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S1213 The Effect of Oral Supplementation with Lactobacillus Reuteri or Tilactase in Lactose-Intolerant Patients: A Placebo Controlled Study
AGA Abstracts
consecutive patients had a LVAD for either BTT or DT. The average age was 62 yrs with 70 (81%) men and 16 (19%) women. LVADs implanted included: 46 (53%) pulsatile flow LVADs (Thoratec PVAD and IVAD, Heartmate XVE) and 40 (47%) continuous flow LVADs (Heartmate II). All data was retrospectively collected. Results: Patients with Heartmate II and Thoratec PVAD and IVAD were on aspirin daily and Coumadin (INR 1.5-2.5). Heartmate XVE patients received aspirin only. GI bleeding occurred in 26 (30%) patients. 26 pts underwent EGD and 22 underwent colonoscopy. Total number of procedures performed were 74 including 46 EGDs (5 jejunoscopies, 3 enteroscopies) 28 colonoscopies (3 flexible sigmoidoscopies, 1 proctoscopy). EGD revealed: gastric and small bowel angiodysplasias in 8 pts, ulcers/erosions 9 pts and mild gastritis 10 pts. 75% of pts with angiodysplasia were actively bleeding. Colonoscopies revealed: bleeding rectal ulcers 4 pts, diverticulosis 8 pts, pseudomembanous colitis 1 pt, internal hemorrhoids 8 pts. Treatment for bleeding included: argon plasma coagulation, electrocauterization and epinephrine injection. Coumadin and aspirin were stopped and proton pump inhibitors, sucralfate and octreotide were used when indicated. 3 required surgical intervention secondary to internal hemorrhoids and bleeding rectal ulcer. Other GI complications included: abdominal pain with constipation 2, abdominal hematoma 1, gastric outlet obstruction 1, elevated transaminases 2 secondary to amiodarone and Acalculous cholecystitis, and 1 patient with acute abdominal distension and a cecal volvulus. Average time of support until GI complication was 174 days. The majority of bleeding complications (73%) occurred in pts with a continuous flow LVAD. Conclusion: GI complications are frequently seen in pts implanted with a LVAD for end-stage heart failure. GI bleeding occurs more frequently in pts with a continuous flow LVAD. Standard therapy including stopping all anticoagulation can be used successfully in this high risk group of pts.
was also suggested. In this context, the objective of our work was to investigate the distribution of the main functional groups of microbes involved in carbohydrate fermentation in IBS subjects compare to healthy ones. Methods. Fourteen IBS patients (IBS-C) fulfilling the Rome II criteria and eleven healthy volunteers who did not have any gastrointestinal disorders were included in this study that was approved by the local ethical committee. All control and IBS volunteers did not receive antibiotics within the 3 months preceding the study and were instructed to follow their ordinary diet including 10-15 g of dietary fibers daily. Fecal samples from each volunteer were collected and processed within few hours. The different functional groups of microbes (fiber-degraders, protein degraders, lactate-utilizers...) were enumerated using cultural methods adapted to strict anaerobes. In parallel, an aliquot of each fecal sample was collected for subsequent in situ hybridization analysis (FISH). After fixation of the samples, bacterial enumerations were performed using a set of 10 oligonucleotide probes. Results. IBS patients showed important disturbances in microbial communities implicated in H2, lactate and butyrate metabolism. The population levels of lactic acid bacteria (bifidobacteria, lactobacilli) as well as lactate-utilizing bacteria were significantly lower in IBS than in healthy volunteers. Similarly, the butyrate-producing Roseburia species were in significant lower numbers in IBS subjects. By contrast, the numbers of Enterobacteriaceae and of sulfate-reducing bacteria were significantly higher in IBS subjects compared to healthy ones. Concomitantly to the predominance of SRB, population levels of others H2consuming microorganisms were significantly affected in IBS. Conclusion. Disruption affecting important functional groups of micro-organisms was evident in the gut of IBS subjects. These results suggest that abnormal fermentation may take place in the gut of IBS subjects, leading to production of deleterious metabolites (such as H2S) that could affect gut health and be responsible for digestive symptoms.
