A wide range of substances are available and used for the treatment of constipation. They include hydrophilic bulking agents, stool softeners and laxatives with a local irritant effect on the colon. However, a bowel regulator should be nontoxic and non-habit-forming and should not exhibit side effects such as diarrhoea or abdominal cramps. Laxatives are usually used for the relief of symptoms of constipation. The use of fiber-bulking laxatives to stimulate peristalsis is a common therapeutic approach. However, high-fiber diet demands a high consumption of fluid to act and the phytic acid present in fiber sources may interfere with mineral absorption (2). Therapeutic effects of L. acidophilus, B. bifidium and other lactobacilli grown in milk have been reported by several investigators (3,4). Some of the first clinical trails carried out with lactobacilli were related to their effects on constipation and more recently on lactobacillus treatment of constipation in geriatric patients.
Milk products containing human strains of lactobacilli have been tested for their ability to alleviate constipation with good results. Thus a daily portion of 150-200 ml of fermented milk containing a human strain of L. acidophilus had a marked effect on the bowel movement rate in severely constipated geriatric patients and reduced their need for laxatives (5). In order to be able to exert an influence on gastrointestinal function and especially on bowel movement rate in aged individuals, it is required that microorganisms should be viable, metabolically active, and present in high numbers in therapeutic milk, and also survive both in the milk during storage and after consumption, all the way down to the lower parts of the colon (6). Survival and presence of L. acidophilus and B. bifidum in faeces after consumption of lactobacilli- and bifidobacteria-containing products have been reported (7,8). However, cell wall materials from dormant and non-colony forming cells of L. acidophilus and B. bifidum supply appreciable amounts of material which can be utlized by the intestinal flora, thus contributing to the production of short chain fatty acids (lactic, acetic, etc). It has been shown that B. bifidum is a more efficient producer of acetic acid than L. acidophilus. The ability to tolerate low pH and high concentrations of bile acids has been considered important when selecting and growing L. acidophilus and B. bifidum together for therapeutic use. The acid tolerance of these bacteria is as low as pH 3; the bile acid resistance has been shown for L. acidophilus to be 2% and for B. bifidum as high as 7-8% bile acid concentration. The two bacteria, mixed in a certain ratio before inoculation, enable the product to contain 800-900 million acidophilus cells per ml and 500-800 million bifidobacteria cells per ml.
L. acidophilus belongs to the group of gram-positive non-sporulating facultative or anaerobic rods and is a natural inhabitant of the normal healthy gut flora. The main end product of glucose fermentation is lactic acid, acetic acid and hydrogen peroxide. These metabolites make the environment less favourable for the in vitro and in vivo growth of potentially pathogenic microorganisms (9). Bifidobacteria are gram-positive, non-motive, anaerobic bacteria and take a variety of shapes. These organisms are likewise natural inhabitants of the gut of humans and animals. Lactobacilli and bifidobacteria play a significant role in controlling intestinal pH by the production of lactic and acetic acids. These acids cause the intestinal pH to drop, which in turn restricts or prohibits the growth of many potentially pathogenic and putrefactive bacteria. By controlling intestinal pH, it is possible to control and limit the production of substances noxious to the host including vasoconstricting amines, phenols, ammonia, steroid metabolites, bacterial toxins, and others. There is a general tendency for both L. acidophilus and B. bifidum to decline in numbers with aging of the individuals. In order to maintain a proper composition and function of the large intestinal flora bifidobacteria are considered especially important. It is assumed that the lowered pH in the lower part of the colon gives rise to increased peristalic movements, decreased transit time and higher faecal fluid content.
Introducing lactobacilli and bifidobacteria into the food chain can be difficult. It has been shown that lactobacilli counts of 1,000 million and bifidobacteria counts of 1-100 million per gram can be established in fermented milk (CULTURA) by proper selection and modified culturing techniques. The ingested portion of 500 ml CULTURA per day contains at least 10,000 million viable cells and also a large number of dormant cells containing a variety of physiologically active compounds. In the presence of lactobacilli and bifidobacteria, bacterial fermentation of intestinal contents produces short chain fatty acids (acetic, lactic, butyric, propionic) and other predigested nutrients, which are easy to absorb and utilise for the aged patient.
The investigation was divided into four periods, each period lasting 5-6 weeks. In periods I (38-44 days) and III (32-42 days) 500 ml CULTURA and in periods II (32-42 days) and IV (15-37 days) 500 ml of non-fermented milk was given daily as a diet supplement. The amount of CULTURA or milk was divided into several portions if needed. Before the first phase of the trial period each patient's bowel habits were registered for several weeks while on traditional regimen. Then, during the study the nursing staff recorded details on the frequency and time of bowel motions and faecal consistency. Medication continued as needed throughtout the study. Laxatives were administered if needed during the whole study. The types of laxatives were: Microlax enema (Sodium acetate, 90 mg, Sodium laurylsulphoacetate, 9 mg); Resulax enema (Sorbitol, 7.5 mg); Laxoberal oral solution (Sodiumpicosulphate; 7.5 mg); Dulcolax tablets (Bisacodyl, 5 mg, lactose 37 mg); Klyx enema (Sodium dioctylsulphoxine, 0.1 mg, Sorbitol); and Castor oil.
This study shows that natural bowel evacuation can be improved in elderly and severely immobilised patients by the administration of lactobacilli and bifidobacteria in the form of CULTURA. The differences in the frequency of bowel movement based on Wilcoxon's signed rank test for paired values between phase I and II (p < 0.001) and between phase II and III (p < 0.05) were statistically significant. The rate of bowel movement increased significantly whereas the administration of laxatives did not change. The sensoric properties of the product were considered very good in our study, CULTURA gaining high acceptability from the geriatric patients as well as from the staff members. There was therefore no difficulty making the patients comsume 500 ml daily as a supplement to their diet. Ingestion of large numbers of viable cells of L. acidophilus and B. bifidum provided no negative side-effects and appears unlikely to exacerbate the electrolyte disturbances which may follow chronic administration of stimulant laxatives. CULTURA can thus be used as an effective supplement to a wide range of treatments for the management of bowel disorders in the elderly. An advantage of CULTURA over conventional bulking agents is its content of viable cells of L. acidophilus and B. bifidum and easily-absorbable nutrients as well as its pleasant flavor and consistency.