Support Guide. Introduction CDSA and CDSA2.0. Comprehensive Digestive Stool Analysis

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Comprehensive Digestive Stool Analysis Support Guide Introduction CDSA and CDSA2.0 This Support Guide is intended to help clinicians understand and use the CDSA & CDSA2.0 Profile, a select set of fecal
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Comprehensive Digestive Stool Analysis Support Guide Introduction CDSA and CDSA2.0 This Support Guide is intended to help clinicians understand and use the CDSA & CDSA2.0 Profile, a select set of fecal biomarkers aimed at identifying key processes that influence both gastrointestinal and overall health. The test report is organized so that the clinician may move through the results in a logical order that enhances clinical utility. Biomarker Review Modern technology allows the use of a growing number of biomarkers found in stool to supplement, and often supplant, more invasive and generally more expensive tests of GI function. While the most obvious role of the human gastrointestinal (GI) tract is the incorporation of nutrients and energy from the diet, and the elimination of waste products and toxins, it is now clear that functions of the GI tract influence, not only GI health, but that of the entire human organism. For these reasons, the results from the CDSA & CDSA2.0 Profiles are reported using the DIG framework, which provides information on the three main categories of GI function: Digestion and Absorption reports on the effectiveness of GI breakdown and absorption of nutrients from ingested food Inflammation and Immunology reports on the functioning of the inflammatory response in the GI tract Gastrointestinal Microbiome reports on the status and function of the hundreds of microbial species (chiefly bacteria and fungi) that constitute the non-host living contents of the human GI tract. Table of Contents Introduction CDSA and CDSA Biomarker Review Digestion and Absorption...3 Pancreatic Elastase 1 (PE-1) CDSA 2.0 & Add-On CDSA Chymotrypsin - CDSA Putrefactive Short Chain Fatty Acids (SCFA) Total CDSA & CDSA 2.0 Meat Fibers & Vegetable Fibers - CDSA Total Fecal Fats CDSA & Add-On CDSA 2.0 Inflammation and Immunology...8 Calprotectin CDSA 2.0 & Add-On CDSA Lactoferrin CDSA Eosinophil Protein X CDSA 2.0 Supporting the Patient with Gastrointestinal Inflammation and Immune Reactions Additional Tests...12 Color CDSA Mucus CDSA Occult Blood CDSA & Add-On CDSA Gastrointestinal Microbiome...13 Metabolic Products: Short-Chain Fatty Acids CDSA & CDSA 2.0 Beta-glucuronidase ph CDSA & CDSA 2.0 Secondary Bile Acids CDSA 2.0 & Add-On CDSA Bacteriology (Culture) Additional Bacteria (Culture) Mycology (Culture) Parasitology...19 Bacteria Sensitivity...21 Mycology Sensitivity...21 Pathogenic Bacteria Add-On for Both CDSA & CDSA References...23 Organization of the Biomarker Review In the following sections, Each biomarker is first identified and described The candidate patient population for the biomarker is described The comparator or existing gold standard for the biomarker is presented (if established), along with performance characteristics of the fecal biomarker when appropriate The interpretation of the fecal biomarker is discussed, including the significance of out-of-range results Desirable outcomes and therapeutic recommendations are discussed, indicating how the specific test might benefit patients in a variety of clinical settings Graphical Representation and Color Coding for Biomarkers In addition to a numeric result and a stated reference range for each result, all biomarker results on the CDSA & CDSA 2.0 report are graphically represented and color-coded in the context of a specific reference population by means of standard deviation (SD). In general, for a 2-tailed test, the green region includes plus or minus 1 SD from the population mean, or 68.2% of all results. The yellow areas include plus or minus 2 SD from the population mean, and encompass 95.4% of the distribution; the red area represents the remainder of the population that falls outside of 2 SD in either direction. Some biomarkers have established threshold values associated with specific clinical conditions, histopathological findings, or recommended clinical interventions, i.e. medical decision points (MDPs). Biomarkers fecal calprotectin and pancreatic elastase-1 have reference ranges based on a clinically characterized healthy reference population (i.e. not a symptomatic tested population) and cutoff points indicating a normal result, a borderline or weakly positive result, and an abnormal or strongly positive result. small intestine, breaking down the three major components of food: complex carbohydrates (starches), proteins, and fats. Absorption of the resulting products of digestion then occurs by several distinct processes. Damage to, or impairment of any of the processes involved in digestion or absorption results in two main problems: inadequate net absorption of nutrients, producing absolute or relative nutrient deficiencies, and/or delivery of intact nutrients to the colon, where gut microbes may inappropriately digest or ferment nutrients. Such fermentation results in byproducts leading to excessive osmotic loads and gasses, leading to abdominal discomfort, diarrhea, flatulence, and other common symptoms. 