Combination Therapy with Bifidobacterium breve, Lactobacillus casei, and. Galactooligosaccharides Dramatically. Improved the Intestinal Function in a Girl.
Digestive Diseases and Sciences, Vol. 46, No. 9 (September 2001), pp. 2010 –2016 (© 2001)
CASE REPORT
Combination Therapy with Bifidobacterium breve, Lactobacillus casei, and Galactooligosaccharides Dramatically Improved the Intestinal Function in a Girl with Short Bowel Syndrome A Novel Synbiotics Therapy for Intestinal Failure YUTAKA KANAMORI, MD,* KOHEI HASHIZUME, MD,* MASAHIKO SUGIYAMA, MD,* MASAMI MOROTOMI, PhD,† and NORIKATSU YUKI† KEY WORDS: synbiotics; short bowel syndrome; bacterial overgrowth syndrome.
It has been well known since ancient times that fermented milk produces beneficial effects on the consumer’s health. In the last few decades, these beneficial effects have been demonstrated to be due to the metabolic action of some bacterial species, including lactobaccilli, bifidobacteria, and streptococci (1–3). Lilly et al. first introduced the term probiotics for such bacteria in 1965 (4). Probiotics are widely used as a live microbial feed supplement that beneficially affects the host animals by improving their intestinal microbial balance (5). Additionally the term prebiotics has been adopted to refer to a nondigestive food ingredient that selectively targets the growth and/or activity of one or a limited number of bacteria in the colon and, thus, has the potential to improve host health. Several types of ingredients, such as fructooligosaccharides, galactooligosaccharides, and inulin, are used as prebiotics (2, 6). Furthermore, the combined use of probiotics and prebiotics is called synbiotics therapy, but few reports concerning synbiotics have been published (7, 8). Short bowel syndrome refers to seriously adverse symptoms that are seen in patients who have been Manuscript May 30, 2000; accepted November 1, 2000. From the *Department of Pediatric Surgery, Faculty of Medicine, University of Tokyo, and †Yakult Central Institute for Microbiological Research, Tokyo, Japan. Address for reprint requests: Yutaka Kanamori, Department of Pediatric Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
2010
subjected to a massive bowel resection. These patients are usually malnourished and have a dilated intestine that results in intestinal bacterial overgrowth syndrome (9, 10). Regulation of intestinal bacterial overgrowth, especially pathogenic bacterial overgrowth, is very important in patients with short bowel syndrome to attain any improvement in intestinal function. For this purpose, various antibiotics have been used to eliminate the intestinal bacteria selectively. An alternative strategy for regulating intestinal bacteria is to apply probiotics and/or prebiotics. In this report, we report the use of synbiotics therapy in the treatment of a 4-year-old girl suffering from short bowel syndrome. For the synbiotics therapy, we used Bifidobacterium breve, Lactobacillus casei, and galactooligosaccharides. This novel combination therapy was expected to act synergistically for the improvement of the subject’s health. We found that the patient’s intestinal absorptive function and motility were dramatically improved by this newly designed synbiotics therapy, and she progressed satisfactorily after 2 years of the therapy. Following the case report, we discuss the beneficial effects of the new synbiotics therapy for intestinal failure. CASE REPORT The patient was diagnosed with gastroschisis as a fetus and delivered by cesarean section in 1994. After delivery, Digestive Diseases and Sciences, Vol. 46, No. 9 (September 2001)
0163-2116/01/0900-2010$19.50/0 © 2001 Plenum Publishing Corporation
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Fig 1. The clinical course of the patient as defined by changes in body weight and serum choline esterase levels before and after the start of the synbiotics therapy. Body weight gain was dramatically accelerated after starting the synbiotics therapy. The serum choline esterase value also increased after the commencement of synbiotics therapy. On the other hand, the episodes of repetitive high fever attacks (E) and severe metabolic acidosis (‚) ceased abruptly soon after the introduction of synbiotics treatment.
