Endoscopic laser endomicroscopy and “leaky gut” in patients with functional gastrointestinal symptoms and food intolerance

Frieling, Thomas; Gjini, Besmir; Melchior, Ilka; Euler, Philipp; Kreysel, C.; Kalde, Sigrid; Krummen, Britta; Kießlich, Ralf; Hemmerlein, Bernhard

doi:10.1055/a-1959-3200

Cited by 5 publications

(5 citation statements)

References 32 publications

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“…This is in contrast to other studies where up to 50 % of patients with disorders of the gut brain barrier had "leaky gut" [14,15]. This finding suggests that fluorescein leakage into the duodenum during eCLE is not a nonspecific phenomenon because the methodological approach in our investigated patients was the same as reported in the other groups [14,15]. In addition, the low rate of "leaky gut" of the duodenal mucosa in our study suggests that the postulated epithelial barrier dysfunction in EoE is limited to the esophageal epithelium and not found in other parts of the gastrointestinal tract.…”

Section: Discussioncontrasting

confidence: 97%

“…Only one patient showed this phenomenon. This is in contrast to other studies where up to 50 % of patients with disorders of the gut brain barrier had "leaky gut" [14,15]. This finding suggests that fluorescein leakage into the duodenum during eCLE is not a nonspecific phenomenon because the methodological approach in our investigated patients was the same as reported in the other groups [14,15].…”

Section: Discussioncontrasting

confidence: 93%

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Eosinophilic esophagitis and duodenal food challenge – evaluation through endoscopic confocal laser endomicroscopy

Frieling,

Gjini,

Melchior

et al. 2023

Z Gastroenterol

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Background Endoscopic confocal laser endomicroscopy (eCLE) is an established technique that allows clinical evaluation of mucosal integrity by fluorescein leaking through the mucosa upon duodenal food challenge (DFC). Analysis of eCLE with DFC in eosinophilic esophagitis (EoE) would be interesting to evaluate epithelial barrier dysfunction also in other regions of the gastrointestinal tract and to characterize potential individual food allergens that trigger the esophageal inflammation. Methods In an observational and proof of concept study we evaluated 9 patients with histologically proven EoE by eCLE and DFC. Severity of symptoms were graduated according to the validated symptom-based EoE activity index. The endoscopic appearance of the esophagus was described according to the Endoscopic Reference Score System (ERERS). Spontaneous and food induced transfer of fluorescein into duodenal lumen were detected 10 minutes following intravenously application of fluorescein and 10 minutes after DFC. Food allergens were yeast, egg, soy, milk, and wheat, respectively. Local application of sodium chloride solution 10 % to the duodenal mucosa before DFC served as a control. Patients responding to DFC received a dietary exclusion therapy according to the results of DFC. Results We investigated 9 patients with EoE (8 men, 49.7±13.8, 36–76 years). Symptom-based EoE activity index was 79±27.4, 33–100. In all patients EoE was confirmed by histology with number of esophageal mucosal eosinophilic granulocytes > 15/HPF, (91.4±77.4, 42–263). Mean ERERS score was 4.5±1.3, 3–7. None of the patients was aware of any food intolerance. eCLE revealed one patient with spontaneous transfer of i. v. fluorescein into duodenal lumen before DFC (“leaky gut”). 40 DFC were performed in the remaining 8 patients of whom 5 patients (61 %) responded to DFC. Rank order of fluorescein leakage upon DFC was wheat and milk in 37.5 % each, soy in 25 %, and egg in 12.5 %. The patients were treated by PPI (n=9), esophageal bouginage (n=5) and/or local corticoid therapy (n=3). The 5 patients responding to DFC received an additional food exclusion dietary advice focussed on the results of DFC. All patients reported a reduction of their symptoms. EoE activity indexes of patients with positive DFC were 73.7+28.6, 33–100 before and 22.7+37.9, 0–79 four weeks after food exclusion. Conclusion The findings of our proof of concept study suggest that eCLE with DFC may be an interesting tool to further evaluate patients with EoE. This technique has the potential to identify patients who may benefit from an additional individual dietary therapy.

