Probiotics in Inflammatory Bowel Disease

Probiotics in Inflammatory Bowel Disease John Keohane, MB, MRCPI, Shomik Sibartie, MB, MRCSI, and Fergus Shanahan, MD, FACP, FRCPI Probiotics are biological control agents that usually take the form of food-grade or commensal bacteria that can be harnessed to confer a beneficial health effect. The promise of probiotics, at present, extends beyond the evidence base in many conditions. However, the efficacy of probiotics in management and prophylaxis of gastrointestinal infections has been confirmed, and there is sound evidence for a role for some but not all probiotics in irritable bowel syndrome. Whether probiotics have a role in other gastrointestinal conditions, such as postoperative wound healing and infections, Helicobacter pylori infection, colon cancer prevention, and inflammatory bowel disease, is less clear. Here we focus on the evidence for probiotics in Crohn’s disease and ulcerative colitis. Results from studies in humans have not been as impressive as data from animal models, and clinical trials have generally had mixed results. Some of the variability may reflect differences in choice of bacterial strains and dosages. The most convincing evidence has been in pouchitis but genetically modified probiotic strains may be required for some patients in the future. Semin Colon Rectal Surg 17:55-60 © 2006 Elsevier Inc. All rights reserved. KEYWORDS probiotics, bacteria, inflammatory bowel disease, Crohn’s disease, ulcerative colitis, pouchitis

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rohn’s disease and ulcerative colitis represent a significant health care burden with between 0.1 and 0.2% of people in developing countries affected.1 While the incidence of Crohn’s disease still appears to be increasing, the frequency of ulcerative colitis seems to have become stable in many countries.2 The etiology of these diseases is complex but a consensus has emerged to suggest the involvement of an exaggerated immune response to enteric microflora in genetically susceptible individuals.3,4 Commonly cited evidence implicating the role of the flora in the pathogenesis of inflammatory bowel disease includes the following: ●

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Areas in the gut with the highest bacterial concentrations are the sites most frequently affected by inflammatory bowel disease.5 The diversion of the fecal stream is associated with distal improvement in Crohn’s disease.6 Immune reactivity against enteric bacteria can be seen in Crohn’s disease patients, thus suggesting a loss of tolerance to commensal bacteria.7,8

Alimentary Pharmabiotic Centre and Department of Medicine, University College Cork, National University of Ireland, Cork, Ireland. Address reprint requests to: Prof. Fergus Shanahan, MD, Alimentary Pharmabiotic Centre, Dept. Medicine, Clinical Science Building, Cork University Hospital, Cork, Ireland. E-mail: [email protected]

1043-1489/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.scrs.2006.06.001

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Therapeutic efficacy is seen with antibiotics in distal Crohn’s disease.9 There have been reports of increased numbers of bacteria within the mucosa of inflammatory bowel disease patients versus healthy controls.10,11 Susceptibility genes such as NOD2/CARD15 code for proteins responsible for interpreting the microbial microenvironment.12 Bacterial colonization is a prerequisite for enterocolitis in animal models and germ-free animals do not develop colitis.13,14

This body of evidence has provided the rationale for therapeutic manipulation of the flora with probiotics as a management or prophylactic strategy for inflammatory bowel disease.

Probiotics Probiotics are described as “living microorganism which on ingestion in certain numbers, exert health affects beyond inherent basic nutrition.”15 The concept of ingesting bacteria for health benefit is not new. A century has elapsed since the Nobel laureate Eli Metchnikoff reported that fermented milk with lactobacilli might be responsible for increased longevity in Bulgarian peasants. Since then, the terminology has 55