she underwent surgery to repair the abdominal wall defect on the same day. Multiple intestinal perforations and severe adhesions between the intestinal tracts indicated the need for a massive intestinal resection, resulting in a residual small intestine of 25 cm. The patient survived the procedure, recovered from the acute phase of short bowel syndrome, and progressed for 2 years. She received an elemental formula diet and intravenous hyperalimentation simultaneously, but her height and body weight were not within normal values for her age, as judged by the standard growth curve of Japanese girls. In addition, she suffered repetitive high fever attacks and severe metabolic acidosis at least once a month (Figure 1). These symptoms were considered to be caused by enterocolitis resulting from a bacterial overgrowth of the intestine and/or a central venous catheter sepsis. Therefore, we decided to discontinue the use of a central venous catheter, and, to control the bacterial overgrowth, we began the administration of synbiotics orally. The synbiotics used consist of the three agents: Bifidobacterium breve Yakult (BBG-1) (11), Lactobacillus casei Shirota (BIOLACTIS Powder) (12), and galactooligosaccharides (Oligomate HR). These bacteria and oligosaccharides were developed and supplied by the Yakult Central Institute, Japan. Each 1.0-g pack of Bifidobacterium breve and Lactobacillus casei included more than 1 ⫻ 109 bacteria, respectively, and we administered these agents at 3.0 g per day. Galactooligosaccharides were also administered at 3.0 g per day. We monitored the growth of the patient through body weight and blood tests. In addition, we performed periodic abdominal X-rays. Fecal samples were collected from the patient every month and sent to the Yakult Central Institute for analysis of fecal bacterial flora and shortchain fatty acid content (13). To maintain strict anaerobic conditions, the fecal samples were collected as soon as the patient passed them and kept in an anaerobic clean bottle at 4°C. Prior to commencement of the synbiotics therapy, the Digestive Diseases and Sciences, Vol. 46, No. 9 (September 2001)
patient’s fecal bacterial flora was quite abnormal, with very few detectable anaerobic bacteria (Table 1). After 1 month of synbiotics therapy, her feces contained a large number of the administered probiotics and another species of bifidobacteria and lactobacilli (Table 1). The administered bacteria, Bifidobacterium breve and Lactobacillus casei, were distinguished from other species using two methods. The first method is to use selective culture media, TCBPC agar and LLV agar, which are suitable for the administered Bifidobacterium breve and Lactobacillus casei to proliferate, respectively. The second method is to ascertain whether or not the colony forming bacteria are administered probiotics by using monoclonal antibodies that specifically recognize Bifidobacterium breve and Lactobacillus casei (11, 12). We consider it very important to distinguish the probiotics from other species of bifidobacteria and lactobacilli to verify that the administered probiotics actually proliferated in the intestine to provide beneficial effects to the patient. The levels of E. coli and Candida were very high in the feces, more than 1 ⫻ 109 in 1.0 g wet feces, prior to treatment. However, they gradually decreased after starting the synbiotics therapy (Table 1). Furthermore, the ratio of facultative anaerobic bacteria to total bacteria was very high before the treatment, but their ratio was dramatically reduced after the synbiotics therapy (Table 1). These observations demonstrate that the ability of the intestine to protect bacterial infections, the intestinal colonization resistance, was reinforced by synbiotics therapy. The profile of fecal short-chain fatty acids was very abnormal before the synbiotics treatment. The levels of lactic acid contents were very high compared to those of other acids, such as acetate, propionate, and butyrate (Table 2). Indeed, the level of lactate in the feces continued to be high throughout the treatment periods (Table 2). However, the patient never experienced severe acidosis after starting the treatment. From this result, we believe that the large percentage of lactate in her feces after the commencement of
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2012
10.85 11.15 11.10 10.98 10.88 10.67 10.26 9.66 9.70 9.78 10.30
Before treatment 1 2 3 4 6 7 9 11 14 19
10.32 9.06 9.16 8.83 9.16 8.62 7.66 6.70 3.34 8.11 8.56
Facultative anaerobic bacteria 29.7 0.814 1.148 0.708 1.91 0.892 ⬍0.01 ⬍0.01 ⬍0.01 2.14 1.82
Aerobes/total bacteria (%)† N.D. 4.43 7.20 8.60 9.49 N.D. N.D. N.D. N.D. N.D. N.D.