S1211
S1213
Dyssynergia, Laxatives and Stool Softeners - Factors That Predispose Demented or Immobile Nursing Home Residents with Impaired Anorectal Function to the Development of Diaper-Dependent Fecal Incontinence Felix W. Leung, Satish S. Rao, John Schnelle
The Effect of Oral Supplementation with Lactobacillus Reuteri or Tilactase in Lactose-Intolerant Patients: A Placebo Controlled Study Veronica Ojetti, Giovanni Gigante, Maria Elena Ainora, Maurizio Gabrielli, Alessio Migneco, Giovanni Gasbarrini, Nicolo Gentiloni Silveri, Antonio Gasbarrini
We performed anorectal measurements in nursing home subjects enrolled in a prompted voiding trial to explain the high prevalence of coexistence of fecal incontinence (FI) and constipation. A catheter with 3 solid state pressure transducers was placed in the anorectum with the subject in the left lateral position. Subjects were asked to squeeze as if to prevent fecal leakage and to strain as if to have a bowel movement. Rectal sensory thresholds were assessed by balloon distensions. Results: 29 subjects (5M/24F, mean age 85±2 years) gave informed consent. 28 were diaper-dependent. 22 had dementia. Immobility affected 26. All were prescribed laxatives and/or stool softeners. FI was confirmed by diaper checks (yes 20, no 8). They had normal sphincter length (3.6±0.2 cm) and rectoanal inhibitory reflex. The volume of threshold (1st) sensation (65.0±8.6 ml) was significantly higher than that which triggered distension-induced sphincter relaxation (15.9±1.7 ml) (p<0.05, paired t test). Two could not follow instructions to strain and 2 were not tested for strain-induced responses. The remaining 25 showed a dyssynergic pattern (6 Type I and 19 Type II) with elevation of anal sphincter pressure when asked to strain. Conclusion: The finding of dyssynergia (elevation of sphincter pressure during strain) in these subjects is novel. The data confirm that nursing home residents with diaper-dependent FI demonstrate weak internal (baseline) and external (squeeze) anal sphincter pressures, and impaired rectal sensation. Taken together these abnormalities of the anorectum coupled with the intensive laxative and stool softener treatment (presumably for prophylaxis against impaction) could explain the high prevalence of coexistence of FI and constipation in elderly nursing home subjects. Biofeedback training or behavioral modification to minimize dyssynergia in addition to or in lieu of the use of stool softeners, laxatives and diapers should be evaluated in their management. Table 1: Anorectal assessment in nursing home residents
Background: Lactase enzyme supplements and probiotics with high beta-galactosidase activity may be useful for the treatment of lactose intolerance. Aim of the study was to assess whether supplementation with tilactase or Lactobacillus reuteri when compared to placebo affects hydrogen breath excretion and gastrointestinal symptoms in lactose intolerant patients during lactose breath test (LBT). Methods: Sixty (60) lactose intolerant patients were consecutively enrolled and randomized into three 20 patients-treatment groups: tilactase group (tilactase 15 minutes before the control LBT); Lactobacillus reuteri group (LR) (Lactobacillus reuteri during 10 days preceding control LBT); placebo group (placebo 15 minutes before the control LBT). The outcomes were LBT normalization rate, and influences of treatments on both mean maximum hydrogen concentration and clinical score. Results: LBT normalization rate was significantly higher in tilactase and LR group with respect to placebo group. Tilactase was significantly more effective than L. reuteri in achieving LBT normalization (p <0.01). Both significant reduction of mean peak H2 excretion and improvement of the mean clinical score were observed in tilactase and LR group after treatment with respect to placebo group (p <0.0001). Tilactase was significantly more effective than L. reuteri in reducing both mean peak hydrogen excretion and mean clinical score. Conclusions: Tilactase significantly improves both LBT results and gastrointestinal symptoms after lactose ingestion by normalizing digestion of lactose intolerant patients. Lactobacillus reuteri may be beneficial in a subgroup of lactose intolerant patients. Future studies should aim to assess which are the lactose intolerant patients that may really benefit by Lactobacillus reuteri treatment. S1214 Malignant Small Bowel Tumors in Patients Undergoing Double-Balloon Enteroscopy (DBE) for Obscure Gastrointestinal Bleeding (OGIB) Lucia C. Fry, Helmut Neumann, Steffen Rickes, Doerthe Kuester, Peter Malfertheiner, Klaus Mönkemüller Introduction: Double balloon enteroscopy (DBE) has become one of the standard endoscopic methods to evaluate the small bowel. The most common indication for DBE is OGIB. Aim: To evaluate utility of DBE for the diagnosis of malignant small bowel tumors in patients presenting with OGIB. Methods: All patients undergoing DBE for the evaluation