56 evolved and the term pharmabiotics now embraces all forms of therapeutic manipulation of the flora with anti-, pro-, pre-, or synbiotics. Prebiotics are nondigestible food products, generally oligosaccharides, which on ingestion stimulate the growth of probiotic bacteria, and the term synbiotics describes the combination of a prebiotic and probiotic. Criteria for designating a bacterial strain as a probiotic include human origin, acid and bile stability, absence of demonstrable pathogenicity, gastrointestinal transit and survival, production of antimicrobial substances, and modulation of the immune response.16 However, the requirement that the bacteria be intact and live may be too restrictive, because recent data suggest that bacterial constituents, such as DNA, have immune modulating effects and may mediate the probiotic effect in some circumstances.17 Furthermore, restricted definitions of probiotics need to take into account recent reports of the therapeutic use of genetically modified bacteria to deliver biologically active molecules such as interleukin-10 and trefoil factors to the gut.18,19 The mechanisms of action of probiotics are numerous and include competitive interaction with pathogens, reduction in bacterial translocation, production of antimicrobial products, and antiinflammatory signaling. There is strong evidence for probiotics in gastrointestinal infections as demonstrated in a recent Cochrane systematic review.20 A total of 23 randomized control trials were reviewed and they concluded that probiotics appear to be a useful adjunct to rehydration therapy in both adults and children. The role for probiotics in irritable bowel is promising with a recent study suggesting that Bifidobacterium infantis 35624 but not lactobacilli results in improvement in the symptom profile of patients with Irritable Bowel Syndrome (IBS) and a normalization of the antiinflammatory to proinflammatory cytokine profiles.21 The evidence in animal models of enterocolitis is also impressive and has been confirmed by many investigators with various probiotic strains.22-24 However, the results in humans are mixed and may relate to the fact that in humans probiotics are given after the establishment of the disease, whereas in the animals they are given before the onset of disease. Second, in animal models the probiotics are given at a young often neonatal age, whereas in humans they have generally been administered after colonization of the bowel. The best evidence for efficacy in human inflammatory bowel disease is in the prevention of pouchitis, but results in clinical practice appear to be inconsistent. This may relate to variability in the quality of probiotic preparations used. There is evidence to suggest that many of the commercially available probiotics do not contain the advertised bacterial strain nor do they have the correct concentration.25 As the functionality and safety of probiotics appear strain-specific, rigorous regulatory control is needed to protect the consumer.

Methods A systematic search of PubMed databases 1966 to 2005 for relevant literature was performed, using the following key word combinations: “Probiotics and inflammatory bowel

J. Keohane, S. Sibartie, and F. Shanahan disease,” “Crohn’s disease,” “ulcerative colitis,” and “pouchitis” in humans. Relevant literature was reviewed and cited accordingly.

Crohn’s Disease The evidence for probiotics in Crohn’s disease is varied with many small studies, the results of which are inconclusive (Table 1). Most of the studies involve the lactic acid bacteria such as lactobacillus rhamnosus GG and lactobacillus salivarius 118. Other strains and probiotics have included Escherichia coli Nissle 1917 (EcN), Saccharomyces boulardii, and the cocktail VSL#3. This is a combination of four lactobacilli strains (Lactobacillus plantarum, L. casei, L. acidophilus, L. delbrueckii ssp bulgaricus), three strains of Bifidobacterium (B. longum, B. breve, B. infantis), and one strain of Streptococcus salivarius ssp thermophilus. The earliest study examined the use of Saccharomyces boulardii in patients with moderately active Crohn’s disease. There was a significant decrease in the Crohn’s disease activity index compared with the control group.26 This yeast was used more recently in combination with mesalamine in the maintenance of remission. After 1 year, there was a significant difference in the relapse rate, 6.25% in probiotic group versus 37.5% in controls.27 There have been two open-label studies on lactobacillus GG in pediatric Crohn’s disease. One study demonstrated the immunostimulatory of L. GG by its ability to increase gut IgA levels but no clinical improvement was noted while the other reported improved intestinal permeability and clinical scores in four children with mildly active Crohn’s disease.28,29 A recent randomized control trial of 45 Crohn’s disease patients after curative surgery compared the recurrence rate in patients treated with Lactobacillus rhamnosus GG or placebo.30 There was no difference in endoscopic recurrence rate between the two groups nor was there any difference in the severity of the lesions seen. The probiotic VSL#3 demonstrated a beneficial effect in addition to the antibiotic rifamixin versus mesalamine alone in the maintenance of a surgically induced remission. This study is in abstract form only.31 Clearly, the role for probiotics in Crohn’s disease needs to be further elucidated and large well-powered randomized control trials are needed.

