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Aerobic jejunal fluid bacteria in patients with gastrointestinal disorders.

Sir,

The gastrointestinal bacterial flora plays an important role in protecting against colonization by invasive pathogens. The entire length of small intestine is microbiologically sparse, being transiently colonized by Gram positive species commonly found in mouth. The degree of bacterial colonization of human small intestine increases with increasing distance from the stomach. The rapid flow of digestive juices and low pH of duodenum both play a part in keeping the bacterial number low. The bacteria that survive the gastric juice reach the duodenum and upper jejunum. Under normal conditions, jejunum may be bacteriologically sterile or low concentration of enterobacteriaceae may be detected in the jejunum of about 10 per cent of healthy adults. Thus jejunal population is sparse and predominantly aerobic floral. Clinical conditions known to favour bacterial growth in small bowel include biliary tract infection, Crohn's disease and hepatic cirrhosis. Abnormal jejunal flora may also be the result of disturbed physical conditions in intestine such as abnormal intestinal fluid pH / composition, improper peristaltic movement, etc. We conducted this study to determine the jejunal fluid bacterial profile in patients with various gastrointestinal disorders and compare it with their faecal isolates.

One hundred consecutive patients suffering from various gastrointestinal diseases attending the Gastroenterology Clinic of Postgraduate Institute of Medical Education & Research, Chandigarh, India, between February 2000 to April 2003, were included in the study. There were 58 males and 42 females with age range of 18-70 yr. The gastrointestinal ailments were epigastric pain, haematemesis, irritable bowel syndrome, reflux diseases, dysphagia, duodenal ulcer, dyspepsia, jaundice, pancreatitis, melena and others.

Jejunal fluid aspirates were collected from all the patients by an enteroscope and a sterile catheter system (Devon Innovations, Bangalore, India). Faecal samples were obtained from 77 patients in sterile stool containers (Stericol Vials, Hi Media, India) or as rectal swabs. The protocol was approved by the Institute's Ethical Committee. All specimens were immediately inoculated into the Selenite F broth, MacConkey agar, Bismuth sulphite agar and xylose lysine deoxycholate agar. Incubation of the agar and broth medium was made for 24 h at 37[degrees]C aerobically. Subcultures were made from Selenite F broth onto the above solid media. In plates showing no growth, the incubation was carried out for another 24 h. Colonies grown were identified by standard biochemical tests (2).

Fifty nine (59%) of the jejunal fluid samples yielded bacterial flora. Pure bacterial isolates were obtained from 45 of the positive samples, whereas the remaining 14 had more than one kind of organisms. The predominant organisms were Pseudomonas aeruginosa (26%), Serratia marcescens (11%), Klebsiella sp (9%) and Acinetobacter (8%). Other organisms were Proteus sp. Enterobacter, Escherichia coli, Citrobacter, Salmonella and Staphylococcus aureus and Streptococcus (Table). The salmonella species isolated were S. Typhi, S. Paratyphi A and S. Choleraesuis in one each of the samples.

Of the 77 faecal samples tested, 66 (85.7%) showed non significant growth. Salmonellae grew in only 2 samples (S. Typhi and S. Paratyphi). Other organisms that grew as pure/predominant growth were E. coli in 4, P. aeruginosa in 3 and Enterobacter sp in one sample. In seven cases both jejunal fluid and faecal samples were positive for the same microorganisms. Similar finding was reported earlier in south Indian infants with acute gastroenteritis (3). Faecal sample could not be obtained from a patient who had S. choleraesuis in the jejunal fluid. The presence of three different salmonellae isolates from the jejunal samples could be a chance finding probably secondary to transient intestinal carriage.

Malabsorption of fat due to bacterial deconjugation of bile acids may result in malnutrition. Small bowel bacterial overgrowth syndrome may be an underappreciated cause of malnutrition, especially in the elderly. Bacterial overgrowth in segments of the intestinal tract not normally inhabited by high loads of microbes is implicated in the pathogenesis of diverse clinical problems such as biliary tract infection, spontaneous bacterial peritonitis complicating cirrhosis, exacerbations of inflammatory bowel diseases and infections that complicate major trauma or surgery (4,5). Clinical features of small bowel bacterial overgrowth are abdominal discomfort, bloating sensation and diarrhoea. Among the pathogens that cause opportunistic infections or small bowel diarrhoea, the microorganisms isolated were S. aureus, P. aeruginosa and K. pneumoniae. Infact P. aeruginosa, was the predominant bacterial isolate grown in 26 per cent of the jejunal samples. Three of these patients also had P. aeruginosa isolated from their stool samples in predominant numbers. P. aeruginosa is known to cause significant morbidity and mortality in immunocompromised hosts, particularly neutropenic cancer patients. Gastrointestinal colonization with P. aeruginosa and subsequent translocation leads to bacteraemia and sepsis.

