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Exper t Inf orm ation 4 /2012 Intes tinal Flor a and Sto ol Diagno s tic s

Intestinal Flora and Stool Diagnostics

On the basis of most recent scientific findings

Intestinal Flora and Stool Diagnostics

… on the basis of most recent findings

Humans are born with sterile intestines and develop

a childlike, individual bacteria profile during their first

year of life, which later adapts to adult structures.

External influences like

• infections

• gastro-intestinal diseases

• stress and

• consumed foods

alter the intestinal microbiota.

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Comprehensive analysis of the intestinal microbiome is very difficult. It can be ac-

complished by cultivation and recently also with the aid of genetic procedures. Cul-

tivation methods are able to identify approximately 30-40% of the intestinal bacte-

ria. In spite of restrictions this method will help to draw first conclusions. In recent

years genetic procedures made it possible to analyse the remaining 60-70 % of the

intestinal bacteria. On the basis of genetic analyses (16s-rRNA-determination) the

following can be determined in the intestinal tract:

approximately 1.800 bacteria species

approximately 40,000 bacteria types

weight up to 2 kg

numbers exceeds 100 trillions!

Intestinal bacteria influence humans in many different ways. By developing a so-

called colonisation resistance against endogenic infections they alter the intesti-

nal milieu (pH value) and occupy mucosa receptors. Intestinal bacteria activate the

mucosa immune system and control development and secretion of sIgA (secretory

immune globulin A). SIgA does not only protect against endogenic infections, but

also prevents excessive stress of the systemic body defence by neutralizing patho-

gens and antigen structures on the mucosa surface.

Not all correlations can be considered individually here, this would fill volumes, but

at least some recent findings should be mentioned to underline the significance

of the microbiota.

E xper t Inf o r m at io n 4 / 2 0 1 2 In t es t in a l Fl o r a a nd Sto o l D iagno s t ic s

Intestinal Bacteria Influence Humans in Many Different Ways

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Superficially there is no connection between intestinal bacteria and central and

peripheral nerve functions, but research results indicate there is a direct link, for

example where liver is concerned:

Liver failure leads to hepatic encephalopathy with cognitive deficits, tremor and

dementia symptoms. Urease developing intestinal bacteria, which release ammo-

niac and other neurotoxic metabolites, play a major role. If these are no longer

decomposed by the liver it leads to systemic “poisoning”. By giving non-absorbable

antibiotics the bacteria and thereby ammoniac production can be repressed and

the condition improved. Similar connections became apparent for a number of

additional diseases.

Microorganisms and Pain Perception

Special lactobacilli strains induce the expression of cannabinoid and µ-opioid re-

ceptors in the intestinal epithelia und thereby promote analgesic effects similar

to those of morphine. This is an explanation for individually different visceral pain

perception.

Microorganisms and the Hypothalamus – Pituitary Gland Axis

Today an altered function of the hypothalamus-pituitary gland axis is considered

to be co-responsible for depression, as frequently depressive patients show incre-

ased cortisol and CRH levels. Stress is regarded as co-factor for the development of

depression and also affects the composition of the microbiome in the intestines.

Under stress potentially pathogenic bacteria, for example, increase significantly.

The growth is triggered in the intestinal mucosa by interactions with the host’s

own adrenalin/noradrenalin. It results in a signal for transcription of virulence ge-

nes in bacteria, which can be specifically blocked by adrenergic antagonists!


Microorganisms and the Nervous System

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Intestinal Flora and Food Utilisation

The intestinal microbiota influences weight development. About 90% of the in-

testinal bacteria can be assigned to two large bacteria groups –“firmicutes” and

“bacteroidetes”. Firmicutes are able to utilize fibres and complex carbohydrates.

Sugar and short-chained fatty acids are developed, which can be absorbed by the

body to build up fat. Therefore high firmicute shares in the intestines also control

the number of calories consumed by the body. In other words: depending on the

intestinal flora composition –when eating the same amount of food - different

amounts of calories are utilized.