Ulcerative Colitis The results of published trials of probiotics in ulcerative colitis are summarized in Table 2. Kruis and coworkers used E. coli Nissle 1917 in two large randomized control trials. Their first study in 1997 showed no difference in relapse rates between probiotic and mesalamine in the maintenance of remission but the dose of mesalamine used was low, ⫺1.5 g/d.32 However, the follow-up study was adequately powered and the hypothesis was a test of equivalence. The study confirmed the equivalence of the probiotic to mesalamine in the maintenance of remission. The side-effect profile was also equivalent.33 Recently an open-label trial of VSL#3 in the induction of remission in 34 patients demonstrated remission in 53%

Probiotics in inflammatory bowel disease

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Table 1 Summary of Human Studies of Probiotics in Crohn’s Disease Study Type RCT in Crohn’s disease Open-labeled trial in paediatric Crohn’s disease RCT in colonic Crohn’s disease Open-labeled trial in children with mildly active Crohn’s disease RCT in maintenance of surgical induced remission Crohn’s disease RCT in maintenance of remission Crohn’s disease Open-labeled trial in mild/ moderately active Crohn’s disease RCT in maintenance of surgical induced remission RCT in induction and maintenance of remission

Organism Used

Trial Outcome

Reference

Saccharomyces boulardii (n ⴝ 20) Lactobacillus GG (n ⴝ 14)

Decrease in diarrhea and CDAI index in probiotic group Increase in gut IgA response

Plein et al, 199326

E. Coli Nissle 1917 (n ⴝ 28)

Relapse rates 30% in probiotic group versus 70% in placebo (NS) Improved intestinal permeability and CDAI

Malchow, 199751

VSL#3 with rifamixin versus mesalamine (n ⴝ 40)

Endoscopic remission of 80% in probiotic group versus 60% in mesalazine group

Campieri et al, 200031

Saccharomyces boulardii and mesalazine versus mesalazine alone (n ⴝ 32) Lactobacillus salivarus UCC118 (n ⴝ 25)

Higher remission in the probiotic plus mesalazine group

Guslandi et al, 200027

Reduction in CDAI and reduced steroid use in the probiotic group

McCarthy et al, 200152

Lactobacillus rhamnosus GG (n ⴝ 45)

No difference between two groups at 1 year

Prantera et al, 200230

Lactobacillus GG (n ⴝ 11)

No benefit in induction or maintenance of remission. Only five completed study

Schultz et al, 200453

Lactobacillus GG (n ⴝ 4)

Malin et al, 199628

Gupta et al, 200029

RCT ⴝ randomized control trial; n ⴝ total number of patients; NS ⴝ nonsignificant; CDAI ⴝ Crohn’s disease activity index.

with a combined remission/response rate of 77%.34 Here the investigators also confirmed the presence of bacterial DNA from the product in three of the patients that entered remission. One randomized control trial of a bifidobacteria-fermented milk administered as maintenance therapy over 1 year in-

volved 21 patients found fewer relapses in the treatment arm (27% versus 90% in control group) but no difference in the endoscopic scores.35 An important point about this study is the lack of blinding among the investigators and patients and a lack of correlation in the outcome measures. Cui and coworkers performed a similar study in 30 patients using a

Table 2 Summary of Human Trials of Probiotics in Ulcerative Colitis Study Type

Organism Used

Trial Outcome

RCT in maintenance of remission

E. coli Nissle 1917 (n ⴝ 120)

Kruis et al, 199732

RCT in maintenance of remission RCT in active ulcerative colitis Open-label study in maintenance of remission Open label study in induction of remission RCT in maintenance of remission RCT in maintenance of remission