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Section: Discussioncontrasting

confidence: 97%

Section: Discussioncontrasting

confidence: 93%

Eosinophilic esophagitis and duodenal food challenge – evaluation through endoscopic confocal laser endomicroscopy

Frieling,

Gjini,

Melchior

et al. 2023

Z Gastroenterol

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“…The study was approved by the local ethic commission (IRB Fr-21-01). The patients were recruited consecutively and offered an additional laser endomicroscopy for further diagnostic as described before [9]. The main symptoms of the patients were evaluated via a standardized DSFQ symptom questionnaire [10].…”

Section: Methodsmentioning

confidence: 99%

Gastrointestinal adverse reaction to food (GARF) and endoscopic confocal laser endomicroscopy (eCLE)

Frieling,

Gjini,

Melchior

et al. 2024

Z Gastroenterol

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Background and study aims Gastrointestinal adverse reaction to food (GARF) is reported frequently in the general population and even more in patients with disorders of the gut brain axis. However, there is a significant difference between self-reported and objective proven GARF. The aim of the study was to characterize a mucosal correlate of GARF by endoscopic confocal laser endomicroscopy (eCLE) with duodenal food challenge (DFC). Patients and methods In an observational and proof of concept study we evaluated 71 patients with disorders of the gut brain axis without (group I, n=19) and with (group II, n=52) GARF by eCLE and DFC. Spontaneous and food induced transfer of fluorescein into duodenal lumen was detected 10 minutes following intravenously application of fluorescein and 10 minutes after DFC. Results According to Rom IV, the patients (group I/II) could be classified as irritable bowel syndrome (IBS) 32%/31%, functional abdominal pain without changes in bowel movement 47 %/48 %, functional abdominal bloating/distension 0 %/10 %, functional diarrhea 5 %/ 2 %, and unspecified functional bowel disorder 16 %/10 %, respectively. 21 %/27 % of the patients responded with a fluorescein leakage into the duodenal lumen before and 74 %/69 % following to DFC. Frequency rank order of food components that induced a response were soy (55.5 %/60 %), wheat (60 %/45.5 %), egg (35.7 %/8.3), milk (30 %/18.2 %) and yeast (10 %/6.6 %), respectively. Histology of duodenal biopsies, number, form and distribution of intraepithelial lymphocytes and mucosal mast cells as well as mast cell function were normal. Overall, 14 %/79 % reported main symptom benefit following a food exclusion therapy according to eCLE and DFC that was significant different between the groups. Conclusion The results of our study indicate that eCLE with DFC is a technique to clinically evaluate patients with disorders of the gut brain axis and GARF resulting in a high proportion of patients reporting symptom benefit upon food exclusion dietary advice focussed on the results of eCLE.

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“…With the objective of both understanding the pathophysiology and finding a new diagnostic method, confocal laser endomicroscopy (CLE) was applied to IBS patients, food intolerance patients, food allergy, dyspepsia, and IBD patients [181]. The scientific rationale for applying this technique in food-intolerant individuals is that there may be reactions to some foods that trigger functional changes that go undetected by classic histology [181].…”

Section: Other Food-specific Intolerancesmentioning

confidence: 99%

Myths and Facts about Food Intolerance: A Narrative Review

Zingone,

Bertin,

Maniero

et al. 2023

Nutrients

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Most adverse reactions to food are patient self-reported and not based on validated tests but nevertheless lead to dietary restrictions, with patients believing that these restrictions will improve their symptoms and quality of life. We aimed to clarify the myths and reality of common food intolerances, giving clinicians a guide on diagnosing and treating these cases. We performed a narrative review of the latest evidence on the widespread food intolerances reported by our patients, giving indications on the clinical presentations, possible tests, and dietary suggestions, and underlining the myths and reality. While lactose intolerance and hereditary fructose intolerance are based on well-defined mechanisms and have validated diagnostic tests, non-coeliac gluten sensitivity and fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) intolerance are mainly based on patients’ reports. Others, like non-hereditary fructose, sorbitol, and histamine intolerance, still need more evidence and often cause unnecessary dietary restrictions. Finally, the main outcome of the present review is that the medical community should work to reduce the spread of unvalidated tests, the leading cause of the problematic management of our patients.

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Endoscopic laser endomicroscopy and “leaky gut” in patients with functional gastrointestinal symptoms and food intolerance

Cited by 5 publications

References 32 publications

Eosinophilic esophagitis and duodenal food challenge – evaluation through endoscopic confocal laser endomicroscopy

Eosinophilic esophagitis and duodenal food challenge – evaluation through endoscopic confocal laser endomicroscopy

Gastrointestinal adverse reaction to food (GARF) and endoscopic confocal laser endomicroscopy (eCLE)

Myths and Facts about Food Intolerance: A Narrative Review

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