Page Two

wpid-IMAG0513.jpgI had the 2100 test done to help evaluate my chronic constipation.  Neither myself nor my general surgeon really knew what in the heck we were looking at when we got the results.  So I’ve been going through each section to try to figure out what the test has to offer to help me manage my chronic constipation and just brushing up on my general knowledge.

Currently, I have been reading up on the pathogenic bacteria Metametrix reports.  Other than it’s perhaps too far-reaching of a test panel, nothing absurd jumps out at me here.  Did I need to know my H. pylori status or C. diff status?  No.  I don’t have symptoms consistent with those.  So, except for the idea that the test results offer information beyond what is necessary and which may be exceptionally confusing with regard to whether to treat or not in an asymptomatic patient, I don’t have much to say.

This is not meant to be a conclusive summary or viewpoint.  It is not meant to be a means of medical advice.  These are just some things I’ve looked up and found and thought about that I am sharing.  Consider it fodder for discussion, that’s all.

Lingo

Helpful information to know:

  • GI Effects Profile= 2100
  • Microbial Ecology Profile= 2105= Only the second page of the GI Effects Profile
  • The “second page” reports pathogenic bacteria, yeast/fungi, parasites, adiposity index, and drug resistance genes.

Where to See More on the 2100/2105

Below are two Metametrix links to videos containing descriptions/case studies of the 2100 and/or the 2105 which will allow you to see more test results and how somebody on their staff interpreted them.  Sound starts as soon as you open the link.  There are outlines provided so you may speed through to specific slides and topics if you wish.

  • IBS and GI Effects:  A video with a straightforward, simple case of irritable bowel syndrome and how the GI Effects Profile was used to address the patient’s irritable bowel syndrome.
  • GI Effects test description with two case studies:   Gives an overall summary of what the test is, what it tests for, and two case studies.  Case study one is regarding gluten removal.  Case two is more of an overhaul approach; please note on the treatment slide that they forgot to put that she was also taking bifidobacter and lactobacillus probiotics, which also contributed greatly to her probiotic flora levels increasing.

SCD Lifestyles–these guys, their passion is infectious–gives an overview of the second page (also known as the Microbial Ecology) and some examples.

Metametrix selected four pathogenic bacteria to report:  Helicobacter pylori, E. coli 0157:H7, Clostridium difficile, and Campylobacter sp.

I think it is helpful to remember that even some of these pathogenic bacteria can exist normally in normal people.  They are not always pathogenic, although at times they (or particular strains of them) can be horribly pathogenic.  Escherichia coli 0127:H7 and Campylobacter jejuni you can pretty much count on being invaders intent on destruction, and they usually cause acute, more aggressive type symptoms, to let you know that.  H. pylori and C. diff’s stories are not so clear.

Metametrix uses PCR to detect these bacteria, offering high sensitivity.  No dispute about how the test is peformed, collected, validity of what they’re testing for, or if the results are misleading.  Wandering thoughts include:

  • Since H. pylori and C. diff can be present in asymptomatic carriers, and the medical field doesn’t know what to do with that information at present, will positive tests on the 2100/2105 lead to over treatment?   Over treatment can lead to encouragement of antibiotic resistance and also a huge shift in a person’s bacterial flora, perhaps predisposing the patient to other issues.
  • Should the 2100/2105 be broken apart into smaller pieces rather than offered as this huge, sweeping “shot-gun”, “let’s cover all of our bases” test?  Metametrix does broach that topic here, Which GI Test is Best?  The approach the writer advocates goes against my training as a medical doctor, which tells me to look at the patient, order tests based on my assessment, and then pursue further testing if needed based on those tests and how the patient is doing.
  • How often are Campylobacter sp. and E. coli 0157:H7 picked up on using this test?  Unlike H. pylori and C. diff, Campylobacter and E. coli 0157:H7 don’t usually transpire into indolent, low symptom disease states.  They’re usually, like, “BAM”–diarrhea, stomach cramps, and an apparent acute illness.  Just because you can test for something, does it make sense to?  I can’t see a physician ordering the GI Profile or Microbial Ecology for an acute illness, as the turn-around time isn’t rapid.  And you don’t need to know about yeast, fungi, and H. pylori when someone shows up with fevers, diarrhea, and stomach cramps.  It seems like these could have been omitted, maybe cutting costs and not changing the usefulness of the test.  But since I don’t know if it would cut cost or change resource allotment, I can’t really say much.  Sometimes adding on an element to a test does not actually require any more work, time, or money.  This may be an instance.