E. coli Nissle 1917 (n ⴝ 327)

No difference in relapse rates between probiotic and mesalamine Equivalent to mesalamine

Rembacken et al, 199954

VSL#3 (n ⴝ 20)

68% response to probiotic versus 75% in mesalamine 75% in remission

VSL#3 (n ⴝ 34)

53% remission rate

Biblioni et al, 200534

Bifidobacterium bifidum (n ⴝ 21) Bifidobacteria, Lactobacilli, Enterococci combination (n ⴝ 30) Bif longum and prebiotic (n ⴝ 18) S. boulardii (n ⴝ 25)

27% relapse rate treatment arm versus 90% control arm 20% relapse in treatment arm versus 93% placebo group (P < 0.01) Significant differences in inflammatory cytokines 17/24 clinical remission

Ishikawa et al, 200335

RCT in active disease Open label in mild/moderate ulcerative colitis

E. coli Nissle 1917 (n ⴝ 116)

RCT ⴝ randomized control trial; n ⴝ total number of patients.

Reference

Kruis et al, 200433

Venturi et al, 199955

Cui et al, 200436

Furrie et al, 200537 Guslandi et al, 200338

J. Keohane, S. Sibartie, and F. Shanahan

58 Table 3 Summary of Clinical Trials of Probiotics in Pouchitis Study Type Open-label trial

RCT to maintain remission after antibiotic-induced remission RCT in postoperative prevention RCT to maintain remission in relapsing/recurrent pouchitis after antibiotic induced remission Open-label study in antibiotic-dependent pouchitis RCT in acutely active pouchitis Case control study in postoperative prevention Open-label study in prevention of acute pouchitis

Organism Used Lactobacillus GG and prebiotic with antibiotic (n ⴝ 10) VSL#3 (n ⴝ 40) VSL#3 (n ⴝ 40) VSL#3 (n ⴝ 36)

Trial Outcome

Reference

Effective in inducing remission.

Friedman et al, 200056

15% relapse in probiotic arm vs 100% placebo arm.

Gionchetti et al, 200044

Acute pouchitis in 10% probiotic arm vs 40% placebo group (P < 0.01). Remission in 85% probiotic group vs 6% placebo (P < 0.0001).

Gionchetti et al, 200346 Mimura et al, 200445

VSL#3 (n ⴝ 31)

After 8 months only 6 remained on probiotic. No difference in PDAI.

Shen et al, 200547

Lactobacillus GG (n ⴝ 20)

No benefit in clinical or endocsopic response. Decreased risk of pouchitis. Cumulative risk at 3 years: 7% vs. 29% (P ⴝ 0.011). Improvement in PDAI, but not histology.

Kuisma et al, 200348

Lactobacillus GG (n ⴝ 117)

Lactobacillus acidophilus and Bif lactis (n ⴝ 51)

Gosselink et al, 200450

Laake et al, 200449

RCT ⴝ randomized control trial; n ⴝ total number of patients; PDAI ⴝ pouchitis disease activity index.

capsule of Enterococci, Bifidobacteria, Lactobacilli in the maintenance of remission. The relapse rate in the probiotic group was 20% versus 93% relapse in the placebo; the activation of NF-␬B was significantly attenuated in the probiotic group and there was an upregulation of IL-10.36 The period of follow-up in this study was short at 2 months but results were encouraging for this particular combination. Another strain of Bifidobacteria, B. longum combined with the prebiotic inulin-oligofructose, was used in a randomized control trial of 18 patients with active ulcerative colitis for 1 month.37 However, while it did show a significant reduction in inflammatory cytokines such as tumor necrosis factor alpha and interleukin-1 alpha, the endoscopic differences were not significant. Guslandi and coworkers performed an uncontrolled trial of S. boulardii in 25 patients with mild-to-moderate ulcerative colitis along with maintenance mesalazine. Of the 24 that completed the study, 17 achieved clinical remission, which was confirmed endoscopically.38 To further define the role of probiotics in ulcerative colitis, larger placebocontrolled trials should be performed. The largest trial by Kruis and coworkers would suggest that E. Coli Nissle is as good as mesalamine in the maintenance of remission in ulcerative colitis.

