The document discusses the importance of gut health and maintaining a balanced intestinal flora. It provides details on different bacteria in the gut and factors that can disrupt the balance. The case studies demonstrate how probiotics like Lactobacillus can help treat conditions like ulcerative colitis, radiation proctitis, and celiac disease by improving gut health and reducing symptoms.

1. Mrs Anita Jatana
Chief Dietitian
Batra Hospital

2. GUT HEALTH
 70% of our immune system is located in the gut.
 Keeping it healthy is the key to good health.
 The average human body consists of about 10¹³
(10,000,000,000,000 or ten trillion) cells, has about
ten times that number of microorganisms and about
500-1000 different bacterial species in the gut.
 The metabolic activity performed by these bacteria
is equal to that of a virtual organ making the gut
bacteria termed as a “Forgotten organ”.

3. INTESTINAL FLORA (A BALANCED
ECOSYSTEM)
Potentially Harmful Bacteria Pseudomonas
Potentially Helpful Bacteria
• Diarrhea/constipation
Proteus
• Infections • Inhibition of exogeneous and/or
• Production of Toxins harmful bacteria
Staphylococci
• Stimulation of immune functions
• Aid in digestion and/or absorption
Clostridia • Synthesis of vitamins
Enterococci
E. coli
Lactobacilli
Streptococci
Eubacteria
Bifidobacteria
Bacteroides
From: Gibson GR. J Nutrition 1995; 125:1401-1412.

4. A closer look at our intestinal
bacteria
Lactobacillus E. coli Staphylococcus
Bifidobacterium Bacteroides C. perfringens

5. Adult Microbiota: A Complex Ecosystem
Esophagus
No own microbiota
Microbes from food
and oral cavity Stomach
Duodenum
104 CFU/g
Candida albicans
500 - 1000
103-104 CFU/g
Bacteroides
Helicobacter pylori
Lactobacillus
species
Candida albicans Streptococcus
Lactobacillus
Streptococcus
Jejunum
105-107 CFU/g
Colon Bacteroides
1010-1011 CFU/g Candida albicans
Bacteroides Lactobacillus
Bacillus Streptococcus
Bifidobacterium
Clostridium
Ileum
Enterococcus
107-108 CFU/g
Eubacterium
Bacteroides
Fusobacterium
Clostridium
Peptostreptococcus
Enterobacteriaceae
Ruminococcus
Enterococcus
Streptococcus
Lactobacillus
Veillonella

6. The Mucosal surface of the GI tract forms an important
organ of host defense.
Anaerobic bacteria influence gut physiology & health by exerting a
number of activities including:-
 Barrier protection against colonization of pathogens;
 Regulation of Intestinal transit;
 Deconjugation of bile acids and promotion of enterohepatic
circulation;
 Degradation and digestion of some undigested carbohydrates;
 Improvement of lactose intolerance;
 Limitation of bacterial translocation and thus dissemination of
bacteria in the peripheral organs;
 Production of vitamins and growth factors for host intestinal cells;
 Maturation and stimulation of the gut immune system.

7. Studies show that intestinal flora remains quite stable
despite the variation in the ingested micro organisms in
food.
Factors influencing the balance of intestinal bacteria flora adversely
are :-
 Congenital or acquired immuno-deficiencies.
 Illness
 Intestinal motility disorders
 Digestive stasis
 Parenteral nutrition
 Antibiotic treatment
These can act by inhibiting certain commensal bacterial strains and by
making the normal flora unable to act as barrier. This may promote the
growth of potentially pathogenic germs ( eg. Clostridium difficle,
Klebsiella oxytoca).

8. Potential beneficial effects of colonic foods
mediated by the human large gut microbiota
 Alleviate the symptoms of lactose malabsorption
 Boost natural resistance to infectious disease of the
intestinal tract
 Neutralize certain toxins
 Suppress cancer
 Supply SCFA as energy substrates
 Lower serum lipids
 Affect hormonal regulation
 Aid digestion
 Produce vitamins
 Stimulate gastrointestinal immunity

9. Inflammatory Bowel Disease
[Mitsuyama K et al 2008, J Clin Biochem Nutr 43 (Suppl.1):78-81]
 An open label preliminary trial conducted on 10 patients with mildly
to moderately active Ulcerative Colitis (UC)
 Intervention: LcS (8x1010 CFU/day) in addition to conventional
therapy daily for 8 weeks
 Significantly better clinical activity index score seen after LcS
treatment as compared with pre-treatment and control group
CONLUSION: LcS effectively treats UC at least in part through the
inhibition of interleukin-6 signalling

10. Inflammatory Bowel Disorders
[Sang et al, 2010 World of Gastroenterol 16:(15)1908-1915]
 Meta-analysis of thirteen randomized controlled studies - seven
studies evaluated the remission rate and eight studies estimated
the recurrence rate, two studies evaluated both remission and
recurrence rate.
 Compared with the non probiotic group, the remission rate for
ulcerative colitis patients who received probiotics was better.
 In the mild to moderate group who received probiotics compared
to the group who did not receive probiotics, the recurrence rate
was less.
CONCLUSION: Probiotic treatment was more effective than
placebo in maintaining remission in ulcerative colitis.