Helicobacter pylori (H. pylori):  H. pylori is a known gastric colonizer.  You, and about 50% of the world’s adults, are not alone if you have H. pylori in your gut.  So what’s the fuss?  Some people will live with H. pylori and be asymptomatic all of their lives, but other unlucky people may get ulcers or cancers associated with H. pylori.  A friend told me just yesterday that she’d been recently treated for H. pylori by a chiropractor.  Treatment decision was based on a stool test result and used antibiotics and proton pump inhibitors.  Her symptoms had not been GI (gastrointestinal) related, and she was questioning why he chose to treat based on what she was now reading.  And therein lies a problem.

What do you do with a positive test in an asymptomatic patient?

Gnawing abdominal pain and nausea, it’s a no-brainer.  No GI symptoms, and my friend wouldn’t even have been tested for H. pylori by most medical doctors.  But what do you do now as a practitioner with a GI asymptomatic patient with a positive H. pylori on a “shotgun” test ordered for something like fibromyalgia or fatigue?

  • Why treat an asymptomatic, positive test?  “Treatment of asymptomatic patients is somewhat controversial given the high prevalence of H. pylori–associated superficial gastritis and the relatively low incidence of clinical sequelae (ie, peptic ulcer disease). However, H. pylori is a class J carcinogen; eradication removes the cancer risk.”  (1)  H. pylori increases the risk of ulcers, gastric cancer and a certain lymphoid cancer. (2)
  • Why not treat any positive test?  Aren’t ulcers and cancer bad?  Of course they are!  However, there are always two sides to every story.  In Journal of Clinical Investigation’s article “Coadaption of Helicobacter pylori and humans:  ancient history, modern implications” (scroll down to “Absence of H. pylori as a risk factor for disease”), the evidence that H. pylori belongs in our gut for particular reasons is discussed:  “In historical terms, H. pylori is part of the normal microbiota of humans.”  The authors assert that reflux esophagitis and esophageal cancer are likely outcomes of H. pylori absence and also speculate obesity and allergic disorders may go hand in hand, as well.  In addition, the article cites many sources which are available for reading online which may interest anyone with a positive H. pylori test.

From Metametrix’s own blog comes  “What’s the H. pylori Story?”:

“Most clinicians carefully weigh the patient’s clinical presentation to determine if H. pylori needs to be treated. Treatment is only warranted if lab data, symptoms, and clinical history are consistent with H. pylori infection. Adjunctive or repeat testing should be ordered to verify the presence of H. pylori.”

and

“Most people infected with H. pylori are asymptomatic and never develop a complication.  Some experts have suggested that H. pylori may be a normal, commensal bacterium and should not be treated in asymptomatic individuals. In fact, non-ulcer dyspepsia and GERD have not been shown to improve with H. pylori eradication.  Patients who were seropositive for H. pylori had markedly lower risk of developing Barrett’s esophagus, suggesting that H. pylori may even have a protective effect against certain illnesses.”

E. coli 0157:H7:  E.coli 0157:H7 does not belong in your gastrointestinal tract.  It is a type of Escherichia coli that makes a special toxin (called Shiga toxin or Vero toxin) that attaches to and damages the lining of the small intestine, allowing toxin access to the blood.  This can be a terrible player.  Severe bloody diarrhea, nausea, vomiting, abdominal cramps, hemolytic anemia, kidney failure, and death are potential outcomes.  Not a good player, especially for young children and older adults.  On the flip side, a person may develop only mild diarrhea and cramping.

The source of E. coli 0157:H7 is often cattle, who can be asymptomatic carriers of it in their guts (3).  Thus, undercooked ground beef can be a source of outbreak if contamination occurs during slaughtering, but other sources include raw milk, unpasteurized juice, contact with infected animals, infected drinking water, or contaminated recreational water (lakes, swimming pools) (2, 3, 4).

Although knowing if you have this bacteria would be very important, in fact it’s a “reportable” illness to the CDC, I find it an interesting choice for inclusion on this panel.  Usually the illness is acute (lasting 5-7 days from onset of symptoms), and this 2100/2105 panel seems more geared for longer lasting, more indolent type of issues.  Doctors and hospitals wouldn’t be using the Metametrix test for E. coli 0157:H7 because they need more rapid turn-around time, and they don’t need all other information provided to evaluate bloody diarrhea (for example, yeast and H. pylori).  So, for whatever reason, they chose to put this bug on there.  Don’t know why.  I’d love to hear why or if somebody had this come back positive.  Seems like a waste.  But maybe I’m missing something.

