Neurogastroenterology & Motility

Neurogastroenterol Motil (2013) 25, 415 doi: 10.1111/nmo.12046

REVIEW ARTICLE

Gut microbiota and gastrointestinal health: current concepts and future directions
, A. EMMANUEL , F. GUARNER Q. AZIZ ,* J. DORE

&

E. M. M. QUIGLEY

*Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK dEcologie et Physiologie du Syste ` me Digestif, Institut National de la Recherche Agronomique, Jouy en Josas, France Unite GI Physiology Unit, University College, London, UK Digestive System Research Unit, University Hospital Vall dHebron, Barcelona, Spain Department of Medicine, Alimentary Pharmabiotic Centre, University College Cork, Cork, Ireland

Abstract Background The microbial community of the human gut the enteric microbiota plays a critical role in functions that sustain health and is a positive asset in host defenses. In recent years, our understanding of this so-called human super organism has advanced, following characterization of fecal metagenomes which identied three core bacterial enterotypes, and based on basic and clinical research into the impact and consequences of microbiota biodiversity and change on gastrointestinal disorders and diseases. Purpose This article considers current knowledge and future perspectives on the make-up and function of human gut microbiota, with a particular focus on altered microbiota and gastrointestinal disorders, nutritional inuences on the gut microbiota, and the consequences for gastrointestinal health, as well as improved understanding of gut-microbiotabrain communication. Keywords brain gut axis, functional, gut, microbiota.

INTRODUCTION
In recent decades, scientic and clinical research has identied the intestinal microbial community (microbiota) as an essential super organism pivotal to health and disease. There is great symbiosis between the human host and its gut microbiota. The enteric microbiota play a key role in immune function, are important in digestion and metabolism, affect and inuence braingut communication, and are thus essential to normal gut physiology and health. Consequently, alteration or instability of the microbiota and changes in its biodiversity are characteristic of a number of gastrointestinal disorders and metabolic diseases. Understanding the complex hostmicrobiota relationship and how it may be modulated is of importance from a health and from a societal perspective. The study of gut microbiota is a rapidly moving eld of research. Knowledge about the various contributions of the microbiota to health is still in its infancy and much remains to be discovered. This article provides an overview of some of the recent hypotheses, theories, and research regarding the role of gut microbiota in health and disease, and provides thoughts and concepts for future areas of research. Specically, this study focuses on ve related topics: 1 The human gut microbiota as a super organism. 2 Alterations in the microbiota in gastrointestinal disorders. 3 Nutritional inuences on the gut microbiota and the consequences for gastrointestinal health.

Address for Correspondence Prof. Qasim Aziz, PhD FRCP, The Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, 26 Asheld Street, Whitechapel, London E1 2AJ, UK. Tel: +44 (0)20 7882 2630; fax: +44 (0)20 7882 2655; e-mail: q.aziz@qmul.ac.uk Received: 27 August 2012 Accepted for publication: 20 October 2012

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4 Gut-microbiotabrain communication. And concludes with 5 Implications of current knowledge and on-going research for the future of gastrointestinal health care.

The human gut microbiota super organism

The human gut is the habitat for a diverse and dynamic microbial ecosystem a so-called microbiota superorganism. Each individual has a unique signature gut ora, composed of some 1001000 microbial species,1 made up of a common core, composed predominantly of bacterial species.2,3 Colonization of the gastrointestinal (GI) tract starts at birth and evolves and changes over a lifetime, such that the adult human GI tract is home to a unique ecosystem of several billion bacteria. The density of gut microbiota reaches its maximum in the distal colon with an estimated concentration of 1011 bacteria per gram of gut contents.4 While the gut microbiota evolves with age and varies in composition along the length of the GI tract, the microbiota is, in general, fairly resistant to environmental change, as illustrated by the remarkable stability of its species prole over time-scales spanning days to months and even years.1,5,6 A current goal is to characterize the human microbiota, enabling the study of its variation according to factors such as population, genotype, disease status and prole, age, nutrition, as well as exposure to various medications, and dietary factors. Worldwide, scientic and commercial interest in the cross-talk between microbes and their human hosts has also intensied fueled by the recognition that the intestinal microbiota plays a pivotal role in many aspects of human disease,79 and by the expanding markets for probiotics and prebiotics, some of which have shown signicant health benets in clinical trial settings10,11 (see also section 3). The make-up of the human gut microbiota metagenomics Advances in culture-independent techniques have spearheaded our knowledge of the complexity of this ecosystem. A detailed review of these techniques is beyond the scope of this article, but readers are referred to recent reviews by Fraher et al.12 and Simren et al.13 In summary, metagenomics involves the direct and complete assessment of the genomic content of an environmental sample or ecosystem, and has been crucial in characterizing and advancing our understanding of human gut microbiota. In Europe, the MetaHIT-integrated project (http:// www.metahit.eu) has contributed immensely to this effort.