Pouchitis It is estimated that between 24 and 46% of patients after ileal pouch anal anastomosis for ulcerative colitis will experience at least one episode of pouchitis. The majority of these patients respond to antibiotics but between 8 and 32% develop chronic pouchitis.39-41 The etiology of this entity remains

unknown but an imbalance in the bacterial flora in the pouch including reduced Bifidobacteria and Lactobacilli may be contributory.42,43 This has led to interest in microflora manipulation with probiotics. The human studies to date are summarized in Table 3. Two trials looked at VSL#3 in the maintenance of remission involving a total of 76 patients. In the first trial Gionchetti and coworkers looked at it in the maintenance of an antibiotic-induced remission. After 9 months 85% of the probiotic arm remained in remission, whereas the entire placebo group relapsed. They also showed that all those in remission following the probiotic relapsed on completion of the trial.44 Mimura and coworkers confirmed this in their study over a year, with 85% in remission in the probiotic arm and 6% in the placebo arm. Patients on the probiotic also demonstrated a higher quality of life as measured by the inflammatory bowel disease questionnaire.45 In a follow-up trial by Gionchetti and colleagues, VSL#3 was used in the postoperative prevention of pouchitis. Patients were randomized to placebo or VSL#3 as prophylaxis after ileal pouch anal anastomosis surgery. After 1-year follow-up of the 40 patients recruited, 10% of the probiotic-treated patients had pouchitis compared with 40% of the placebo group.46 However, more recently Shen and colleagues published an openlabel study in 31 patients with antibiotic-dependent pouchitis using VSL#3. They found only six patients remained on the probiotic for the 8-month duration of follow-up, and there was no difference in the Pouchitis Disease Activity Index from baseline in that group.47 There were some inherent problems with this study in that patients had to purchase the

Probiotics in inflammatory bowel disease medication themselves and bear the cost, and the medication was self-administered with no measure of adherence made. In contrast to VSL#3, studies on the lactobacillus have been less than encouraging. Kuisma and coworkers demonstrated that, while L. rhamnosus GG did change the pouch microflora, it had no significant effect on clinical or endoscopic response.48 Similarly Laake and coworkers used a fermented drink containing L. acidophilus and Bifidobacteria lactis, which did show an improvement in the Pouchitis Disease Activity Index score but not in the histology.49 The only positive study from the lactobacillus group came from Gosselink and coworkers, which showed a decreased cumulative risk of pouchitis in 117 patients taking L. rhamnosus GG.50 While results from these studies are encouraging, certain questions need to be addressed including the choice of probiotic and whether or not pre-treatment with antibiotics is necessary to induce remission prior to probiotic therapy.

Turbo Probiotics Genetic engineering of probiotic strains as described by Steidler and coworkers may increase the potential role of probiotics. Proof of principle has been established in animal models of inflammatory bowel disease. Genetically modified L. lactis producing the antiinflammatory cytokine interleukin-10 was deployed and resulted in a significant reduction in inflammation when fed to different murine models of IBD.19 This represents a novel use for probiotics which avoids the inconvenience, toxicity, and cost of parenteral administration of the cytokine. The same strategy can be adapted to the delivery of other biologically active molecules including trefoil factors, enzymes, and vaccines. While the general public remains wary of genetically modified food/organisms, this approach may be an acceptable alternative for patients with chronic disabling disease. Further research is needed to establish the role of this approach in humans, but we already have a glimpse of what may be to come.