Bacteroides
OF THE
N.D. 10.61 8.34 10.39 7.30 10.40 9.29 5.95 2.60 7.12 7.75
B. breve
AND
N.D. 8.70 6.73 7.87 7.41 6.89 6.38 5.95 4.73 5.45 8.05
L. casei
FECES BEFORE THE
6.91 11.04 10.90 10.19 9.25 9.00 8.48 7.48 7.65 9.30 9.74
OF
N.D. 9.02 9.07 9.37 9.03 9.20 9.78 9.39 8.99 8.88 8.62
Lactobacilli¶
COMMENCEMENT
Bifidobacteria‡
AFTER
9.20 8.43 8.35 7.97 8.08 7.82 7.35 6.58 3.00 8.09 7.90
E. coli
9.9 N.D. 8.27 7.88 8.68 6.99 N.D. N.D. 2.78 7.13 8.09
Strepto and enterococci
SYNBIOTICS*
2.78 N.D. N.D. N.D. 3.89 2.78 N.D. N.D. N.D. N.D. N.D.
Staphylococci
9.36 8.50 8.18 8.81 7.43 5.75 7.37 5.79 2.60 N.D. 2.60
Candida
*Bacterial number is expressed as log 10 per 1.0 g wet feces. N.D., corresponding bacteria were not detected In our culture system. †Ratio of total facultative anaerobic bacteria to total bacteria. Total anaerobic bacteria were caliculated by serial dilution cultures of feces in VLM medium under strictly anaerobic conditions. Total facultative anaerobic bacteria were also caliculated by serial dilution cultures in TSA medium. ‡Bifidobacteria other than administered B. breve, which were detected by culture in MNP medium. ¶Lactobacilli other than administered L. casei, which were detected by culture in LBS ager gel.
Total bacteria
Treatment period (months)
TABLE 1. BACTERIAL FLORA
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Digestive Diseases and Sciences, Vol. 46, No. 9 (September 2001)
A NOVEL SYNBIOTICS THERAPY TABLE 2. SHORT-CHAIN FATTY ACIDS
IN THE
FECES BEFORE
AND
AFTER
THE
COMMENCEMENT
OF
SYNBIOTICS
Treatment period (months)
Lactate* Acetate, propionate, and butyrate* Lactate/acetate ⫹ propionate ⫹ butyrate
Before treatment
1
2
3
4
6
7
9
11
14
19
47.54 16.22 2.93
62.60 73.30 0.85
12.09 33.48 0.45
103.45 64.78 1.60
19.06 34.33 0.56
84.24 96.33 0.87
127.44 64.09 1.99
85.44 8.65 9.88
50.40 53.20 0.95
6.50 6.50 0.065
0 36.52 0
*The short-chain fatty acids contents are given as mol/1.0 g wet feces.
synbiotics was L-lactate that replaced D-lactate, which is thought to cause severe lactic acidosis. The clinical course of the patient after the introduction of synbiotics was very satisfactory. She experienced a high fever attack soon after starting synbiotics therapy, but after that initial episode, the patient never suffered from either a high fever attack or metabolic acidosis (Figure 1). Abdominal X-rays, taken periodically, clearly showed that the abnormal intestinal dilatation, seen in 1996 and 1997, gradually improved ac-
cording to the synbiotics therapy, suggesting a restoration of her intestinal motility (Figure 2). The patient’s bowel movements were also restored after synbiotics therapy. Body weight gain was dramatically accelerated after the commencement of therapy. The values of rapid turnover proteins (prealbumin, transferrin) (data not shown) and choline esterase in the serum increased in proportion to the body weight gain, clearly demonstrating a nutritional improvement serologically (Figure 1). The patient became
Fig 2. Abdominal roentogenograms taken periodically from age 2 to age 5 years. Synbiotics therapy was introduced at the age of 3 years 3 months. Prominently dilated intestinal loops gradually disappeared after the commencement of start the synbiotics therapy. (a) Taken at 2 years 4 months; (b) taken at 2 years 7 months; (c) taken at 3 years 3 months; (d) taken at 3 years 11 months; (e) taken at 4 years 6 months; (f) taken at 5 years 2 months. Digestive Diseases and Sciences, Vol. 46, No. 9 (September 2001)
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KANAMORI ET AL able to eat an ordinary diet with her parents, and after 1 year of therapy, she stopped taking an elementary formula diet.