Low carbohydrate diets lead to relative increases of bacteroidetes species and

thereby to reduced energy intake by food consumed. Also special prebiotics and

probiotics will positively influence the firmicutes/ bacteroidetes ratio and thus

counteract gaining weight.

Summary

According to current knowledge the intestinal flora influences the human orga-

nism in many ways. It does not only protect against infections, but also influences

our nervous system pain perception and food utilization. Many papers published

in recent years show that diseases allegedly induced by the central nervous sys-

tem had been subject to considerable co-influence by gastro-intestinal bacteria.


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Significance and Importance of Stool Flora Analyses

Presently stool flora analyses can be done with cultural or genetic assays. Whi-

le the majority of the intestinal bacteria can be determined and quantified via

genetic procedures, the cultural assay can only identify 30-40%. As genetic pro-

cedures on the basis of 16s-rRNA determination are very complex and expensive,

classic cultivation procedures are for applied most of the analyses. Same as for the

determination of pathogens (salmonella, shigella, clostridium difficile etc.) stool

samples are put on culture media. The culture media is incubated and growth is

analysed after one respectively two days.

The evaluation is based on

• existing potentially pathogenic organisms,

• the relation of certain main organisms of anaerobic

and aerobic flora to each other and

• stool consistency (colour and water content).

Today’s stool analyses contain – in addition to microbiota analysis – parameters,

which allow statements about the patient’s digestive performance (digestive

residues, pancreas elastase) and provide for evaluation of the intestinal mucosa

condition (calprotectin, alpha-1-anti-trypsine and zonulin) or the mucosa immune

system (sIgA). With the aid of all results causes of complaints can be recognized

or excluded and specific therapy approaches can be established. Based on the de-

termined values probiotic therapies can be optimized. The selection of the correct

probiotics will significantly improve therapy success.


Probiotics become more and more established on the market. Numerous studies

documented their effectiveness. But probiotic therapies are only successful if cor-

rect strains with sufficient bacterial count are applied.

The Deutsche Ärzteblatt 2005 (No. 11 of March 18, 2005) (German Medical News-

paper) wrote:

“The effectiveness of selected probiotic strains in the scope of prophylaxis and the-

rapy of chronic inflammatory, infectious and allergic diseases has been documented

by prospective, controlled studies. The recurrence rate of Colitis ulcerosa (E.coli Nissle

1917) as well as the occurrence of pouchitis after colectomy is reduced by the probi-

otic mixture VSL#3. Lactobacillus rhamnosus GG as well as saccharomyces boulardii

are effective in treatment and prevention of infectious diarrhoea in childhood and

antibiotic associated diarrhoea. For small children Lactobacillus rhamnosus GG has

preventive effects in regard to the development of allergic symptoms. Mode of ac-

tion and pharmacokinetics are not explained. This as well as the low amount of stu-

dies with a prevailingly small number of cases allows no general recommendation

of probiotics in case of the listed diseases yet. Nevertheless probiotics can be recom-

mended as effective alternative in individual cases .....”

Research in the field of probiotics was able to answer a lot of questions. The num-

ber of studies has increased significantly. By selecting the correct probiotics an-

tibiotic-associated diarrhoea can be reduced by 95 %, Mast cell stabilization and

reduction of inflammatory cytokines considerably minimized inflammatory mu-

cosa reactions. Modern multi-strain probiotics are able to counteract increased

intestinal permeability or prevent the infant allergies.


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With the aid of stool flora findings and supplementary parameters one can decide

whether probiotic therapies are sensible for individual persons and which bacteria

strains (which probiotic) will be most effective. Without respective pre-diagnos-

tics this is hardly possible.

Furthermore there will be indications of maldigestion or malnutrition, which will

help the patient to fight these by substitution or dietary measures.

In addition there might be evidence of superficial or invasive mucosa irritations,

which need further diagnostic clarification.