Conclusion Although the rationale for probiotics in inflammatory bowel disease seems to be sound, their promise in clinical practice remains to be fulfilled. Evidence for a role of probiotics in enteric infections is strong, and there is emerging evidence for their role in IBS, but results of probiotic trials in humans with Crohn’s and colitis have been less impressive than what was predicted from studies of animal models of enterocolitis. Rigorous scientific scrutiny of probiotic selection criteria is required. It is evident that not all probiotics are the same, and strains that appear to have efficacy in certain clinical conditions may not be effective in others. Strict regulatory constraints need to be introduced to protect consumers and to ensure quality control and the elimination of unsubstantiated claims. In addition, statistically powered clinical trials are needed with strict categorization of patient subtypes at study entry. Another issue that needs to be resolved is whether the use of probiotics should be preceded by a course of antibiotics to open the microbial niche as may have been achieved in

59 some trials of probiotics in pouchitis. Finally, for severely ill patients with inflammatory bowel disease, the use of genetically engineered or “turbo” probiotics offers a new strategy for more targeted delivery of antiinflammatory molecules to the inflamed mucosa.

Acknowledgments The authors are supported in part by grants from Science Foundation Ireland, the Higher Education Authority of Ireland, and the Health Research Board of Ireland.

References 1. Shanahan F: Immunology. Therapeutic manipulation of gut flora. Science 289:1311-1312, 2000 2. Askling J, Grahnquist L, Ekbom A, et al: Incidence of paediatric Crohn’s disease in Stockholm, Sweden. Lancet 354:1179, 1999 3. Elson CO: Commensal bacteria as targets in Crohn’s disease. Gastroenterology 119:254-257, 2000 4. Shanahan F: Probiotics and inflammatory bowel disease: is there a scientific rationale? Inflamm Bowel Dis 6:107-115, 2000 5. Simon GL, Gorbach SL: Intestinal flora in health and disease. Gastroenterology 86:174-193, 1984 6. Shanahan F: Crohn’s disease. Lancet 359:62-69, 2002 7. Duchmann R, Kaiser I, Hermann E, et al: Tolerance exists towards resident intestinal flora but is broken in active inflammatory bowel disease. Clin Exp Immunol 102:448-455, 1995 8. Macpherson A, Khoo UY, Forgacs I, et al: Mucosal antibodies in inflammatory bowel disease are directed against intestinal bacteria. Gut 38: 365-375, 1996 9. Ursing B, Alm T, Barany F, et al: A comparative study of metronidazole and sulfasalazine for active Crohn’s disease: the cooperative Crohn’s disease study in Sweden. Gastroenterology 83:550-562, 1982 10. Swidsinski A, Ladhoff A, Pernthaler A, et al: Mucosal flora in inflammatory bowel disease. Gastroenterology 122:44-54, 2002 11. Schultsz C, Van Den Berg FM, Ten Kate FW, et al: The intestinal mucus layer from patients with inflammatory bowel disease harbors high numbers of bacteria compared with controls. Gastroenterology 117: 1089-1097, 1999 12. Ogura Y, Bonen DK, Inohara N, et al: A frameshift mutation in NOD2 associated with susceptibility to Crohn’s disease. Nature 411:603-606, 2001 13. Sellon RK, Tonkonogy S, Schultz M, et al: Resident enteric bacteria are necessary for development of spontaneous colitis and immune system activation in interleukin-10-deficient mice. Infect Immunol 66:52245231, 1998 14. Rath HC, Herfarth HH, Ikeda JS, et al: Normal luminal bacteria, especially Bacteroides species, mediate chronic colitis, gastritis, and arthritis in HLA-B27/human beta2 microglobulin transgenic rats. J Clin Invest 98:945-953, 1996 15. Guarner F, Schaafsma GJ: Probiotics. Int J Food Microbiol 39:237-238, 1998 16. Dunne C, O’Mahony L, Murphy L, et al: In vitro selection criteria for probiotic bacteria of human origin: correlation with in vivo findings. Am J Clin Nutr 73:386S-392S, 2001 17. Rachmilewitz D, Karmeli F, Takabayashi K, et al: Immunostimulatory DNA ameliorates experimental and spontaneous murine colitis. Gastroenterology 122:1428-1441, 2002 18. Vandenbroucke K, Hans W, Van HJ, et al: Active trefoil factors by genetically modified Lactococcus lactis prevents and heals acute colitis in mice. Gastroenterology 127:502-513, 2004 19. Steidler L, Hans W, Schotte L, et al: Treatment of murine colitis by Lactococcus lactis secreting interleukin-10. Science 289:1352-1355, 2000 20. Allen SJ, Okoko B, Martinez E, et al: Probiotics for treating infectious diarrhoea. Cochrane Database Syst Rev 4:CD003048, 2003 21. O’Mahony L, McCarthy J, Kelly P, et al: Lactobacillus and bifidobacte-