DISCUSSION We have reported a case involving a patient with short bowel syndrome that showed a dramatic improvement of intestinal function and motility through the use of a newly designed synbiotics therapy. Patients with short bowel syndrome often suffer from high fever attacks in the late phase due to central venous catheter sepsis and severe enterocolitis, which are often caused by bacterial overgrowth in the dilated and dysmotile intestine. Catheter sepses are considered to be induced not only by bacterial invasion via the skin route, but also by bacterial translocation from the intestinal lumen to the systemic circulation. This is especially true in patients with short bowel syndrome (14). Bacterial translocations have been demonstrated in compromised patients with severe trauma (15) and in postoperative patients (16). In addition, the bacterial overgrowth in the dilated intestine is also accepted as a cause of bacterial translocation. This pathological status is also called bacterial overgrowth syndrome (17) and is often experienced in patients with short bowel syndrome (9, 10). Furthermore, the overgrown bacteria may produce a large amount of D-lactate, which is absorbed and results in D-lactate acidosis in patients with short bowel syndrome (18 –20). The patient reported here had suffered from repetitive high fever attacks and severe metabolic acidoses upon reaching 2 years old, and her nutritional state was quite deteriorated (Figure 1). She had no spontaneous bowel movement and she was dependent on an enema every day. The fecal bacterial flora was investigated for the presence of a pathogenic bacterial overgrowth in the intestine. The fecal bacterial flora of the patient was demonstrated to be quite abnormal, as shown in Table 1. Very few anaerobic bacteria were detected, while facultative anaerobic bacteria were detected at high levels in the patient. This result is in contrast to the intestinal bacterial flora in normal children at this age, which show an anaerobic bacteria dominant profile (21). The ratio of the number of total facultative anaerobic bacteria to that of total bacterial is considered to be a useful index to represent the protective ability of the intestine from bacterial infection. This protective ability is called colonization resistance (22). This index in the patient examined here was very high, suggesting that she was very susceptible to enterocolitis (Table 1).
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From these clinical symptoms and abnormal intestinal bacterial flora, we concluded that the patient suffered from the bacterial overgrowth syndrome, and we decided to apply synbiotics therapy to the patient. Currently, probiotics and prebiotics are widely accepted as a treatment for patients with antibiotic induced diarrhea (3) and enterocolitis due to rota virus infection (23) or other pathogenic organisms (24). However, there are few reports that apply these living bacteria to patients with intestinal failure. We believe that patients with intestinal failure are good candidates because they have been administered antibiotics very often and are frequently assigned a restricted oral intake due to severe infection, and they are expected to have quite abnormal bacterial flora and suffer from the overgrowth of pathogenic bacteria in the intestine. Indeed, some reports have commented that the selective decontamination of pathogenic bacteria by antibiotics in patients with bacterial overgrowth syndrome was effective (25). However, such an approach has a strong risk of producing antibiotic-resistant bacteria, such as methycillinresistant Staphylococcus aureus and vancomycinresistant enterococcus (26). In contrast, probiotic and prebiotic treatments aim to regulate bacterial overgrowth by several mechanisms, such as the competition for nutrients between bacteria and the production of antibacterial substances (1–3). These sophisticated regulatory systems produced by probiotics are expected to be more beneficial to seriously ill patients. Many probiotics are used throughout the world, such as Bifidobacterium, Lactobacillus, Streptococcus, and Saccharomyces (1–3, 5, 7, 8). Among these bacteria, we adopted two living bacteria for use here, Bifidobacterium breve and Lactobacillus casei. These bacterial species were established several decades ago at the Yakult Central Institute and have a relatively long history of application to humans. Moreover, they are thought to be very safe bacteria because no severe complications have been reported. In addition, their use has a specific advantage in that they have specific monoclonal antibodies that are used for their detection by immunological techniques (11, 12). In our patient, the administered probiotics were easily detected at high levels in the feces. From these data, we strongly suggest that the probiotics therapy truly affected the intestinal functions. Various desirable effects of probiotics on the host have been reported. Probiotics have the ability to suppress the proliferation of pathogenic bacteria by nutrient competition and to produce large amounts of Digestive Diseases and Sciences, Vol. 46, No. 9 (September 2001)