2 Biomarkers of digestion and absorption provide information about nutrient breakdown and entry into the circulation. They ultimately indicate how well the GI tract is performing its basic digestive functions. The biomarkers are: Pancreatic Elastase-1 & Chymotrypsin, markers of exocrine pancreatic function Putrefactive SCFAs, markers of undigested protein reaching the colon Fecal Fat, a marker of fat breakdown and absorption Meat and Vegetable Fibers, markers of maldigestion Maldigestion is defined as impaired breakdown of nutrients, and is often the result of inadequate or impaired digestive enzymes (or gastric acid production), while malabsorption refers to impairments in absorption of the normal end products of digestion. 3 When faced with a patient experiencing sub-acute or chronic GI symptoms, it is the task of the clinician to discern which, if any, of these processes is occurring, and then if possible, to identify one or more underlying primary causes. Finally, in many cases, once a primary cause has been identified, a rational and usually simple course of therapy may be prescribed, with the goal of repairing the underlying pathological processes. In many cases, fecal biomarker testing is useful in discerning whether maldigestion, malabsorption, or both, are present. Such testing is also helpful in identifying the underlying causes, for which treatment may be available. Digestion and Absorption For proper nutrition and gastrointestinal (GI) function, ingested nutrients must first be broken down (digested, in a biochemical sense), and the products of digestion must then be absorbed through a variety of physical and biochemical processes. In good health, digestion is accomplished in several steps. First by chewing and other physical processes, and then by the actions of stomach acid and a host of enzymes produced in the pancreas and Pancreatic Elastase 1 (PE-1) CDSA2.0 & Add-On CDSA The exocrine portion of the pancreas (the cells and structures not related to endocrine functions, such as insulin production) secretes numerous digestive enzymes, among them pancreatic elastase 1 (PE1) PE1 is a robust proteolytic enzyme that reaches the colon without itself being digested, is not greatly affected by 3 increases or decreases in intestinal transit times, and is not affected by pancreatic enzyme replacement therapy The PE1 reference range was adopted from an FDA-approved kit Noninvasive biomarker of pancreatic exocrine (i.e., digestive) function Is not affected by supplemental pancreatic enzymes Reflects true pancreatic exocrine function 4 Fecal PE1 testing can be used for initial determination of pancreatic exocrine insufficiency in suspected patients, as well as the monitoring of pancreatic exocrine function in patients under treatment. Patients in whom PE1 testing may be useful include those with: Unexplained diarrhea Weight loss Other symptoms of maldigestion Abdominal pain Including symptoms meeting clinical criteria for irritable bowel syndrome (IBS) Low bone density In addition, pancreatic exocrine insufficiency may occur secondary to: Chronic pancreatitis Diabetes Celiac disease Cystic fibrosis Inflammatory bowel disease (IBD) Excessive alcohol consumption Gallstones Fecal PE1 testing can be used for initial determination of pancreatic exocrine insufficiency in suspected patients There is also evidence that aging populations may exhibit a progressive loss of PE1, since pancreatic exocrine function may decrease with age PE1 has a strong correlation with the gold-standard test for pancreatic insufficiency, the secretin-caerulein test. 4,11 (Caerulein is a synthetic analog for pancreozymin and stimulates pancreatic activity in a similar manner.) Fecal PE1 Value (µ/g) 12,13 200 Normal exocrine pancreatic function 100 to 200 Mild-to-moderate exocrine pancreatic insufficiency 100 Severe pancreatic insufficiency Results are based on Medical Decision Points: Fecal PE1 testing may have reduced sensitivity for detecting mild pancreatic exocrine insufficiency in children 14 Consumption of vegetarian or vegan diets, or other diets involving decreased meat intake, have been associated with reductions in fecal PE1 15,16 Pancreatic exocrine insufficiency occurs in about 50% of type 1 diabetics, and in about 33% of type 2 diabetics 17 Chronic pancreatitis patients may have compromised antioxidant systems 2 Patients with PE1 results suggestive of exocrine pancreatic insufficiency should undergo further investigation to address the underlying causes of insufficiency. Additionally, complications may result from pancreatic exocrine insufficiency and additional testing may be considered, as shown in the following table: Additional Testing Evaluation of fecal fats 18 Full nutritional assessment Rationale Excess fecal fat may be due to: Lack of bile acids (due to liver