Probiotics have an important place in the supplement regime of a pre and post weight loss surgical (WLS) patient. It seems some DS/WLS patients may be predisposed to pathogenic bacteria overgrowth. One primary reason resulting from the alteration of the gut. Most people are dis-biotic to begin with due to western diet, etc. Weight loss surgical patients have colons which are simply far more nutrient rich than a non DS gut. The malabsorption greatly exacerbates the issue. Bacteria readily bloom under the advantageous conditions presented to them. The WLS patients’ gut is prime real estate, ripe for colonization with little or no competition from an established microbiome, pathogens can soon dominate. When we have antibiotic therapy the gut can be rapidly exposed to the very persistent C. diff spores.
There have been several questions regarding Clostridium difficult (C. Diff) and other bacterial overgrowth in the intestines. It is a gram-positive spore forming bacteria that is opportunistic. It is a small part of the normal colonic bacteria but can overgrow in people who have had antibiotic treatment. It is often spread very easily in hospitals, rehab centers or doctors’ offices. The spores live on objects for long periods of time and are not destroyed by hand sanitizers. The mode of infection is usually oral ingestion and hand washing and inflection control mechanisms can inhibit its spread. C.diff’s acid resistance nature makes it easy for the spores to travel into the intestines.
People at risk may have been on fluoroquinolones, cephalosporins, carbapenems, and clindamycin antibiotic therapy due to the destruction of the normal colonic bacterial groups. Also, daily use of medication to suppress gastric acid production is a risk factor. The low acid state does not destroy the C. diff spores.
The symptoms are flu like symptoms with moderate to severe diarrhea, abdominal pain, gas and bloating with or without fever. Complications of C. diff can lead to dehydration and colitis. Stool sampling is the usual definitive test.
Treatment for C.diff is Flaygyl, Vancomycin, or Fidaxomicin, Probiotics, hydration and possible electrolyte replacement.
Probiotics are also important in the general health of the colon. Research has shown in recent years that intestinal health can lead to improved immune function, diarrhea symptoms, improved symptoms and inflamation from Irritable Bowel Syndrome and Crohn’s Disease. Probiotic therapy is also showing great signs for treatment of H. Pylori infection, which can cause gastritis and ulceration. The Probiotic bacteria can also aid in the conversion of Vitamin K1 to Vitamin K2 although, the intestines are not the only point of Vitamin K conversion. Probiotic bacteria can improve lactose digestion in the lactose intolerant population. Probiotic use has also shown a positive effect on the weight loss, Vitamin B12 absorption and normalization of intestinal flora after RNY. Although this is not specifically DS research, we can potentially extrapolate the outcomes to DS. There is further research into Probiotic benefits in oral health, UTI and vaginal health, effect of LDL and total cholesterol absorption and bile salts hydrolase.
Calcium Oxalate Kidney Stones:
One DS specific advantage to adding a probiotic regime is the possible decrease in enteric hyperoxaluria, calcium oxalate kidney stones. Enteric hyperoxaluria is the mechanism of malabsorbed fatty acids in the colon binding with calcium thereby allowing oxalate to be absorbed into the blood stream. Also there is the theory that the unapposed bile salts may change the epithelial cells allowing oxalate absorption. “This increases the chance for oxalate kidney stone formation. Enteric hyperoxaluria is caused by jejunoileal bypass, as well as the modern bariatric procedure Roux en Y bypass. Patients with inflammatory bowel disease, pancreatic insufficiency, and intestinal resection for any reason are also at risk.” John Leske, M.D., Mayo Clinic. The fat blocking drug Zetia has also been linked to enteric hyperoxaluria. These research articles suggests that the use of Oxadrop ® probiotics, along with a low fat, low oxalate diet and increased hydration and increase calcium intake with meals, deceased the amount of oxalate absorption. Oxadrop® contains the bacteria Lactobacillus acidophilus, Lactobacillus brevis, Streptococcus thermophilus, and Bifidobacteria infantis. They suggest that the probiotic should be taken with meals and hypothesize that the probiotic bacteria possibly bind with oxalate, therefore deceasing oxalate absorption in the colon and also improve colon cells health. This is an area that needs additional study.
Another research study suggests that Oxalobacter formigenes may reduce the risk of Calcium Oxalate Kidney Stones. The study was a relatively small sample size but reports a 70% decrease in stone reoccurrence.
There are several forms of Probiotics and the following list is not meant to be inclusive. When starting a Probiotic regime there may be increased loose stool, gas and or bloating until the normal intestinal flora are re-established. In order for the beneficial flora to repopulate the intestines the pathological flora need to be eliminated. This can take time but the benefits of adding a Probiotic far outweigh the short term negative side effects. Please consult with your physician regarding any contraindications for starting probiotic therapy including allergies, medication interactions, etc.
1. Saccharomyces boulardii has demonstrated the ability to restore normal gut flora after antibiotic therapy. It is the primary constituent in Florastor and can be used at same time as antibiotic therapy. It is important to note that people with central lines, ie; PICC, central venous catheters or implantable ports should NOT take this probiotic. There have been rare cases of Fungemia reported with patients taking Saccharomyces boulardii and having central lines.
2. VSL #3 is a high-potency probiotic containing 8 diffeent strains of live lactic acid bacteria. The 8 strains are:
a. Bifidobacterium breve*
b. Bifidobacterium longum
c. Bifidobacterium infantis*
d. Lactobacillus acidophilus*
e. Lactobacillus plantarum
f. Lactobacillus paracasei
g. Lactobacillus bulgaricus
h. Streptococcus thermophile*
*Four of the strains in VSL#3 are found in the Oxadrop probiotic to possibly reduce oxalate absorption
3. Align contains Bifidobacteria infantis
In conclusion, adding probiotics to the pre and post DS supplement regime can have benefits of improved weight loss, immune function, decreasing loose stools and possibly decreasing oxalate kidney stone formation. There are many types of probiotics on the market. In the U.S., probiotics are sold as a dietary supplement and are not held to the same standard that the medication are. There is no guarantee that the types of bacteria listed on a label are effective for the condition you’re taking them for. Health benefits are strain-specific, and not all strains are necessarily useful. It is beneficial to work with your physician to decide which probiotic may be the best choice for you.
A special thank you to Dr. David Caya, D.C. for his input into this post.