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short-chain fatty acids in the intestine. Short-chain fatty acids have been demonstated to possess many beneficial effects for the intestinal epithelium and intestinal motility (27, 28). Furthermore, the probiotics are believed potentially to upregulate the immune system, especially for resistance to bacterial infection (1–3). In the case reported here, the nutritional state of the patient was dramatically improved (Fig. 1), and the pathogenic bacterial overgrowth in the intestine was suppressed (Table 1). Two years after the synbiotics therapy, the patient’s fecal bacterial flora was anaerobic bacteria dominant, and the proliferation of pathogenic bacteria, such as E. coli and Candida, was suppressed (Table 1). These beneficial effects were attained through improvement of the intestinal motility and through upregulation of the intestinal immune system through the actions of the probiotics, as described in this section. The galactooligosaccharides not only were a substrate for the administered bacteria, but also were a good substrate for the few residing bifidobacteria and lactobacilli in the intestine because many bifidobacteria and lactobacilli species other than these administered probiotics were detected in the feces after the synbiotics therapy. Therefore, administered galactooligosaccharides also played a very important role as a prebiotic in the improvement of the intestinal function of the patient. Short-chain fatty acids, such as acetate, propionate, and butyrate, are thought to play various important roles in in the large bowel. They are thought to stimulate proliferation of the intestinal epithelium (29), to stimulate intestinal motility (30), and to stimulate excretion of pancreatic enzymes (31). These short-chain fatty acids are the end products of the normal bacterial fermentation of carbohydrates arriving in the large bowel (27). If the fermentation of carbohydrates by intestinal bacteria is impaired, acetate, propionate, and butyrate levels decrease in the intestine, whereas the levels of intermediate products of impaired fermentation, such as lactate, increase. This increase in intermediate products results in the induction of various undesirable conditions. In the case reported here, the feces of the patient contained very high levels of lactate before and after the synbiotics therapy (Table 2). These high levels of lactate suggested that the impaired fermentation of the unabsorbed carbohydrates continued in the colon by the colonic-residing bacteria. However, the increased levels of lactate produced in the colon after synbiotic treatment might consist of L-lactate rather than DDigestive Diseases and Sciences, Vol. 46, No. 9 (September 2001)
lactate. We suggest this switch from two observations. First, the severe acidosis that was experienced often before treatment was never experienced after treatment. Second, Bifidobacterium breve and Lactobacillus casei are known to produce L-lactate only (data not shown), and these administered bacteria resided very efficiently in the colon of the patient. Additionally, judging from our case, L-lactate does not seem to have the same adverse effects to the intestinal function as D-lactate, even though it, exists at high levels in the intestinal lumen. Together, these results suggest that the synbiotic therapy designed by us, using the two types of probiotics (Bifidobacterium brevs and Lactobacillus casei) and the prebiotic (galactooligosaccharides), is a very effective and promising treatment for patients with short bowel syndrome. REFERENCES 1. Fuller R: Probiotics in human medicine. Gut 32:439 – 442, 1991 2. Fuller R, Gibson R: Modification of the intestinal microflora using probiotics and prebiotics. Scand J Gastroenterol 32 (Suppl 222):28 –31, 1997 3. Vanderhoof JA, Young RJ: Use of probiotics in childhood gastrointestinal disorders. J Pediatr Gastroenterol Nutr 27:323–332, 1998 4. Lilly D, Stillwell RJ: Probiotics; Growth promoting factors produced by microorganisms. Science 147:747–748, 1965 5. Fuller R: A review: Probiotics in man and animals. J Appl Bacteriol 66:365–378, 1989 6. Gibson GR, Beatty ER, Wang X, Cummings JH: Selective stimulation of Bifidobactera in the human colon by oligofructose and inulin. Gastroenterology 108:975–982, 1995 7. Gibson GR, Roberfroid MB: Dietary modulation of the human colonic microbiota: Introducing the concept of prebiotics. J Nutr 125:1401–1412, 1995 8. Colins MD, Gibson GR: Probiotics, prebiotics, and synbiotics: Approaches for modulating the microbial ecology of the gut. Am J Clin Nutr 69 (Suppl):1052S–1057S, 1999 9. Kaufman SS, Loseke CA, Lupo JV, Young RJ, Murray ND, Pinch LW, Vanderhoof JA: Influence of bacterial overgrowth and intestinal inflammation on duration of parenteral nutrition in children with short bowel syndrome. J Pediatr 131:356 –361, 1997 10. Vanderhoof JA, Young RJ, Murray N, Kaufman SS: Treatment strategies for small bowel overgrowth in short bowel syndrome. J Pediatr Gastroenterol Nutr 27:155–160, 1998 11. Kitajima H, Sumia Y, Tanaka R, Yuki N, Takayama H, Fujimura M: Early administration of Bifidobacterum breve to preterm infants: Randomised controlled trial. Arch Dis Child 76:101–107, 1997 12. Yuki N, Watanabe K, Mike A, Tagami Y, Tanaka R, Ohwaki M, Morotomi M: Survival of a probiotic, Lactobacillus casei strain Shirota, in the gastrointestinal tract: Selective isolation from faeces and identification using monoclonal antibodies. Int J Food Microbiol 48:51–57, 1999 13. Chonan O, Matsumoto K, Watanuki M: Effect of galactooli-
2015
KANAMORI ET AL
14. 15.
16.
17. 18.
19.
20.
21. 22.