J. Keohane, S. Sibartie, and F. Shanahan

60

22.

23.

24.

25. 26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

rium in irritable bowel syndrome: symptom responses and relationships to cytokine profiles. Gastroenterology 128:541-551, 2005 McCarthy J, O’Mahony L, O’Callaghan L, et al: Double blind, placebo controlled trial of two probiotic strains in interleukin 10 knockout mice and mechanistic link with cytokine balance. Gut 52:975-980, 2003 O’Mahony L, Feeney M, O’Halloran S, et al: Probiotic impact on microbial flora, inflammation and tumour development in IL-10 knockout mice. Aliment Pharmacol Ther 15:1219-1225, 2001 Madsen KL, Doyle JS, Jewell LD, et al: Lactobacillus species prevents colitis in interleukin 10 gene-deficient mice. Gastroenterology 116: 1107-1114, 1999 Coeuret V, Gueguen M, Vernoux JP: Numbers and strains of lactobacilli in some probiotic products. Int J Food Microbiol 97:147-156, 2004 Plein K, Hotz J: Therapeutic effects of Saccharomyces boulardii on mild residual symptoms in a stable phase of Crohn’s disease with special respect to chronic diarrhoea—a pilot study. Z Gastroenterol 31:129134, 1993 Guslandi M, Mezzi G, Sorghi M, et al: Saccharomyces boulardii in maintenance treatment of Crohn’s disease. Dig Dis Sci 45:1462-1464, 2000 Malin M, Suomalainen H, Saxelin M, et al: Promotion of IgA immune response in patients with Crohn’s disease by oral bacteriotherapy with Lactobacillus GG. Ann Nutr Metab 40:137-145, 1996 Gupta P, Andrew H, Kirschner BS, et al: Is lactobacillus GG helpful in children with Crohn’s disease? Results of a preliminary, open-label study. J Pediatr Gastroenterol Nutr 31:453-457, 2000 Prantera C, Scribano ML, Falasco G, et al: Ineffectiveness of probotics in preventing recurrence after curative resection for Crohn’s disease: a randomised control trial with Lactobacillus GG. Gut 51:405-409, 2002 Campieri M, Rizzello F, Venturi A, et al: Combination of antibiotic and probiotic is efficacious in prophylaxis of post operative recurrence of Crohn’s disease: a randomised control study vs mesalazine. Gastroterology 118:A781, 2000 (abstr) Kruis W, Schutz E, Fric P, et al: Double-blind comparison of an oral Escherichia coli preparation and mesalazine in maintaining remission of ulcerative colitis. Aliment Pharmacol Ther 11:853-858, 1997 Kruis W, Fric P, Pokrotnieks J, et al: Maintaining remission of ulcerative colitis with the probiotic Escherichia coli Nissle 1917 is as effective as with standard mesalazine. Gut 53:1617-1623, 2004 Biblioni R, Fedorak RN, Tannock GW, et al: VSL#3 probiotic-mixture induces remission in patients with active ulcerative colitis. Am J Gastroenterol 100:1539-1546, 2005 Ishikawa H, Akedo I, Umesaki Y, et al: Randomized controlled trial of the effect of bifidobacteria-fermented milk on ulcerative colitis. J Am Coll Nutr 22:56-63, 2003 Cui HH, Chen CL, Wang JD, et al: Effects of probiotic on intestinal mucosa of patients with ulcerative colitis. World J Gastroenterol 10: 1521-1525, 2004 Furrie E, Macfarlane S, Kennedy A, et al: Synbiotic therapy (Bifidobacterium longum/Synergy 1) initiates resolution of inflammation in patients with active ulcerative colitis: a randomised controlled pilot trial. Gut 54:242-249, 2005. Guslandi M, Giollo P, Testoni PA: A pilot trial of Saccharomyces bou-

39. 40.