of obscure and overt GIB during a 4-year period at a university referral hospital were studied. DBE was performed using Fujinon DBE enteroscopes (Fujinon, Saitama, Japan). OGIB was defined according to the AGA guidelines (Gastroenterology, 2005 and 2008). The types of tumors were documented, as well as endoscopic technique of removal, surgery and complications. Capsule endoscopy (CE) was performed in 71% of patients with obscure occult GIB and 45% of patients with obscure overt CE was became available in our center in 2007. Complications of DBE were categorized based on standard criteria (Mensink et al, Endoscopy 2007). Results: We performed 152 DBE procedures in 114 patients. The type of OGIB was obscure overt (n=87) and obscure occult (n=27). A total of 14 malignant tumors were found: jejunal adenocarcinoma n = 6, GIST n=3, neuroendocrine tumour n=2, small bowel lymphoma n= 2, metastasis n=1. Thus, the overall incidence of malignant tumours in patients undergoing DBE for OGIB was 12.3%. The incidence of tumors in obscure overt GIB was 8.1% (n=7) and in patients investigated for obscure occult GIB it was 25.9% (n=7). In two patients CE was negative for malignancy (one adenocarcinoma, one GIST), whereas this occurred in 2 other patients undergoing DBE (GIST n=2) (miss rate 14.3%). Because of severe or persistent anemia these patients were sent for exploratory laparotomy. With the exception of two patients with small bowel lymphoma all other patients underwent exploratory laparotomy with resection of the tumor. No major complications occurred during DBE. Conclusions: The relative incidence of malignant small bowel tumors in patients undergoing DBE for OGIB is 12.3%, being the highest in patients with obscure occult GIB (25.7%). DBE missed 2 tumors, both of which were also missed on initial CE. Therefore, in the presence of severe or persistent anemia, even if both CE and DBE are negative, more invasive methods such as intraoperative enteroscopy or exploratory laparotomy should be pursued.
All pressure values are in mm Hg. *vs. baseline before squeeze or strain, p<0.05, paired t test S1212 The Intestinal Microbiota of Irritable Bowel Syndrome Patients Is Characterized By Functional Dysbiosis Christophe Chassard, Michel C. Dapoigny, Karen Scott, Christophe Del'Homme, Claude Dubray, Alain Eschalier, Harry J. Flint, Annick Bernalier-Donadille Background. Irritable bowel syndrome (IBS) is a common gastrointestinal disorder characterized by abdominal pain and disturbances in bowel function. Etiology of IBS is complex, associating psychological factors to altered gastro-intestinal motility and visceral hypersensitivity. Recent studies suggest that the intestinal microbiota may also play a role in the onset and maintenance of this pathology. Disturbances in the composition and stability of the gut intestinal microbiota were recently reported in IBS patients whereas abnormal fermentation
AGA Abstracts
A-214
consecutive patients had a LVAD for either BTT or DT. The average age was 62 yrs with 70 (81%) men and 16 (19%) women. LVADs implanted included: 46 (53%) pulsatile flow LVADs (Thoratec PVAD and IVAD, Heartmate XVE) and 40 (47%) continuous flow LVADs (Heartmate II). All data was retrospectively collected. Results: Patients with Heartmate II and Thoratec PVAD and IVAD were on aspirin daily and Coumadin (INR 1.5-2.5). Heartmate XVE patients received aspirin only. GI bleeding occurred in 26 (30%) patients. 26 pts underwent EGD and 22 underwent colonoscopy. Total number of procedures performed were 74 including 46 EGDs (5 jejunoscopies, 3 enteroscopies) 28 colonoscopies (3 flexible sigmoidoscopies, 1 proctoscopy). EGD revealed: gastric and small bowel angiodysplasias in 8 pts, ulcers/erosions 9 pts and mild gastritis 10 pts. 75% of pts with angiodysplasia were actively bleeding. Colonoscopies revealed: bleeding rectal ulcers 4 pts, diverticulosis 8 pts, pseudomembanous colitis 1 pt, internal hemorrhoids 8 pts. Treatment for bleeding included: argon plasma coagulation, electrocauterization and epinephrine injection. Coumadin and aspirin were stopped and proton pump inhibitors, sucralfate and octreotide were used when indicated. 3 required surgical intervention secondary to internal hemorrhoids and bleeding rectal ulcer. Other GI complications included: abdominal pain with constipation 2, abdominal hematoma 1, gastric outlet obstruction 1, elevated transaminases 2 secondary to amiodarone and Acalculous cholecystitis, and 1 patient with acute abdominal distension and a cecal volvulus. Average time of support until GI complication was 174 days. The majority of bleeding complications (73%) occurred in pts with a continuous flow LVAD. Conclusion: GI complications are frequently seen in pts implanted with a LVAD for end-stage heart failure. GI bleeding occurs more frequently in pts with a continuous flow LVAD. Standard therapy including stopping all anticoagulation can be used successfully in this high risk group of pts.
