CASE REPORT

Evaluation of Gut Microflora During Administration of an Elemental Diet in a Patient with an Ileoproctostomy M.D. Dickman, PhD, A.R. Chappelka, CAPT MC USN, and R.W. Schaedler, PhD "Elemental diets" have been employed therapeutically for such diverse purposes as treatment in acute pancreatitis (I), protection against the adverse effects of 5-fluorouracil (2), healing of fecal (3) and perianal (4) fistulas, preoperative bowel preparation (5), and nutrition in short bowel syndromes (6). The one beneficial effect of such low-bulk regimens has been attributed to their rapid assimilation in the proximal small bowel. The decreased fecal output observed in patients on these regimens attests to their near total absorption (7, 8). As these diets alter the available substrate in the large and small bowel, the question arises as to whether there are any secondary changes in the small-bowel resident microflora. Previous studies have been confined to the microflora of the large bowel of normal subjects on such diets. While some investigators have reported dramatic decreases and simplification of microflora in such subjects (7), others have observed no change (8, 9). There are, however, no data on the fecal and small-bowel microflora of patients with bowel abnormalities and resections while on such elemental diets. For these reasons, it was decided From the Gastroenterology Division and Clinical Investigation Center, US Naval Hospital, Philadelphia, Pennsylvania, and the Department of Microbiology of the Thomas Jefferson University Medical School, Philadelphia, Pennsylvania. This work was supported by the Department of the Navy Clinical Investigation Program Grant 5-05-439 and in part by #N00014-68-A-0516. The opinions expressed herein are those of the author and are not to be construed as reflecting the views of the Navy Department or of the Naval Service at large. Address for reprint requests: Dr. A.R. Chappelka, U.S. Naval Hospital, Philadelphia, Pennsylvania 19145.

Digestive Diseases, Vol. 20, No. 4 (April 1975)

to monitor the patterns of microflora in the small bowel and feces in a patient with an ileoproctostomy for ulcerative colitis, who exhibited bacterial overgrowth in the small bowel and symptoms of chronic diarrhea.

CASE REPORT W K is a 25-year-old male who had undergone an ileoproctostomy for biopsy-proven ulcerative colitis prior to evaluation at the Philadelphia Naval Medical Center. Sigmoidoscopic examination at the time of admission revealed severe involvement of the rectal segment and changes consistent with ulcerative colitis. He passed an average of 20 liquid stools per day. Subsequently W K developed smallbowel obstruction necessitating lysis of adhesions. Following surgery, his diarrhea persisted. He was placed on Vivonex | for 11 days as a sole dietary regimen in an effort to starve out microflora and hopefully lessen inflammatory changes at the rectal segment. During this time, stool frequency decreased to 5 to 7 bowel movements per day, and the volume of fecal mass decreased. Sigmoidoscopic examination during this period revealed no appreciable reduction in inflammation. After 11 days, the diet proved unpalatable to the patient and he refused further treatment. Following failure of a trial of Azulfidine 2 g/day and prednisone 20 mg/day, surgical correction involving a permanent ileostomy and removal of the rectal stump was performed. Table 1 shows the numbers and types of bacteria in the small bowel of this patient, beginning 6 weeks following surgery for lysis of adhesions. Cultures were obtained before and after Vivonex therapy. These samples were obtained through a nasogastric tube positioned at the ligament of Treitz, or through direct threading of a jejeunal fistula placed for drainage following surgery. Enterobacteriaceae, generally undetectable at this site in control subjects (1012), were present at numbers of 106 to 107 with as many as 4 distinct genera detected. Although this spectrum of microflora suggested that small-bowel stasis was a factor, the colonic anaerobes including clostridia and bacteroides were not detected. It should be emphasized that specimens were taken under strict anaerobic conditions and were immediately transported to the laboratory where all dilutions and platings

377

DICKMAN ET AL TabLe 1. Microflora in the Small Bowel of Patient (WK) with an Ileoproctostomy Aspirates Organisms Total n u m b e r of o r g a n isms/ml Streptococci Staphylococci Yeast

It

2

4

5

Postileostomy

Vivonex* 3i

10 7

10 7

10 7

10 4

10 6

10 2

10 6

10 6

10 6

10 3

10 3

10 2

10 8 10 6

10 8 10 5

10 8

10 4

10 4

101 10 ~

Neisseria Pseudomonas

E. coil E. coil (delayed lactose fermenter) Klebsiella Proteus Lactobacilli Veillonella Fusiforms

10 6

10 6 10 6 10 6 10 6 10 7 10 3

10 7

10 7 10 7 101 10 8 10 6

10 6

10 2 101

Table 2. Microflora in the Feces of Patient (WK) with an Ileoproctoatomy 10 6 10 6 10 6 10 7