41.

42.

43. 44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

lardii in ulcerative colitis. Eur J Gastroenterol Hepatol 15:697-698, 2003 Fazio VW, Ziv Y, Church JM, et al: Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 222:120-127, 1995 Meagher AP, Farouk R, Dozois RR, et al: J ileal pouch-anal anastomosis for chronic ulcerative colitis complications and long-term outcomes in 1310 patient. Br J Surg 85:800-803, 1998 Sandborn WJ, Tremaine WJ, Batts KP, et al: Pouchitis after ileal pouchanal anastomosis: a Pouchitis Disease Activity Index. Mayo Clin Proc 69:409-415, 1994 Sandborn WJ: Pouchitis following ileal pouch-anal anastomosis: definition, pathogenesis, and treatment. Gastroenterology 107:1856-1860, 1994 Ruseler-van Embden JG, Schouten WR, van Lieshout LM: Pouchitis: result of microbial imbalance? Gut 35:658-664, 1994 Gionchetti P, Rizzello F, Venturi A, et al: Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology 119:305-309, 2000 Mimura T, Rizzello F, Helwig U, et al: Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis. Gut 53:108-114, 2004 Gionchetti P, Rizzello F, Hellwig U, et al: Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. Gastroenterology 124:1202-1209, 2003 Shen B, Brzezinski A, Fazio VW, et al: Maintenance therapy with a probiotic in antibiotic-dependent pouchitis: experience in clinical practice. Aliment Pharmacol Ther 22:71-78, 2005 Kuisma J, Mentula S, Jarvinen H, et al: Effects of Lactobacillus rhamnosus GG on ileal pouch inflammation and microbial flora. Aliment Pharmacol Ther 17:509-515, 2003 Laake KO, Line PD, Grzyb K, et al: Assessment of mucosal inflammation and blood flow in response to four weeks’ intervention with probiotics in patients operated with a J-configurated ileal-pouch-analanastomosis (IPAA). Scand J Gastroenterol 39:1228-1235, 2004 Gooselink MP, Schouten WR, van Lieshout LM, et al: Delay of the first onset of pouchitis by oral intake of the probiotic strain Lactobacillus rhamnosus GG. Dis Colon Rectum 47:876-884, 2004 Malchow HA: Crohn’s disease and Escherichia coli. A new approach in therapy to maintain remission of colonic Crohn’s disease? J Clin Gastroenterol 25:653-658, 1997 McCarthy J, O’Mahony L, Dunne C, et al: An open trial of a novel probiotic as an alternative to steroids in mild/moderately active Crohn’s disease. Gut 49:2447, 2001 (suppl III) (abstr) Schultz M, Timmer A, Herfarth HH, et al: Lactobacillus GG in inducing and maintaining remission if Crohn’s disease. BMC Gastroenterol 15: 4-5, 2004 Rembacken BJ, Snelling AM, Hawkey PM, et al: Non-pathogenic Escherichia coli versus mesalazine for the treatment of ulcerative colitis: a randomised trial. Lancet 354:635-639, 1999 Venturi A, Gionchetti P, Rizzello F, et al: Impact on the composition of the faecal flora by a new probiotic preparation: preliminary data on maintenance treatment of patients with ulcerative colitis. Aliment Pharmacol Ther 13:1103-1108, 1999 Friedman G, George J: Treatment of refractory “pouchitis” with prebiotic and probiotic therapy. Gastroenterology 118:A4167, 2000 (abstr)