The most recent metagenomic explorations into the composition of human gut microbiota have employed direct shotgun sequencing of combined mixed genomes of gut microbiota, building on earlier studies involving comparative ribosomal DNA sequencing of complete or partial ribosomal DNA (16S rDNA).14,15 This sequencing has permitted a description of the complete repertoire of human gut microbial genes, highlighting the dominance of bacteria, and, strikingly, identifying that, despite the richness and high individual specicity of the human gut microbiota, there are some common and core patterns and features.3,15 Age-related changes in gut microbiome are now recognized. The microbiota of infants is seeded at birth with dominance of aerobes and factors such as mode of delivery, breast feeding, weaning, and antibiotic use inuencing its composition which usually alters to a predominance of anaerobes within a few weeks of life.16 In adults, the human gut microbiota appears to have a dominant phylogenetic core.2 Initial 16S rDNA sequencing identied Gram-negative Bacteroidetes, Gram-positive Firmicutes, and Grampositive Actinobacteria as the dominant phyla.14 Direct metagenomic sequencing of the gut microbiome has identied and dened three robust clusters or enterotypes each characterized by a specic set of networked bacterial genera.15 These are the Bacteroides-, the Prevotella- and the Ruminococcus-dominated enterotypes, proles which may, in part, be determined by long-term nutritional habits.17 This ground-breaking research highlights this across the globe; although each individuals microbiota prole is unique, all humans share a common pattern of gut microbiota in which three main bacterial phyla are likely to determine an individuals response to diet or drug therapy. However, these observations may not apply to the elderly as with advancing age immune function declines with an increase in facultative anaerobes, shifts in ratios of bacteroides to rmicutes species, and marked decrease in bidobacteria in those over 60 years.18 Furthermore, in the elderly, microbial diversity and composition is primarily driven by dietary factors and the microbiota, in turn, may signicantly inuence inammatory tone and health status.19 Although the core nature of the human gut microbiota is fairly resistant to environmental changes,1,5,6,20 factors which predispose toward alterations in the make-up of the gut microbiota can precipitate specic disease states or, in contrast, be protective against disease, as will be described in later sections of this review (Fig. 1).

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Figure 1 The human gut microbiota main enterotypes (Based on image from Arumugam et al.).15

Summary and future directions: the human gut microbiota super organism 1 What is currently known about this topic The gut microbiota constitute an essential ecosystem a super organism vital to normal health. The human gut plays host to around 1000 microbial species including several billion bacteria. Each individual has a unique signature gut microbiota ora. Metagenomic sequencing has allowed for a description of the complete repertoire of human gut microbial genes highlighting a bacterial core that is common to all humans. There are three dominant enterotypes of networked bacteria. s The Bacteroides-, the Prevotella- and the Ruminococcus-dominated enterotypes. Shifts, or an imbalance in, gut bacterial colonies can precipitate specic disease inducing activity (dysbiosis) or may engender disease protective activity (probiosis). 2 Future directions/impact on clinical practice in the foreseeable future Metageonomics may play a future role in diagnosis, prognostication, and in the optimization of treatment optimization. The composition and functional characteristics of a healthy gut microbiota remain to be ellucidated. The impact of diet and dietary changes in the short- and long term on the microbiota.