10 8

10 3

10 3 10 4

10 4 10 8

Pretreatment specimens

Vivonex* regimen

101

10 ~

* S p e c i m e n 4 w a s o b t a i n e d on t h e 4th d a y of V i v o n e x therapy. S p e c i m e n 5 w a s o b t a i n e d on t h e 11th d a y of V i v o nex therapy. TAll specimens were o b t a i n e d f r o m t h e l i g a m e n t of Treitz e x c e p t n u m b e r s 1 a n d 3, w h i c h w e r e t a k e n by direct i n t u b a t i o n of a jejunal fistula.

were performed on prereduced media within an anaerobic chamber. During administration of the Vivonex diet, the total number of bacteria in the small bowel decreased by 2 logs, and the types of Enterobacteriaceae simplified. However, both E. coli and Klebsiella persisted after 11 days on the regimen and pseudomonas was also detected. Other organisms including lactobacilli, streptococci, and veillonella, transient at this site in normal subjects (12), persisted in the small bowel of this patient. The microflora in the small bowel completely normalized after the creation of a permanent ileostomy (Table 1). Table 2 depicts the numbers and types of bacteria in the feces of W K prior to and during Vivonex administration and in 1 sample of ileostomy effluent. The faeuhative aerobic mieroflora prior to the elemental diet was generally s~milar to that reported for normal subjects (13, 14) and in-

378

cluded coliforms, proteus, and a late lactose-fermenting E. coli strain. Yeast and mixed flora of lactobacilli, streptococci, and veillonella were generally present. Although clostridia were consistently present, bacteroides, the predominant anaerobe in the normal stool(13-15), were undetected in the pretreatment specimens and fluctuated sporadically during Vivonex administration. During severe diarrhea there are often drastic reductions of the strict anaerobes in the bowel with a resultant reversal in the aerobe/anaerobe ratio. Hence, the absence of bacteroides in some specimens from this patient is not surprising. Bacteroides were not recovered from the ileostomy effluent. It should be stressed that during administration of the elemental diet, the total number of bacteria never decreased below 108 organisms per gram of feces, and that by the end of Vivonex treatment, the flora was as complex as before treatment.

{leosOrganisms Total n u m b e r of organisms/g feces Streptococci Staphylococci Yeast

E. coil E. coil ( d e l a y e d lactose fermenter) Klebsiella Proteus Enterobacter NFGR:~ Pseudomonas Bacteroides Clostridia Lactobacilli Veillonella Fusiforms

1

2J-

3t

4

tomy

10 7 10 7

10 8 10 7

10 8 10 8 10 4

10 9 10 8

10 8 10 8

10 5 10 8

10 lo 10 s 10 8 10 3 101~

10 6

10 8

10 9 10 ~

10 8 10 8 101

10 9 10 6

10 4 10 6 10 8

10 7 10 6 10 6 10 4

10 7 10 7 10 6 10 4

10 6 10 9 10 8 10 7

101 10 8 10 7 10 5

10 8 10 6 10 8 10 8 10 6 10 8 10 8 10 4 10 3

* S p e c i m e n 3 was o b t a i n e d on t h e f o u r t h d a y of V i v o nex therapy. S p e c i m e n 4 w a s o b t a i n e d on t h e e l e v e n t h d a y of Vivonex therapy. 1-Obtained at s i g m o i d o s c o p y . ~;Nonfermentative g r a m - n e g a t i v e rods.

Digestive Diseases, Vol. 20, No. 4 (April 1975)