was also suggested. In this context, the objective of our work was to investigate the distribution of the main functional groups of microbes involved in carbohydrate fermentation in IBS subjects compare to healthy ones. Methods. Fourteen IBS patients (IBS-C) fulfilling the Rome II criteria and eleven healthy volunteers who did not have any gastrointestinal disorders were included in this study that was approved by the local ethical committee. All control and IBS volunteers did not receive antibiotics within the 3 months preceding the study and were instructed to follow their ordinary diet including 10-15 g of dietary fibers daily. Fecal samples from each volunteer were collected and processed within few hours. The different functional groups of microbes (fiber-degraders, protein degraders, lactate-utilizers...) were enumerated using cultural methods adapted to strict anaerobes. In parallel, an aliquot of each fecal sample was collected for subsequent in situ hybridization analysis (FISH). After fixation of the samples, bacterial enumerations were performed using a set of 10 oligonucleotide probes. Results. IBS patients showed important disturbances in microbial communities implicated in H2, lactate and butyrate metabolism. The population levels of lactic acid bacteria (bifidobacteria, lactobacilli) as well as lactate-utilizing bacteria were significantly lower in IBS than in healthy volunteers. Similarly, the butyrate-producing Roseburia species were in significant lower numbers in IBS subjects. By contrast, the numbers of Enterobacteriaceae and of sulfate-reducing bacteria were significantly higher in IBS subjects compared to healthy ones. Concomitantly to the predominance of SRB, population levels of others H2consuming microorganisms were significantly affected in IBS. Conclusion. Disruption affecting important functional groups of micro-organisms was evident in the gut of IBS subjects. These results suggest that abnormal fermentation may take place in the gut of IBS subjects, leading to production of deleterious metabolites (such as H2S) that could affect gut health and be responsible for digestive symptoms.
S1211
S1213
Dyssynergia, Laxatives and Stool Softeners - Factors That Predispose Demented or Immobile Nursing Home Residents with Impaired Anorectal Function to the Development of Diaper-Dependent Fecal Incontinence Felix W. Leung, Satish S. Rao, John Schnelle
The Effect of Oral Supplementation with Lactobacillus Reuteri or Tilactase in Lactose-Intolerant Patients: A Placebo Controlled Study Veronica Ojetti, Giovanni Gigante, Maria Elena Ainora, Maurizio Gabrielli, Alessio Migneco, Giovanni Gasbarrini, Nicolo Gentiloni Silveri, Antonio Gasbarrini
We performed anorectal measurements in nursing home subjects enrolled in a prompted voiding trial to explain the high prevalence of coexistence of fecal incontinence (FI) and constipation. A catheter with 3 solid state pressure transducers was placed in the anorectum with the subject in the left lateral position. Subjects were asked to squeeze as if to prevent fecal leakage and to strain as if to have a bowel movement. Rectal sensory thresholds were assessed by balloon distensions. Results: 29 subjects (5M/24F, mean age 85±2 years) gave informed consent. 28 were diaper-dependent. 22 had dementia. Immobility affected 26. All were prescribed laxatives and/or stool softeners. FI was confirmed by diaper checks (yes 20, no 8). They had normal sphincter length (3.6±0.2 cm) and rectoanal inhibitory reflex. The volume of threshold (1st) sensation (65.0±8.6 ml) was significantly higher than that which triggered distension-induced sphincter relaxation (15.9±1.7 ml) (p<0.05, paired t test). Two could not follow instructions to strain and 2 were not tested for strain-induced responses. The remaining 25 showed a dyssynergic pattern (6 Type I and 19 Type II) with elevation of anal sphincter pressure when asked to strain. Conclusion: The finding of dyssynergia (elevation of sphincter pressure during strain) in these subjects is novel. The data confirm that nursing home residents with diaper-dependent FI demonstrate weak internal (baseline) and external (squeeze) anal sphincter pressures, and impaired rectal sensation. Taken together these abnormalities of the anorectum coupled with the intensive laxative and stool softener treatment (presumably for prophylaxis against impaction) could explain the high prevalence of coexistence of FI and constipation in elderly nursing home subjects. Biofeedback training or behavioral modification to minimize dyssynergia in addition to or in lieu of the use of stool softeners, laxatives and diapers should be evaluated in their management. Table 1: Anorectal assessment in nursing home residents