Summary:

Intestinal microbiota analyses are procedures, which have been applied for a long

time, and which still make sense today. Even if many former statements of authors

are not maintainable any longer, it nevertheless offers the opportunity to be used

as basis for subsequent therapies.


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Shipping Problems / Sample Stability

When shipping stool samples the following points should be taken into

consideration:

Stool samples should not be older than 2 days (maximum) and should be stored

in the fridge. Heat or frost has to be avoided under all circumstances, as they con-

siderably influence the microbiota. There has to be enough stool*) to provide for

anaerobic conditions inside of the sample container.

(*Filling volume at least 50%, better 75 %)

These conditions assumed, cultivation methods will be able to provide reliable in-

formation about 30-40% of the microbiota – which can be the basis of necessary

therapies. Respective analyses concerning sample stability are available.

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Modern Stool Diagnostics at biovis

Motivated by new insights and steadily improving studies we have decided to revi-

se our stool diagnostic spectrum and to offer new indication specific profiles.

Basic Probiotic Profile

The basic probiotic profile is a low cost introduction to modern stool diagnostics.

All information necessary to provide effective, well-aimed therapies are taken into

consideration. Following factors are included:

· Age and weight of patient

· Ratio of putrefactive and acidification flora

· Potential pathogenic agents

· Yeasts and clostridia

· Activity degree of the mucosa immune system

· Indication of microscopic colitis

· Indication of Leaky Gut

· Influence of stress or food intolerances

S t o o l P r o f i l e I n d i c a t i o n s P r o b i o t i c C r i t e r i a

Basic Profil Probiotics OptimazationProbiotic Therapy

(Competitive Introductory Profile)

Flora Status

Antitrypsin

sIgA

Histamine (Testset)

Zonulin (optional)

Microbiota Alterations

Microskopic Colitis

Activity Mucosa Immune System

Stress, NUN* (NAL*, PAR*)

Leaky Gut

Age / Weight of PatientPPO*, CI*, Candida

Inflammations

MIS*

Stress, NUN*

Leaky Gut

*NUN- Food Intolerances, *NAL = Food Allergies, *PAR=Pseudo-allergic Reactions, MIS = Mucosa Immune System, *PPO=Potentially Pathogenic Organism, *Cl=Clostridia

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On the basis of the stool test results commercially available probiotics can be de-

termined. These probiotics were tested in approximately 15 studies. From these

products the ones best suited for the individual patient can be chosen. This pro-

vides for therapeutic success, which cannot be achieved by standard probiotics

without specific indication.

Basic Intestinal Profile

With the aid of our Basic Intestinal Profile – which has already been part of our

spectrum for several years – it is possible to draw conclusions for optimized pro-

biotic therapies. Aside from histamine and zonulin all relevant parameters are

contained. In addition the Basic Intestinal Profile also provides indications about

digestive disorders in the sense of maldigestion or malabsorption or allows con-

clusions about invasive mucosa alterations, which have to be clarified. The Basic

Intestinal Profile is a widely spread profile, which is optimal for clarification of dif-

fuse gastro-intestinal complaints.

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S t o o l P r o f i l e

Flora StatusDigestive ResiduesPancreas Elastase

Bile AcidsAntitrypsin

CalprotectinsIgA

Microbiota AlterationsMaldigestion

Exocrine Pancreas DeficiencyLacking Bile Acid

Microscopic ColitisInvasive Intestinal Diseases

Activity Mucosa Immune System

Age /Weight of PatientPPO*, Cl*, Candida

Inflammations

MIS*

I n d i c a t i o n s P r o b i o t i c C r i t e r i a

Diffuse Gastro-Intestinal Complaints


Basic Intestinal Profile

Basic Profile Stress

The Basic Profile Stress offers everything sensible and possible in the range of stool

diagnostics presently. It contains all relevant factors to recommend those probi-

otics to your patients, which really help. Furthermore it offers all supplementary

parameters of the Basic Intestinal Profile as well as histamine and zonulin. This

profile should before all be applied in case of diseases, which come along with inc-

reased intestinal permeability in their pathogenesis. These are among others auto

immune diseases, like diabetes type 1, celiac disease, rheumatoid arthritis etc.