11. Probiotics useful in Celiac Disease
 Probiotics have shown promise for treating autoimmune and
allergic disorders by altering intestinal microbiota composition and
fermentation derived metabolite, thereby regulating epithelial
cell barrier function and modulating immune response.
(Licciardi PV et al 2010, Gut Pathol 2-24)
Dietary changes include probiotics/prebiotics may help alleviate
the severity of celiac disease for some patients.
 Differing intestinal bacteria in celiac patients could influence
inflammation to varying degrees. This suggests that manipulating
the intestinal microbiota with dietary strategies such as probiotics
and prebiotics, could improve the quality of life for celiac
patients, as well as patients with associated diseases such as type
1 diabetes and other autoimmune disorders.
(Rossi M et al 2010 Journal of Leukocyte Biology 87:749 -751)

12. CASE 1
(Age- 2yrs)
Celiac Disease
PATIENT HISTORY
 c/o loose stool ( 7-8 times) with vomiting on and off
( 2 months) and 1 episode of blood in stool.
 c/o abdominal distension
 Less oral intake
 History of wt loss- 3-4kg in 2months.
 Feeding history- home based soft diet + milk.
 On examination stomach distended Bs (positive)
 Liver spleen not palpable.

13. Biochemical investigations
Urea 9.0
Creatinine 0.2
Protein 6.8
Albumin 3.2
SGOT 34
SGPT 44
Sodium 135
Potassium 4.3
Haemoglobin 7.6

14. INVESTIGATIONS
 Ultrasound- liver normal- gaseous distention of
stomach
 Endoscopy- pale mucosa seen of duodenal folds
 Blood test- anti tissue tranglutaminase antibody
( tTG) positive
 Duodenal biopsy report- partial villous atrophy
with intraepithelial lymphocytosis, possibility of
coeliac disease.
 Stool report - fat globules positive
- reducing substance negative

15. Endoscopic findings
Esophagus: pale mucosa
Stomach: pale mucosa seen
Duodenum: duodenal folds scalloping seen
Impression: celiac disease,biopsy took.

16. DIETARY MANAGEMENT
 Patient was put on a lactose and gluten free
diet.
 Probiotics (LcS) was introduced 1/day
 Frequency of stools decreased to 5/day and
decreased stomach distension
 On 3rd day- frequency of stools was 3 and
semiformed.
 Patient was discharged with instructions of
gluten free diet with probiotics (LcS) once a day.

17. CASE 2
77 year -male
HISTORY:
 Carcinoma prostate
 Post b/l orchidectomy on radical Radiation
and has completed 18 radiations.
 Diabetes 25 yrs
 CAD with CABG

18. Symptoms Patient Admitted With
 Loose motions,
 vomiting,
 2 day Blackstools ++
 Poor oral intake

19. MEDICATION
 Injection raciper 40mg IVBD
 Emset 8mg IVBD
 Pantocid
 Metrogyl
 Monocef 2gm

20. INVESTIGATIONS
 Endoscopy- antral gastritis
 Colonoscopy- seen upto desending colon
diffuse erythma with multiple ulcers in
rectum
 Radiation proctitis
 Bone scan –no mets.
 SPSA- markedly elevated

21. DIETARY MANAGEMENT
 19/3/2012- patient on clear liquid diet
frequency of stool 6-8/day
 20/3/2012-patient was on full liquid diet
probiotic (LcS) introduced – 1BD
frequency of stools 4-5/day
 21/3/2012-patient was on soft diet
frequency of stools decreased to
2 but the stools were formed.

22. CASE 3
age:58yrs male
Ulcerative Colitis
General Information
 Age : 58yr
 Wt: 72kg
 Ht: 175cm
 BMI: 23.51kg/msq
 BP: 130/90

23. HISTORY
 h/o Diabetes
 Complain of bleeding per rectum.
 Increased frequency of stools with
mucosa since 1-1/2 months.
 There was no history of fever.
 Also developed osteoporosis.
 Patient was on steroids since 22yrs.

24. MEDICATION
 Medication on admission
1. Inj. Pantocid
2. N. Saline
3. Metrogyl
4. Inj. Forzid
5. Efcorlin 50ml/6hrly

25. INVESTIGATIONS
 Colonoscopy: Seen upto Caecum.
 Showed diffused mucosal ulceration with
erosion.
 Chronic proctosigmoidotis and ulcerative
colitis.

26. DIETARY MANAGEMENT
 DIET: The patient was kept on Bland soft –
Lactose free diet
 2 probiotics (LcS) were introduced per day.
 On third day frequency of stools reduced to 3
from initial 5
 Stools were formed.
 Patient was discharged after a week on a
diabetic lactose free with instructions to continue
probiotics (LcS) BD.