damage, hypolipidemic drugs, or impaired gallbladder function) Celiac disease Small bowel bacterial overgrowth Other conditions and medications (e.g., Orlistat) Defective exocrine pancreatic function may be associated with: Abnormal blood lipids Low levels of minerals (magnesium, zinc, selenium, and calcium) Low levels of fat soluble vitamins (A, D, E, and K) 19 4 Supporting the Patient with Evidence of Pancreatic Exocrine Insufficiency Certain lifestyle, medication, and supplement interventions may be appropriate for patients with abnormal fecal PE1 results suggestive of pancreatic exocrine insufficiency. Lifestyle Support 19 Small, frequent meals (better absorbed) Reduce alcohol consumption Smoking cessation Medication/Supplement Support 18,20-22 Support patients with pancreatic exocrine insufficiency by pancreatic enzyme replacement therapy (PERT) at doses appropriate for degree of insufficiency and based on symptom improvement; in some conditions PE1 levels normalize as underlying disorders improve 23 (improved PE1 levels reflect functional improvements, not supplementary enzymes). Chymotrypsin - CDSA Chymotrypsin is one of the numerous digestive enzymes secreted by the exocrine portion of the pancreas. Specifically, it is a protein-digesting enzyme which can be useful when monitoring pancreatic exocrine function in patients with normal stool transit time (degradation of proteases can result in higher chymotrypsin levels in response to diarrhea, and lower levels in response to slow transit time). 24 Noninvasive biomarker of pancreatic exocrine (i.e., digestive) function Affected by exogenous supplementation making it an ideal marker for monitoring dosing adequacy 25 Altered gut transit may effect chymotrypsin 24 Patients in whom Chymotrypsin testing may be useful include those with: 26 Unexplained diarrhea Steatorrhea Weight loss Abdominal distention and flatulence Signs of nutrient deficiency Other symptoms of maldigestion The gold-standard test for pancreatic insufficiency is the secretinpancreozymin test. Unlike PE1, chymotrypsin has not been correlated with the gold standard test, 4,27 although it has been compared to the 72-hour fecal fat test. 25 Low levels of chymotrypsin ( 0.9 U/g) in the presence of normal transit time are indicative of exocrine pancreatic insufficiency. Low chymotrypsin can also result from slowed transit time (constipation). 28 High levels of chymotrypsin ( 26.8 U/g) suggests a rapid transit time (diarrhea) or may be due to excessive pancreatic enzyme supplementation. 28 Chymotrypsin is a simple and non-invasive screening test and can assist the physician in assessing exocrine pancreatic insufficiency. Patients with altered chymotrypsin levels should undergo further investigation to determine the underlying causes of their dysfunction; refer to the corresponding Pancreatic Elastase-1 table (on previous page) for information about additional testing. Pancreatic dysfunction typically leads to malabsorption, the severity of which is relative to the degree of exocrine pancreatic impairment. Evaluation of absorptive markers will provide valuable insight into the degree of malabsorption present. Supporting the Patient with Evidence of Pancreatic Exocrine Insufficiency Certain lifestyle, medication, and supplement interventions may be appropriate for patients with abnormal chymotrypsin results suggestive of pancreatic exocrine insufficiency. Please refer to the corresponding Pancreatic Elastase section. Putrefactive Short Chain Fatty Acids (SCFA) Total CDSA & CDSA2.0 When proteins or their digestion products (oligopeptides and amino acids) reach the distal colon, they are fermented by colonic organisms (a process known as proteolytic fermentation) into the characteristic short-chain fatty acids (SCFAs), isovalerate, isobutyrate, and valerate. Normal protein digestion and absorption is relatively complete in stomach and small intestine 5 Healthy colonic contents therefore include only small amounts of protein-derived SCFAs Protein fermentation can yield a diversity of end products, including SCFAs, amines, phenols, indoles, thiols, sulfur compounds, and branched chain fatty acids 29 Though many have shown toxic properties in vitro and in animal models, the relationship between gut health and protein fermentation in humans has not been thoroughly investigated The result for putrefactive SCFAs reflects the sum of fecal valerate, isovalerate, and isobutyrate. Patients with elevated putrefactive SCFAs should be evaluated for common causes of insufficient protein digestion and/or excessive protein presenting to the colon. Primary colonic SCFAs from protein breakdown are valerate, isovalerate, and isobutyrate 16,17 The result on the CDSA & CDSA 2.0 report reflects a combined total of valerate, isovalerate, and isobutyrate measurements Source of Elevated Colonic Products of Protein Breakdown Insufficient Protein Digestion 33,34 Possible Causes Hypochlorhydria Pancreatic exocrine insufficiency Therapeutic Response Reduce acidblocking medications Add betaine HCl Evaluate fecal PE1 Patients with protein