Abnormality of the jejunal flora may be mainly due to conditions such as strictures, adhesions, surgery and diabetic neuropathy (6), which delay the passage of material. Five of our patients had oesophageal strictures, one each had carcinoma and diabetes mellitus.

Another reason could be the intake of antibiotics and/or other medication. Nearly all antibiotics have been implicated in the suppression of some component of the microflora. Antibiotics have been shown to facilitate the selection of resistant mutants and in vivo acquisition of resistant plasmids by salmonellae (7). Though our patients had no history of antibiotic intake, it could have contributed to the disruption of the finely tuned and stable gut flora due to over-the-counter availability or due to earlier prescriptions.

Abnormalities of the stomach function may result from achlorhydria which may inhibit the destruction of the ingested microbes. Sharma et al (8) showed that a single dose of omeprazole may inhibit gastric acidity by 90 per cent over a full day's course. Shindo et al (9) reported jejunal bacterial overgrowth in patients treated with omeprazole,. We had 27 per cent patients who were diagnosed to have gastroesophageal reflux disease. Dyspepsia was also seen in 12 per cent of the patients.

In conclusion, our study showed a change in the bacterial growth of the jejunal fluid in patients with gastrointestinal disorders though a transient carriage of pathogenic organisms in apparently healthy individuals may also occur. Healthy controls could not be included in our study for ethical reasons which otherwise would have provided authentic comparative information.

Acknowledgement

Authors acknowledge the Indian Council of Medical Research, New Delhi, for financial support, and thank Shri Baljit Singh and Ms. Manpreet Kaur for technical assistance.

Chetana Vaishnavi, * Satnam Singh & Rakesh Kochhar

Department of Gastroenterology

Postgraduate Institute of Medical Education & Research

Chandigarh 160012, India

* For Correspondence

e-mail: cvaishnavi@rediffmail.com

References

(1.) Gregg CR, Toskes PP. Enteric bacterial flora and small bowel bacterial overgrowth syndrome. In: Feldman M, Friedman LS, Sleisenger MH, editors, Sleisenger & Fordtran's gastrointestinal and liver disease, 7th ed., vol.2. Philadelphia: Saunders Publication, 2002.

(2.) Collee JG, Miles RS, Walt B. Tests for the identification of bacteria. In: Collee JG, Fraser AG, Marmion BP, Simmon A, editors, Mackie & McCartney practical microbiology, New York: Churchill Livingstone, 1996 p. 131-49.

(3.) Albert MJ, Bhat P, Rajan D, Maiya PP, Pereira SM, Mathan M, et al. Jejunal microbial flora of southern Indian infants in health and with acute gastroenteritis. J Med Microbiol 1978; 11 : 433-40.

(4.) Chang C-S, Chen G-H, Lien H-C, Yeh H-Z. Small intestine dysmotility and bacterial overgrowth in cirrhotic patients with spontaneous bacterial peritonitis. Hepatology 2003; 28 : 1187-90.

(5.) Abell TL, Minocha A. Gastrointestinal complications of bariatic surgery: diagnosis and therapy. Am J Med Sci 2006; 331 : 214-8.

(6.) Sosnowski KM. Normal gastrointestinal tract flora. Gastrointestinal tract specimens. In: Dalton HP, Nottebart HC editors, Interpretive medical microbiology; 1986 p. 486-90.

(7.) Aserkoff B, Bennett JV. Effect of antibiotic therapy in acute salmonellosis on the faecal excretion of salmonellae. N Engl J Med 1969; 281 : 636-40.

(8.) Sharma BK, Walt RP, Pounder Re, Gomes MD, Wood EC, Logan LH. Optimal dose of oral omeprazole for maximal 24 hour decrease of intragastric acidity. Gut 1984; 25 : 957-64.

(9.) Shindo K, Yamazaki R, Koide K, Fukumura M, Hirai Y. Alteration of bile acid metabolism by cimetidine in healthy humans. J Investig Med 1996; 44 : 462-9.
Table. Distribution of aerobic bacterial isolates from jejunal fluid
and faecal samples

Bacterial isolates Jejunal fluid Faecal samples
 (n= 100) (n=77)

Escherichia coli 3 4
Citrobacter sp 3 0
Salmonella sp 3 2
Proteus sp, 5 1
Enterobacter sp 4 1
Staphylococcus sp 1 0
Acinetobacter sp 8 0
Pseudomonas aeruginosa 26 3
Serratia marcescens 11 0
Klebsiella sp, 9 0
Streptococcus sp 1 0
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Author:Vaishnavi, Chetana; Singh, Satnam; Kochhar, Rakesh
Publication:Indian Journal of Medical Research
Article Type:Letter to the editor
Geographic Code:9INDI
Date:Jul 1, 2007
Words:1382
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