Background: Lactase enzyme supplements and probiotics with high beta-galactosidase activity may be useful for the treatment of lactose intolerance. Aim of the study was to assess whether supplementation with tilactase or Lactobacillus reuteri when compared to placebo affects hydrogen breath excretion and gastrointestinal symptoms in lactose intolerant patients during lactose breath test (LBT). Methods: Sixty (60) lactose intolerant patients were consecutively enrolled and randomized into three 20 patients-treatment groups: tilactase group (tilactase 15 minutes before the control LBT); Lactobacillus reuteri group (LR) (Lactobacillus reuteri during 10 days preceding control LBT); placebo group (placebo 15 minutes before the control LBT). The outcomes were LBT normalization rate, and influences of treatments on both mean maximum hydrogen concentration and clinical score. Results: LBT normalization rate was significantly higher in tilactase and LR group with respect to placebo group. Tilactase was significantly more effective than L. reuteri in achieving LBT normalization (p <0.01). Both significant reduction of mean peak H2 excretion and improvement of the mean clinical score were observed in tilactase and LR group after treatment with respect to placebo group (p <0.0001). Tilactase was significantly more effective than L. reuteri in reducing both mean peak hydrogen excretion and mean clinical score. Conclusions: Tilactase significantly improves both LBT results and gastrointestinal symptoms after lactose ingestion by normalizing digestion of lactose intolerant patients. Lactobacillus reuteri may be beneficial in a subgroup of lactose intolerant patients. Future studies should aim to assess which are the lactose intolerant patients that may really benefit by Lactobacillus reuteri treatment. S1214 Malignant Small Bowel Tumors in Patients Undergoing Double-Balloon Enteroscopy (DBE) for Obscure Gastrointestinal Bleeding (OGIB) Lucia C. Fry, Helmut Neumann, Steffen Rickes, Doerthe Kuester, Peter Malfertheiner, Klaus Mönkemüller Introduction: Double balloon enteroscopy (DBE) has become one of the standard endoscopic methods to evaluate the small bowel. The most common indication for DBE is OGIB. Aim: To evaluate utility of DBE for the diagnosis of malignant small bowel tumors in patients presenting with OGIB. Methods: All patients undergoing DBE for the evaluation of obscure and overt GIB during a 4-year period at a university referral hospital were studied. DBE was performed using Fujinon DBE enteroscopes (Fujinon, Saitama, Japan). OGIB was defined according to the AGA guidelines (Gastroenterology, 2005 and 2008). The types of tumors were documented, as well as endoscopic technique of removal, surgery and complications. Capsule endoscopy (CE) was performed in 71% of patients with obscure occult GIB and 45% of patients with obscure overt CE was became available in our center in 2007. Complications of DBE were categorized based on standard criteria (Mensink et al, Endoscopy 2007). Results: We performed 152 DBE procedures in 114 patients. The type of OGIB was obscure overt (n=87) and obscure occult (n=27). A total of 14 malignant tumors were found: jejunal adenocarcinoma n = 6, GIST n=3, neuroendocrine tumour n=2, small bowel lymphoma n= 2, metastasis n=1. Thus, the overall incidence of malignant tumours in patients undergoing DBE for OGIB was 12.3%. The incidence of tumors in obscure overt GIB was 8.1% (n=7) and in patients investigated for obscure occult GIB it was 25.9% (n=7). In two patients CE was negative for malignancy (one adenocarcinoma, one GIST), whereas this occurred in 2 other patients undergoing DBE (GIST n=2) (miss rate 14.3%). Because of severe or persistent anemia these patients were sent for exploratory laparotomy. With the exception of two patients with small bowel lymphoma all other patients underwent exploratory laparotomy with resection of the tumor. No major complications occurred during DBE. Conclusions: The relative incidence of malignant small bowel tumors in patients undergoing DBE for OGIB is 12.3%, being the highest in patients with obscure occult GIB (25.7%). DBE missed 2 tumors, both of which were also missed on initial CE. Therefore, in the presence of severe or persistent anemia, even if both CE and DBE are negative, more invasive methods such as intraoperative enteroscopy or exploratory laparotomy should be pursued.
All pressure values are in mm Hg. *vs. baseline before squeeze or strain, p<0.05, paired t test S1212 The Intestinal Microbiota of Irritable Bowel Syndrome Patients Is Characterized By Functional Dysbiosis Christophe Chassard, Michel C. Dapoigny, Karen Scott, Christophe Del'Homme, Claude Dubray, Alain Eschalier, Harry J. Flint, Annick Bernalier-Donadille Background. Irritable bowel syndrome (IBS) is a common gastrointestinal disorder characterized by abdominal pain and disturbances in bowel function. Etiology of IBS is complex, associating psychological factors to altered gastro-intestinal motility and visceral hypersensitivity. Recent studies suggest that the intestinal microbiota may also play a role in the onset and maintenance of this pathology. Disturbances in the composition and stability of the gut intestinal microbiota were recently reported in IBS patients whereas abnormal fermentation
AGA Abstracts
A-214