maldigestion, or those with abnormally large amounts of protein presented to the distal colon, may demonstrate increased products of colonic protein breakdown in the stool. Increased fecal presence of putrefactive SCFAs may be present in patients with: Excessive delivery of protein to colon 43 High-protein diet GI irritation/ inflammation, bleeding, bacterial overgrowth Review protein/ carbohydrate intake Additional testing, e.g., fecal calprotectin, fecal eosinophil protein X (EPX), fecal occult blood, stool culture for beneficial bacteria Hypochlorhydria (diminished hydrochloric acid secretion in the stomach), which is associated with: 33 Advanced age in roughly 30% of elderly patients, gastric acid secretion is diminished Use of acid-blocking medications or dietary supplements that produce too high a gastric ph to allow for complete protein digestion in the stomach 34 Food reactions; elevated gastric ph (less acidic) has been associated with increased risk for food reactions, possibly from hindering protein breakdown Pancreatic exocrine insufficiency or pancreatitis; insufficient pancreatic proteases leave improperlydigested protein fragments that reach the colon 38,39 Excessive protein intake 40 Gastrointestinal bleeding or irritation, mucosal desquamation, and bacterial overgrowth; these conditions result in excessive selfderived proteins in the intestinal lumen 41 Currently there is no gold standard assessment for fecal putrefactive SCFAs. Putrefactive SCFAs are utilized as a contributory diagnostic tool. Testing for fecal nitrogen may indicate the presence of protein malabsorption, but fecal nitrogen is difficult to measure and is not in widespread clinical use. 42 Meat Fibers & Vegetable Fibers - CDSA Meat and vegetable fibers in the stool have been used to identify adequate digestion and absorption when used in combination with clinical presentation and other biomarkers, such as Pancreatic Elastase-1. Meat and vegetable fibers are digested in the upper gastrointestinal tract, therefore the presence of these food fibers are suggestive of maldigestion and malabsorption or increased gut transit (diarrhea). 44 Patients with signs and symptoms of incomplete digestion including diarrhea, steatorrhea, weight loss, flatulence, abdominal distention, signs of nutrient deficiency and other possible symptoms of maldigestion 26 There is no correlation between fecal presence of food fibers and the gold standard for the assessment of digestion and absorption. Used in combination with other digestion and absorption biomarkers, food fibers can help determine insufficiency and monitor treatment progression. 6 The presence of meat fiber or more than a few vegetable fibers in the stool suggests incomplete digestion (e.g. pancreatic insufficiency, hypochlorhydria). 44,45 Elevated levels can also result from inadequate mastication 46 or hypermotility 47,48 Stool food fibers is a simple screening test and can assist the clinician in assessing digestion and absorption. Patients with increased food fibers in the stool should undergo further investigation into causes, and other biomarkers of absorption and digestion should be evaluated. Supporting the Patient with Evidence of Maldigestion and Malabsorption Certain lifestyle, medication, and supplement interventions may be appropriate for patients with the presence of stool food fibers (e.g. pancreatic enzyme therapy). Refer to other biomarkers of digestion and absorption in conjunction with the clinical presentation of the patient to best determine which therapeutic option to select for the patient. Total Fecal Fats CDSA & Add-On CDSA2.0 Under normal conditions, the bulk of dietary fat is digested and absorbed in the small intestine, leaving only small amounts for delivery to the colon and fecal stream. Fecal fat measurements determine the amount of fat in stool, and may therefore identify fat maldigestion, malabsorption, or steatorrhea. The test is a fecal fat extraction method that results in a quantitative value Fecal fat extraction methods have been found to correlate with degree of fat malabsorption 49 Total fecal fat is made up of long-chain fatty acids (LCFA), cholesterol, triglycerides, and phospholipids Fecal fats should be measured in any patient for whom steatorrhea (passage of pale, bulky, and malodorous stools) may be a symptom of underlying digestive or non-digestive disorders. Symptoms suggesting evaluation of fecal fat as a means of detecting root causes include: Fatigue Unexplained anemia Nutrient deficiencies Unintended weight loss The 3-day stool collection with total fecal fat determination is the gold standard test for fecal fat. This test is unwieldy and unpleasant for patients and lab personnel. The total fecal fat extraction on a single specimen provides a quantitative value to identify patients that may benefit from the more in-depth 3-day test. Limited research has found extraction methods to correlate with the gold-standard. 49 Total fecal fat is the sum of fecal triglycerides, long-chain fatty acids, chole
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