Alterations in the microbiota and gastrointestinal disorders

The human host and its indigenous microbiota have coevolved such that the normal interaction between

gut bacteria and host is a symbiotic relationship in which the microbiota has become integral to host homeostasis,21 physiology, metabolism, and immune responses.22,23 The main functions of the microbiota can be broadly categorized into three groups metabolic, protective, and trophic functions.21 In terms of their metabolic importance, the gut microbiota maximize caloric availability of ingested nutrients by extracting additional calories from indigestible oligosaccharides and by modulating the absorptive capacity of the intestinal epithelium to key nutrients and minerals.24 Bacteria contribute enzymes that are absent in humans and thus contribute to catabolism of dietary bers and complex carbohydrates,25 and play a role in vitamin synthesis. The gut microbiota also ferment malabsorbed carbohydrates to provide energy for bacterial growth a by-product of which is the production of short-chain fatty acids (SCFA) which have a trophic role in the GI tract (see below). The protective functions of gut microbiota occur at several levels through mucosal adhesion and the crowding out of potential pathogens, through the elaboration and secretion of anti-microbial peptides (such as bacteriocins), as well as through interactions with various components of the intestinal barrier26 and immune response. The disruption of this symbiotic equilibrium can be altered through the use of antibiotics and lead to the emergence of opportunistic enteric pathogens such as Clostridium difcile. Gut microbiota can also have trophic functions modulating and inuencing gut epithelial cell differentiation and proliferation, affecting neuroendocrine pathways, and impacting on homeostatic regulation of the immune system. Extensive cross-talk between the gut bacteria and the immune system, contributes to the development of a healthy immune system. Gut commensals can also induce regulatory T cells, allowing the host to tolerate the massive burden of antigens presented to the gut, ensuring that innocuous antigens

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do not trigger inammation; the phenomenon known as tolerance2729 Among the gastrointestinal (GI) conditions linked with altered gut microbiota are acute diarrhea, irritable bowel syndrome (IBS), and inammatory bowel diseases (IBDs).30 Certain malabsorption syndromes have been associated with an excess of colonic-type ora within the small intestine; small intestinal bacterial overgrowth (SIBO).31 Emerging evidence also suggests that intestinal bacterial may initiate colon cancer through the production of carcinogenic chemicals.32 Finally, antibiotics can have short-term effects on gut microbiota and cause diarrhea due to pathological overgrowth of, for example, C. difcile or vancomycin-resistant Enterococci,21 as well as long-lasting effects on certain species and strains.33 Irritable bowel syndrome Irritable bowel syndrome is characterized by recurrent abdominal pain or discomfort, accompanied by abnormal bowel habits, in the absence of any discernible organic abnormality.34 Multiple pathological mechanisms are likely to be involved in IBS.35 A link between the intestinal microbiota and IBS has been suggested by differences between the microbiota of control groups vs that seen in groups of patients with IBS, where a relative reduction in lactobacilli and bidobacteria, combined with increased numbers of enterobacteria, coliforms, bacteroides, and rmicutes species, have been noted.3537 These modications may constitute a primary or secondary phenomenon.13,38 Certain IBS symptoms, including those of abdominal pain, bloating, and atulence may be related to excessive production of gas by bacterial fermentation in the distal bowel and colon. However, this mechanism is unlikely to explain symptoms in all patients, as overall gas volumes in IBS patients have been reported to be normal.39 Small intestinal bacterial overgrowth has also been controversially implicated in the pathophysiology of IBS40 as most studies describing this association have used breath tests41 which are not well validated as they can be inuenced by rapid small intestinal transit, use of proton pump inhibitors, and differences in diet etc. Furthermore, postinfectious IBS has been associated with a subtle and persistent inammatory process in the epithelium of the colon and it is increasingly thought that disturbances in gut microbiota, may occur and contribute to the symptomatology of IBS.4749 Other hypotheses include the activation of mucosal adaptive and innate immune response by abnormal microbiota, leading to altered epithelial permeability, activation of nociceptive sensory pathways, and