Clostridium dificile:  C diff. has toxin producing strains and non-toxin producing strains. It’s the C. difficile that makes a toxin, toxigenic C. diff, that is the problematic strain here.  “It has been known for >25 years that nontoxigenic C. difficile strains occur naturally and, when given to hamsters during or after antibiotic treatment, are able to harmlessly colonize the gut and prevent subsequent infection challenge with toxigenic strains of C. difficile. It has also been shown in patients that natural asymptomatic colonization with C. difficile (toxigenic or nontoxigenic strains) is associated with decreased risk of CDI [C. diff infection].” (5)

Up to Date has some C. diff information if you’re interested (symptoms, diagnosis, treatment, and special considerations such as in inflammatory bowel disease):

PCR detection of C. diff with the toxigenic gene seems as good, if not better, than most of the prior tests for C. diff diagnosis. (6)  I left a question on Metametrix’s blog about their C. diff test, and it was promptly responded to.  I questioned, “Does Metametrix’s PCR for C. diff test for the toxigenic genes or just C. diff in general?”

They responded, “Our C diff detection method looks for the Toxin A gene in C diff. If that is present in sufficient numbers for a positive it will be reported as positive. In the next version of the GIfx test (and the 2105) C diff findings will reflect the Toxin B gene as well, but not currently.”  There was a bit of controversy in medicine about whether toxin A or toxin B was the problem, but the good news is Metametrix will soon test for both.  And based on this article, it should: The role of toxin A and toxin B in Clostridium difficile infection.

Dr. Peterson [MD, director of microbiology and infectious diseases research, Department of Pathology and Laboratory Medicine, Evanston (Ill.) Hospital, and associate epidemiologist, NorthShore University HealthSystem] has been emphatic about testing only patients who meet the clinical criteria for C. difficile illness, Dr. Crist [PhD, technical director/ clinical microbiologist, Department of Laboratory Services, Division of Clinical Microbiology, York (Pa.) Hospital] points out. “At this point our data support that premise,” Dr. Crist says of the chart review for one-fourth of the patients in his study. “In that subset there were no positive PCR results in patients who did not fulfill clinical criteria. All PCR-positive patients were clinically ill, not just colonized, even if they were culture negative.” (6)

  • Even if you have diarrhea, it’s possible that you’re a carrier and your diarrhea is caused by something else.  Dr. Timothy O’Leary in Sensitivity, Specificity Higher With PCR Than Conventional EIA in C Difficile-Associated Diarrhea states, “It’s [PCR] not necessarily the perfect assay because, while it is extremely sensitive, it’s possible, for example, that an individual may harbor this organism and not have the disease. You will detect that they are a carrier, which is important knowledge, but it’s not actually diagnosing the cause of their diarrhea. So, as with all laboratory tests, this has to be put into context.”  (7)

An aside–Interesting treatment for C. diff:  http://ir.viropharma.com/releasedetail.cfm?ReleaseID=758059

Campylobacter sp. Some strains from Campylobacter sp. can be part of the normal flora; however, some species/strains of species are associated with disease.  This seems pretty cut and dry.  If you have had symptoms of new acute onset diarrhea for a while and you’re testing positive, you’ve likely found a contributing culprit.  If you’re asymptomatic and positive, what do you do, since it has been found to be present in our flora?  The links below talk about some species of campylobacter.

I’m a bit curious as to why, if campylobacter and E. coli 0157:H7 were included, why bacteria like Salmonella and Shigella were not also included.

That’s it.  Will start reading about yeasts, which will be completely overwhelming.  Yeasts?  Sure, candida UTIs, candida pneumonia, thrush, etc, but not an overwhelming “candidiasis” in an immunocompetent patient.

1. http://www.merckmanuals.com/professional/gastrointestinal_disorders/gastritis_and_peptic_ulcer_disease/gastritis.html

2.  http://en.wikipedia.org/wiki/Escherichia_coli_O157:H7

3.  http://www.medicinenet.com/e_coli__0157h7/page3.htm

4.  http://legacy.jyi.org/volumes/volume6/issue5/features/hu.html

5.  http://cid.oxfordjournals.org/content/51/11/1306.full

6.  http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&cntvwrPtlt%7BactionForm.contentReference%7D=cap_today%2F0510%2F0510a_smart_choice.html&_pageLabel=cntvwr

7.  http://www.medscape.com/viewarticle/713134

2 thoughts on “Page Two

  1. Pingback: How Many Medical Doctors Does It Take To Order A Metametrix Stool Test? | The HSD

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