23.
24.
gosaccharides on calcium absorption and preventing bone loss in ovariectimized rats. Biosci Biotech Biochem 59:236 –239, 1995 Kukchubasche AG, Smith SD, Rowe MI: Catheter sepsis in short-bowel syndrome. Arch Surg 127:21–24, 1992 Brathwalt CEM, Ross CE, Nagele R: Bacterial translocation occurs in humans after traumatic injury: Evidence using immunofluorescence. J Trauma 34:586 –590, 1993 MacFie J, O’Boyle C, Mitchell CJ, Johnstone DJ, Sudworth P: Gut origin of sepsis: A prospective study investigating association between bacterial translocation, gastric microflora, and septic morbidity. Gut 45:223–228, 1999 Sherman P, Lichtman S: Small bowel bacterial overgrowth syndrome. Dig Dis 5:157–171, 1987 Oh MS, Phelps KR, Traube M, Barbosa-Saldivar JL, Boxhill C, Carroll HJ: D-lactic acidosis in a man with the short-bowel syndrome. Engl J Med 301:249 –252, 1979 Cardarini MI, Pons S, D’Agostino D, Depaula JA, Greco G, Negri G, Ascione A, Bustos D: Abnormal fecal flora in a patient with short bowel syndrome. An in vitro study on effect of pH on D-lactic acid production. Dig Dis Sci 41:1649 –1652, 1996 Bongaerts GPA, Tolboom JJM, Naber AHJ, Sperl WJK, Severijnen RSVM, Bakkeren JAJM, Willems JL: Role of bacteria in the pathogenesis of short bowel syndrome-associated D-lactic acidemia. Microbial Pathogen 22:285–293, 1997 Simon GL, Gorbach SL: Intestinal flora in health and disease. Gastroenterology 86:174 –193, 1984 Van der Waaij, Berghuis-De Vries JM, Lekkerkerk-Van der Wees: Colonization resistance of the digestive tract in conventional and antibiotic-treated mice. J Hyg 69:405– 411, 1971 Majamaa H, Isolauri E, Saxelin M, Vesikari T: Lactic acid bacteria in the treatment of acute rotavirus gastroenteritis. J Pediatr Gastroenterol Nutr 20:333–338, 1995 Mitra AK, Rabbani GH: A double-blind, controlled trial of
2016
25.
26.
27.
28.
29.
30.
31.
Bioflorin(Streptococcus faecium SF68) in adults with acute diarrhea due to Vibrio cholerae and enterotoxigenic Escherichia coli. Gastroenterology 99:1149 –1152, 1990 Spath G, Hirner A: Microbial translocation and impairment of mucosal immunity induced by an elemental diet in rats is prevented by selective decontamination of the digestive tract. Eur J Surg 164:223–228, 1998 Jumaa PA, Hateley PM, Tabaqchali S: Methicillin-resistant Stapyhlococcus aureus and vancomycin-resistant enterococci. Lancet 350:738 –739, 1997 Macfarlane GT, Gibson GR: Microbiological aspects of the production of short-chain fatty acids in the large bowel. In Physiological and Clinical Aspect of Short-Chain Fatty Acids, JH Cummings, JL Rombeau T Sakata (eds). Cambridge, Cambridge University Press, 1995, pp 88 –106 Livesey G, Elia M: Short-chain fatty acids as an energy source in the colon: Metabolism and clinical implications. In Physiological and Clinical Aspect of Short-Chain Fatty Acids, JH Cummings, JL Rombeau, T Sakata (eds). Cambridge, Cambridge University Press, 1995, pp 427– 482 Cherbut C: Effects of short-chain fatty acids on gastrointestinal motility. In Physiological and Clinical Aspect of Short-Chain Fatty Acids, JH Cummings, JL Rombeau, T Sakata (eds). Cambridge, Cambridge University Press, 1995, pp 191–208 Sakata T: Effects of short-chain fatty acids on the proliferation of gut epithelial cells in vivo. In Physiological and Clinical Aspect of Short-Chain Fatty Acids, JH Cummings, JL Rombeau, T Sakata (eds). Cambridge, Cambridge University Press, 1995, pp 289 –305 Katoh K: Effects of short-chain fatty acids on exocrine and endocrine pancreatic secretion. In Physiological and Clinical Aspect of Short-Chain Fatty Acids, JH Cummings, JL Rombeau, T Sakata (eds). Cambridge, Cambridge University Press, 1995, pp 222–242
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