dysregulation of the enteric nervous system.13 In addition, epithelial defense mechanisms, including mucus secretion and host defense peptides (defensins), are dependent on the bidirectional signaling between microbiota and epithelium appear altered in IBS.42 Increased colonic mucosal expression of microbial recognition molecules such as Toll-like receptor 443 and increased circulating antibodies against components of indigenous microbiota have also been detected in IBS patients. Such abnormal microbialhost interactions could alter gut permeability, increase microbial antigenic load, and contribute to the sensory-motor dysfunction often observed in IBS. Furthermore, there is evidence for altered systemic immune response in IBS with an abnormal IL-10/IL-12 ratio in stimulated peripheral blood mononuclear cells which normalized after the use of proboitics.44,46 Evidence to support a role for microbiotahost interactions as important in IBS also comes from clinical trials demonstrating benecial impacts for antibiotics,50 prebiotics,51 and probiotics in IBS.31,47 Recent meta-analysis of randomized controlled trials of probiotics in patients with IBS and related functional disorders found that, overall, these preparations were better than placebo at improving global IBS symptoms11 (Table 1). However, variations in trial design, poor quality of many of the studies, and a paucity of information on the potential mechanisms of actions of probiotics limit that interpretation of available data. Furthermore, benets for probiotics over placebo in IBS have generally been modest and it is not yet known whether specic probiotics help to reduce specic symptoms and whether products with single strain are better than those with multiple strains. Further wellcontrolled studies are required. IBD Inammatory bowel diseases Crohns disease, ulcerative colitis, and pouchitis are also thought to involve a degree of continuous microbial antigenic stimulation of pathogenic immune responses, due to host genetic defects in mucosal barrier function, innate bacterial killing, or immunoregulation.52,53 IBD susceptibility is associated with host polymorphisms in bacterial sensory genes such as nucleotide-binding oligomerization domain-containing 254 and TLR4.55 Early childhood exposure to antibiotics causing diminished microbial diversity has been linked to increased risk of Crohns disease.56 It has been suggested that a subset of Crohns disease and ulcerative colitis patients may have specic abnormalities in microbiota.57,58 For instance Enterobacteriaceae family may interact with a disordered microbiome to increase the risk of UC, whereas a

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Table 1 Meta-analyses and systematic reviews of probiotic therapy in irritable bowel syndrome Number of studies (number of subjects) 3 (168) children only 20 (1414) 8 (922) 20 (1628)

Authors HuertasCeballos et al. McFarland and Dublin Nikfar et al. Moayyedi et al.

Year 2008 2008 2008 2010

Outcome No benet Pooled OR for improvement 1.17 (0.622.21) Less global IBS Symptoms: RR 0.77 (0.60.94) Less abdominal Pain: RR 0.78 (0.690.88) Clinical improvement : RR 1.22 (1.071.4) Outcomes as a dichotomous variable: 11 RCTs (n = 936) RR of IBS not improving = 0.71; 95% CI = 0.57 to 0.87, NNT = 4 IBS score as a continuous outcome: 15 RCTs (n = 1351) SMD = )0.34; 95% CI )0.60 to)0.07) Outcomes as a dichotomous variable: 7 RCTs (n = 895) OR for overall improvement = 1.6 (1.22.2) Continuous data: 6 RCTs (n = 657) SMD for overall improvement = 0.23 (0.070.38) Only Bidobacterium infantis 35624 showed signicant improvement over placebo in an appropriately designed study LGG associated with a signicantly higher rate of treatment responders in children with IBS (RR 1.70, 95% CI 1.272.27, NNT 4)

Ref.
89

90

91 11

Hoyveda et al.

2009

14

92

Brenner et al.

2009

16

93

Horvath et al.

2011

3 (167) children only Lactobacillus rhamnosus GG (LGG) only

94

RCT, randomized controlled trial; RR, relative risk; OR, odds ratio; CI, condence interval; NNT, number needed to treat; SMD, standardized mean difference.

Summary box and future implications: alterations in the microbiota and gastrointestinal disorders 1 What is currently known about this topic The normal interaction between gut bacteria and host is symbiotic the gut microbiota is integral to host homeostasis. Gut microbiota have three broad functions metabolic (supporting digestion), protective (supporting host immunity and defenses), and trophic (involved in cross-talk with the immune system and inuencing cell growth and differentiation). Changes in composition or function of gut microbiota may lead to acute or chronic disease states and syndromes. Some patients with IBS appear to have an abnormal composition and higher temporal instability of their intestinal microbiota. Some probiotics have been shown in randomized clinical studies to improve symptoms of IBS. 2 Future directions/impact on clinical practice in the foreseeable future Further research is needed to better understand the mechanisms through which changes in the microbiota dysbiosis promotes and perpetuate supports disease states or precipitate results in clinical symptom onset. Need to say something about the host immune response to the microbiota and how this needs to be better understood and syndromes. Manipulations in dietary intake and the use of pre, pro, and antibiotics may offer a means to manage or correct microbiota changes important to disease propagation and maintenance.

