children and adolescents. Chronic H. pylori infection appeared to be associated with short stature in children. H. pylori infection did not influence blood pressure, body weight and body mass index either in adults or children and adolescents.

Significant decrease in prevalence ofHelicobacter pylori in the Czech Republic

AIM:To study possible decrease in prevalence of Helicobacter pylori(H.pylori) infection in the Czech Republic within a 10-year period.METHODS:A total of 22 centres entered the study.The catchment areas of these centres covered cities and towns with more than 20 000 inhabitants,smaller towns(≤ 20 000 inhabitants) with surrounding villages and rural areas,and were spread over the whole country,corresponding well to the geographical distribution of the Czech population.A total of 1 837 subjects(aged 5-98 years) took part in the study,randomly selected out of 38 147 people from the general population.H.pylori infection was investigated by means of a 13 C-urea breath test.Breath samples in duplicates were analysed using isotope ratio mass spectrometry.The cut-off point was 3.5.Social and demographic characteristics were based on data from self-completed questionnaires.RESULTS:The overall prevalence of H.pylori infection was 23.5%(430/1826),and 4.8%(20/420) in children aged 15 or less.There was no statistically significant difference in prevalence between males(24.3%;208/857) and females(22.9%,222/969,P = 0.494).H.pylori infection was strongly associated with higher age,among subjects aged 55+ years,prevalence of H.pylori infection was 39.8%(252/633,P < 0.001).The highest prevalence of H.pylori infection was found among persons aged 55-64 years(43.9%,97/221) and 75+ years(37.9%,58/153).Among study subjects aged 15+ years,prevalence of H.pylori infection was significantly increased in those with lowest education(odds risk 3.19,95% CI 1.87-5.47).Compared to never married(14.1%),the prevalence of H.pylori infection was statistically significantly higher among married(35.4%,246/694,P < 0.001),divorced(36.8%,49/133,P < 0.001) and widowed study subjects(40.2%,45/112,P < 0.001),both in minimally and fully adjusted analysis.There was no significant difference in the prevalence of H.pylori infection between married and widowed subjects(35.4%,246/694 vs 40.2%,45/112,P = 0.389).There was little variation in smoking prevalence across categories of smoking and there was no evidence of an increased risk ofH.pylori infection among current or past smokers in our data(odds risk 1.04 with 95% CI 0.78-1.40 for current smokers;odds ratio 0.83 with 95% CI 0.60-1.16 for former smokers).The current prevalence of H.pylori in 2011 was significantly lower compared to the prevalence reported from identical geographical areas in 2001(23.5%vs 41.7%,P < 0.001).CONCLUSION:The overall prevalence of H.pylori infection in the general population has fallen substantially in the Czech Republic over the past 10 years.

Bacteriocinogeny in experimental pigs treated with indomethacin and Escherichia coli Nissle

AIM： To evaluate bacteriocinogeny in short-term highdose indomethacin administration with or without probiotic Escherichia coli Nissle 1917 （EcN） in experimental pigs.METHODS： Twenty-four pigs entered the study： Group A （controls）, Group B （probiotics alone）, Group C （indomethacin alone） and Group D （probiotics and indomethacin）. EcN （3.5 × 10^10 bacteria/d for 14 d） and/or indomethacin （15 mg/kg per day for 10 d） were administrated orally. Anal smears before and smears from the small and large intestine were taken from all animals. Bacteriocin production was determined with 6 different indicator strains; all strains were polymerase chain reaction tested for the presence of 29 individual bacteriocinencoding determinants. RESULTS： The general microbiota profile was rather uniform in all animals but there was a broad diversity in coliform bacteria （parallel genotypes A, B1, B2 and D found）. In total, 637 bacterial strains were tested, mostly Escherichia coli （E. coli. There was a higher incidence of non-E：, coli strains among samples taken from the jejunum and ileum compared to that of the colon and rectum indicating predominance of E. coil strains in the large intestine. Bacteriocinogeny was found in 24/77 （31%） before and in 155/560 （28%） isolated bacteria at the end of the study. Altogether, 13 individual bacteriocin types （out of 29 tested） were identified among investigated strains. Incidence of four E. coli genotypes was equally distributed in all groups of E. coil strains, with majority of genotype A （ranging from 81% to 88%）. The following types of bacteriocins were most commonly revealed： colicins Ia/Ib （44%）, microcin V （18%）, colicin E1 （16%） and microcin H47 （6%）. There was a difference in bacteriocinogeny between control group A （52/149, 35%） and groups with treatment at the end of the study： B： 31/122 （25%, P = 0.120）; C： 43/155 （28%, P = 0.222）; D： 29/134 （22%, P = 0.020）. There was a significantly lower prevalence of colicin Ib, microcins H47 and V （probiotics group, P 〈 0.001）, colicin E1 and microcin H47 （indomethacin group, P 〈 0.001） and microcins H47 and V （probiotics and indomethacin group, P = 0.025） compared to controis. Escherichia fergusonil （E. fergusoniO was identi-fled in 6 animals （6/11 isolates from the rectum）. One strain was non-colicinogenic, while all other strains of E. fergusonii solely produced colicin El. All animals started and remained methanogenic despite the fact that EcN is a substantial hydrogen producer. There was an increase in breath methane （after the treatment） in 5/6 pigs from the indomethacin group （C）. CONCLUSION： EcN did not exert long-term liveabilib/ in the porcine intestine, All experimental pigs remained methanogenic, Indomethacin and EcN administered together might produce the worst impact on bacteriocinogeny.