GUT MICROFLORA ON ELEMENTAL DIET DISCUSSION

Previous studies of bacterial changes during administration of elemental diets have been confined to the feces of normal subjects (7-9). In patients on elemental diets showing bowel pathology, bacterologic studies have been neglected and nonbacteriologic monitoring has been confined to colonic drainage (3). The findings in the present study illustrate the effect of one such preparation, Vivonex, on the microflora in a patient with an ileoproctostomy. Although the diet was without bulk, its use did not completely eliminate bacteria from the proximal small bowel, nor did it greatly reduce their numbers in the feces. The persistence of coliforms (Klebsiella and E. coli) in the proximal small bowel, as well as the diverse spectra of bacteria persisting in the stool during treatment, suggest that other factors may have supplemented the nutritional needs of microorganisms. It may be as suggested by one investigator, that sufficient desquamation of gut epithelial cells occurs and provides suitable substrate for microorganisms (8). Likewise, endogenous proteinaceous material secreted into the bowel may also be used as nutrients by microorganisms. Alternatively, significant bowel pathology may so alter normal physiology as to completely offset the beneficial effects of such a diet. It is difficult to compare these data with those of investigators who studied only the feces of normal subjects. Winitz observed that numbers of bacteria in the feces of controls decreased to 103 within 13 days and that rapid simplification in kinds of bacteria occurred, leaving only coliforms, enterococci, and bacteroides (7). The present findings are more consistent with the recent data of Attebery et al (8) and Bounous and Devroede (9), where no decrease in total numbers of bacteria in the feces was observed, and where the spectrum of isolates detected on the diet was greater than that previously described (7). In addition to the absence of radical changes in the alimentary tract microflora, the patient's Digestive Diseases, Vol. 20, No. 4 (April 1975)

stool frequency, although decreased, remained abnormal. Despite references in the literature to the minimal numbers of stools passed by normal subjects on the diet (7-9), W K continued to pass at least 5 watery stools per day. More importantly, no reduction in inflammation was apparent at the diseased rectal stump. Despite early claims that the diet is palatable, W K could tolerate it no longer than 11 days, at which time it was terminated. These data indicate that in a patient with inflammatory bowel disease and an ileoproctostomy despite a 2 log decrease in bacteria, neither complete normalization of small-bowel microflora, nor reduction in fecal microflora followed administration of an elemental diet. REFERENCES

1. Voitk AJ, Brown RA, McArdle AH, Hinchey E J, Gurd FN: Clinical uses as an elemental dietpreliminary studies. Can Med.Assoc J 107:123129, 1972 2. Bouonos G, Gentile JM, Hogan J: Elemental diet in the management of the intestinal lesion produced by 5-fluorouracil in man. Can J Surg 14:312-324, 1971 3. Bode MM, Hendren WH: Healing of faecal fistula initiated by synthetic low-residue diet. Lancet 1:954, 1970 4. Bury KD, Stephens RV, Randall HT: Use of a chemically defined liquid, elemental diet for nutritional management of fistulas of the alimentary tract. Am J Surg 121:174-183, 1971 5. Records and Reports, Mead Johnson Research Center (Cited in Flexical Physicians Handbook: 1971) 6. Thompson WR, Stephens RV, Randal HT: Use of the "space diet" in the management of a patient with extreme short bowel syndrome. Am J Surg 117:449-458, 1969 7. Winitz M, Adams RF, Seedman DA: Studies in metabolic nutrition employing chemically defined diets. Am J Clin Nutr 23:546-559, 1970 8. Attebery HR, Sutter VL, Finegold SM: Effect of a partially chemically defined diet on normal human fecal flora. Am J Clin Nutr 25, 1391-1398, 1972 9. Bounous G, Devroede G J: Effects of an ele379

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mental diet on human fecal flora. Gastroenterology 66:210-214, 1974 10. Draser BS, Shiner M, McLeod GM: Studies on the intestinal flora I. Gastroenterology 56:7179, 1969 11. Gorbach SL, Plaut AG, Nahas L, Weinstein L, Spanknebel G, Levitan R: Studies of intestinal microflora II. Gastroenterology 53:856-867, 1967 12. Diekman MD: The gut microflora in health and disease. PhD dissertation, The Graduate School,

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Thomas Jefferson University, Philadelphia, Pennsylvania, 1973 13. Zubrzycki L, Spaulding EH: Studies on the stability of the normal human fecal flora. J Bacteriol 83:968-974, 1962 14. Gorbaeh SL, Nahas L, Lerner PI, Weinstein L: Studies of the intestinal microflora I. Gastroenterology 53:845-855, 1967 15. Eggerth AH, Gagnon BH: The bacteroides of human feces. J Bacteriol 25:389-413, 1933

Digestive Diseases, Vol. 20, No. 4 (April 1975)

Evaluation of gut microflora during administration of an elemental diet in a patient with an ileoproctostomy.

CASE REPORT Evaluation of Gut Microflora During Administration of an Elemental Diet in a Patient with an Ileoproctostomy M.D. Dickman, PhD, A.R. Chap...
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