Basisprofil Klassik


Basic Profile Stress Chronic Stress + CEDAutoimmune Diseases

Flora StatusDigestive ResiduesPancreas Elastase

Bile AcidsAntitrypsin

CalprotectinsIgA

ZonulinHistamine (Test Set)

Stress induced Micro-biota Alterations

See Basic Intestinal ProfileSee Basic Intestinal Profile

Lacking Bile AcidStress Induced Microscopic Colitis

See Basic Intestinal ProfileSee Basic Intestinal Profile

Leaky GutStress Induced Histamine Release

Age /Weight of PatientPPO*, Cl*, Candida

Inflammations

Inflammations

MIS*Leaky Gut

Stress, NUN*

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The Basic Profile Classic is an optimal prevention profile, which should be ap-plied from the 45th year of life once every year. It covers digestion disorders, micro-haemorrhage (intestinal cancer screen), invasive mucosa processes, but also stress-induced mucosa alterations and leaky gut as possible causes of intestinal complaint patterns. Target group for the Basic Profile Classic are all physicians and therapists, who want to offer extensive screens and not only the usual tests (e.g. occult blood in stool).

Flora Status Metabolic

Overweight can partially be caused by predominance of firmicutes compared to

bacteroidetes – an imbalance, which can be verified genetically (firmicutes-bac-

teroidetes-ratio) and for orientation also cultural (flora status metabolic). If there

is such an imbalance, it can be altered effectively with the aid of prebiotics and

probiotics in combination with low-carbohydrate diets. Patients lose weight, es-

pecially in case of additional moderate exercise.


Basic Profile Classic Preventive ProfileIntestinal Prevention 1 x per year

Digestive ResiduesPancreas Elastase

CalprotectinHg/HpZonulin

Histamine (Test Set)

Digestive DisordersExocrine Pancreas DeficiencyInvasive Intestinal Diseases

Intestinal Cancer PreventionLeaky Gut

Stress, NUN* (NAL*,PAR*)

Age /Weight of Patient

Inflammations

Leaky GutStress, NUN*

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Basic Profile Classic


Floras Status Metabolic Overweight

Flora Status (for orientation)Firmicutes-Bacteroidetes-Ratio

Microbiota Alterations Age /Weight of PatientPRO*, Cl*, Candida

Special Indications Recommended Parameter Profiles

Irritable Colon Basic Intestinal Profile Flatulence Basic Intestinal Profile Constipation Basic Intestinal Profile Susceptibility to Infections Basic Intestinal Profile Skin Diseases Basic Intestinal Profile

Allergies, NUN Basic Profile Stress Auto-immune Diseases Basic Profile Stress Diabetes mellitus Basic Profile Stress Celiac Disease Basic Profile Stress Rheumatoid Arthritis Basic Profile Stress Multiple Sclerosis Basic Profile Stress

Inflammatory Intestinal Diseases Basic Profile Stress Chronic Stress Basic Profile Stress Depressions, CFS Basic Profile Stress

Protection against AAD Basic Intestinal Profile or Basic Profile Probiotics Underweight Basic Intestinal Profile or Basic Profile Probiotics

Overweight Flora Status Metabolic Firmicutes Ratio


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To make selection of the suitable stool

profile easier, the table shows a small

variety of special indications:

Diagnostik MVZ GmbH

Justus-Staudt-Straße 265555 LimburgTel.: +49/64 31/2 12 48-0Fax: +49/64 31/2 12 [email protected]

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intestinal flora and stool diagnostics · otic mixture vsl#3. ... mode of ac - tion and...

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