deciency of the anti-inammatory bacterium Faecalibacterium prausnitzii59 and an over-representation of enterococcus faecium and protobacteria may occur in Crohns disease. To date, in vitro studies have shown that the proinammatory effects of E Coli on inamed

mucosa in Crohns disease can be counteracted by probiotics,60 but, as yet, there have been relatively few clinical studies of probiotics in the IBD, and results have been mixed and indicate that further appropriately powered, high-quality randomized controlled

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Figure 2 Probiotics potential protective actions (From Guarner 2011, based on Figure 25).

trials are warranted.21 Putative mechanism of probiotic efcacy in IBD include production of bacteriocins (products that alter the growth of certain bacteria) to alter the composition of gut bacteria and reduce proinammatory strains, altered epithelial barrier function by SCFA production, in particular butyrate which may enhance colonocyte function and repair of the mucosa, and activation of regulatory T cells may lead to downregulation of inammation. In terms of therapy, the strongest evidence is in the area of pouchitis, whereas in Crohns and ulcerative colitis the best that can be said is that probiotics are adjunctive therapies61 (Fig. 2).

Bacteroidetes, and bacteria known to contain genes for cellulose and xylan hydrolysis. The authors postulated that the microbial diversity seen in children eating a ber-rich, rural diet (aspects of which were lacking in European children), may be important, not only for maximal energy extraction from the diet, but could also be key to protecting children from inammation and non-infectious colonic diseases.63 Indeed, several lines of research now suggest that diet affects the composition and metabolic activity of the gut microbiota and that this, in turn, can have effects on immune and inammatory responses that have far reaching consequences for host health. A Western diet characterized by food that has been stored, transported, and processed, provides a lower intake of complex plant polysaccharides (ber) which leads to less production, by gut microbiota, of key immunomodulatory products, in particular SCFAs.64 As there is clinical evidence that a diet rich in dietary ber offers clinical benets in IBD,64 it would appear that such a diet, by promoting the proliferation of a gut microbiota capable of producing SCFAs, may exert anti-inammatory effects. Obesity and metabolic diseases A key area of current interest is the role of gut microbiota as an environmental factor in relation to obesity. The obese phenotype is associated with increases in microbial fermentation and energy extraction from nutrients and it appears that alterations in gut microbiota composition may increase the efciency of energy harvest from food stuffs and so contribute to obesity.22,25,6567 The precise pathophysiological processes whereby gut microbiota may contribute to obesity and the metabolic syndrome remain only partly understood.68 However, it is postulated that changes in gut microbiota composition, possibly linked with diet, can lead to production of proinammatory molecules and to changes in host gene expression that affect gut epithelial cells and endocrine functions, perturbing homeostatic pathways, and impacting on insulin resistance and adiposity.25,66,6972 Further evidence showing the inter-relationship between gut microbiota and altered metabolic states comes from the observations that bariatric surgery alters gut microbiota in a manner similar to that related to anorexia and starvation73 and evidence from animal models that gut microbiota may play a role in both the etiology of non-alcoholic fatty liver disease and its progression to its more advanced state, nonalcoholic steatohepatitis. Both of these conditions have been linked with obesity, type 2 diabetes mellitus, and the metabolic syndrome.74

Nutritional inuences on the gut microbiota and the consequences for gastrointestinal health
Diet and gut microbiota Insights into how diet and nutritional status inuence the composition and function of gut microbiota, and consequently GI health, are emerging from both basic and clinical research.62 For instance, a relationship between diet, microbiota, health status, aging, and inammation has recently been described.19 In this study the fecal microbiota composition in elderly subjects signicantly correlated with measures of frailty, comorbidity, nutritional status, markers of inammation, and with metabolites in fecal water. The individual microbiota of people in long-stay care was less diverse than that of community dwellers and loss of community-associated microbiota was associated with increased frailty. Diet has a considerable inuence on microbial composition, and functions, as recently demonstrated in a seminal study comparing the fecal microbiota of European children to that of children from rural Africa.63 The study demonstrated that a diet rich in ber is essential to supporting a microbiota rich in

