Intestinal epithelial barrier integrity is essential for maintaining the homeostasis of mucosal function, and helps to increase the absorption of nutrients. The mucosal epithelial barrier can be challenged by encounters with bacterial or viral pathogens. The foremost drug-resistant barrier is the mucosal barrier which combat with infective pathogens after they enter the intestine.

The bodily fluid layer, the epithelial coating of mucosal tissues, as well as the resistant cells in the subepithelial layer are parts of the mucosal boundary. Microorganisms must cross the mucosal obstruction before they arrive at the epithelium. It very well may be construed that bodily fluid substance and primary changes could influence barrier capability. Investigations have discovered that unsafe microorganisms in the gut can create specific explicit substances to vitiate the mucus, in this manner impairing human wellbeing ⁸.

Augmented permeability of mucosa and disruption in the epithelial mucosa can play a key role in the pathogenesis of many “gastrointestinal disorders such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD)”, metabolic syndrome (obesity) and necrotising enterocolitis (NEC) ⁹. Probiotics can improve the intestinal epithelial barrier and can modulate intestinal mucosal function, thus improving health status by augmenting the mucus secretion by goblet cells (Figure 1). Probiotics augments the IgA levels in IgA secreting cells in the “lamina propria” and increase the secretory IgA into the luminal mucous layer and helps to maintain the epithelial barrier function. For example, probiotic “L. plantarum BMCM12” safeguard the intestinal barrier by secreting extracellular proteins and diminish the pathogenic adhesion. The metabolites of probiotics such as butyric acid exerts beneficial effects in maintaining the epithelial barrier ¹⁰. Previous studies reported that probiotics lessens the permeability of intestine and protect the gut ⁸. Few studies reported that VSL#3, a probiotic mixture can intermingle with epithelial cells in the intestine and aid to sustain the epithelial mucosal barrier integrity ^{11, 12, 13}.

Figure 1

Human intestine harbors a huge number of microorganisms including harmful and beneficial organisms and probiotics. These pathogenic or harmful microorganisms can change the gut microbiota homeostasis and impose a major risk of developing GI diseases ¹⁴. The action of probiotics on inhibiting the pathogenic organisms are illustrated in Figure 2.

Figure 2

Recent findings highlighted that probiotics (live) and their metabolites can exert immunoregulatory functions 15, 16, 17. Modulation of immune system by probiotics use is depicted in Figure 3. More research studies are required to explore the action of probiotics on maturation of gastrointestinal immunity.

Figure 3

Probiotics can regulate the gut microbiota composition and aid in inhibition of intestinal pathogenic bacterial colonisation and augments the immunity and maintain the integrity of mucosal layer of intestine. Modulation of gut microbiota by fermentation of nutrients and thus acidifying the colon and enhances immunity.

The World Gastroenterology Organization, 2011 18 formulated guidelines for the use of probiotics and prebiotics in adults and children Table 1. The diseases are21

Immunonutrition encompasses triggering our body's immune system through the intake of specific nutrients. Immunonutrition uses nutritional interventions to produce health-related effects beyond the primary nutrient value and regulate the neuroendocrine immunoinflammatory responses. Immune Modulating Formulations or immunonutrient are nutritional supplements with arginine, glutamine, nucleotides, omega-3/6 fatty acids, sulphur containing amino acids and antioxidants (Figure 4).

Figure 4

Down regulation of pro-inflammatory cytokines and inflammatory responses

In a recent study recommended the significance of early nutritional planning with nutritional counseling among patients with end stage liver disease patients waiting for liver transplant to improve the clinical outcomes and liver function and the use of immunonutrient didn’t show any statistically significant difference in liver function, but had showed some clinical improvement ³¹.

Nutritional screening/assessment to be performed on all patients with Gastrointestinal disorders at the time of diagnosis or their visits during OPD and/ within 24 hours of admission and thereafter on a regular basis.

A recent study revealed that 45% of patients with GI diseases were malnourished. Hence, it is very essential to detect and manage malnutrition in patients with gastrointestinal disease as it will influence the patient’s clinical outcome and health care costs ³².

Global Leadership Initiative on Malnutrition [GLIM] in 2016 with ESPEN recommended ‘three phenotypic criteria’ (non-volitional weight loss, decreased body mass index, and less muscle mass) and ‘two etiologic criteria’ (less food intake, and inflammation or disease burden). The diagnostic criteria for malnutrition are the presence of at least one phenotypic and one etiologic criterion. Phenotypic criteria are used for assessing malnutrition as ‘stage 1 (moderate)’ and ‘stage 2 (severe)’. The etiologic criteria are intended for planning nutritional intervention and expected clinical outcomes ³³. CLD patients have less capacity to bear protein and PEM is corresponded with lack of vitamin A, zinc and magnesium.

Probiotics have not been tested for use in SBS (short bowel syndrome) rehabilitation. A few articles have portrayed the utilization of probiotics in SBS for treating D-lactic acidosis ³⁷.

“Grade of recommendation B/0 e consensus (89% agreement)”

Grade of recommendation 0/GPP e majority agreement, 64% agreement” ^{38 .}