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Taken together, current basic and clinical research suggests that the gut microbiota are, therefore, a potential nutritional and pharmacological target in the management of obesity and obesity-related disorders. Other GI/nutritional disorders Functional symptoms: An area of continuing research interest is how gut microbiota and nutrition impact on constipation. Dietary ber is important both for avoidance and for management of constipation and has been used empirically in clinical settings for decades. There is now interest in delineating the colonic microbiota implicated in constipation, how microbiota and ber interact to inuence gut and colonic function and motility, and in how pre- and probiotics may inuence constipation in general and constipation in IBS (C-IBS) in particular.48 In addition, altered intestinal fermentation has been related to functional alteration in gut microbiota in C-IBS patients where the numbers of lactate-producing and lactate-utilizing bacteria and the number of H2-consuming populations, methanogens and reductive acetogens, are reported to be lower compared with control subjects; whereas the number of lactate- and H2-utilizing sulfate-reducing population was increased. It is suggested that such microbiota-related metabolic changes could inuence gut physiology and contribute to IBS pathogenesis.75 Celiac disease and SIBO: Celiac disease is an immune-mediated enteropathy characterized by chronic inammation of the small intestinal mucosa and there is some evidence to suggest that gut microbiota may play a role in proinammatory processes in the duodenum contributing to disease pathology and symptoms.76 Small intestinal bacterial overgrowth can be considered an example of a situation in which dramatic alterations in the gut microbiota, usually in the context of small intestinal stasis, impact negatively on nutritional status producing maldigestion and malabsorption, leading to nutritional and vitamin deciencies. Management of SIBO involves, ideally, the correction of the underlying disorder, or, if this is not possible, the use of antibiotics to suppress the bacterial population of the small intestine. There is as yet little evidence, despite their theoretical potential, that probiotic supplements have a role in patient management in SIBO77 (Fig. 3).

Figure 3 How diet impacts on microbiota and health (based on gure from Maslowski).64

Summary and future implications: nutritional inuences on the gut microbiota and the consequences for gastrointestinal health 1 What is currently known about this topic The diet has a considerable inuence on microbial composition and on the functions and effects of the microbiota. A ber-rich diet appears to promote microbial diversity and maximal energy extraction and may help protect against inammation and non-infectious colonic diseases. It may be possible to manipulate the gut microbiota to manage aspects of inammatory diseases and disorders of the GI tract. 2 Future directions/impact on clinical practice in the foreseeable future Future research is likely to employ dietary databases that monitor and capture information on patterns and trends in food consumption that may inform understanding of the inuence of human nutrition on the gut microbiota and GI health. Carefully controlled trials are needed to determine the inuence of diet on development of inammation and in the etiology of GI diseases. brain axis acknowledges an ability of gut microbiota to communicate with the gut and the brain and is emerging as an exciting concept in health, affording as it does, new opportunities for potential intervention in GI disease states and functional syndromes.7880

Microbiota and braingut communication in health and disease

The braingut axis is a recognized homeostatic construct that in recent years has been expanded to encompass the gut microbiota. The microbiota-gut

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Comprising the CNS, the neuroendocrine and neuroimmune systems, the autonomic nervous system, the enteric nervous system, and the intestinal microbiota, the microbiota-gutbrain axis is a bidirectional system. Signals from the brain can inuence motor, sensory, and secretory modalities of the gastrointestinal tract and in turn, visceral messages from the gastrointestinal tract can inuence brain function.81 In one direction, the brain can indirectly affect enteric microbiota by effecting changes in gastrointestinal motility, secretion, and/or intestinal permeability, or may directly inuence microbiota via neuronally signaled release of molecules from enterochromafn cells, neurons, and immune cells. In the other direction, enteric microbiota communicate with the brain via multiple mechanisms that may include direct stimulation of receptor-mediated signaling, enterochromafn-cell signaling, through vagal afferents,81 and the recently described humoral route.45 This gut brain signaling can alter brain morphology, and neurochemistry such as GABA and serotonin levels.45,78,81 This microbiota-related brain communication is implicated in pain perception, and the modulation of immune responses and emotions. Inuence of gut microbiota on CNS signaling comes from various strands of evidence. For instance, studies in germ-free mice (GFM) have shown the importance of gut microbiota in the development of the hypothalamic pituitary adrenal (HPA) axis. For instance, restrained stress caused an increase in HPA response in GFM compared with controls, which was partially reversed after recolonization in GFM with fecal matter control mice and by administration of Bidobacterium infantis in a time-dependent manner. This study suggested that gut microbial colonization must occur during a critical period in early life to ensure normal development of the HPA axis. Other inuences of microbiota on CNS development include descriptions in GF animals of reduced brain-derived neurotrophic factor82; a key neurotrophin involved in neuronal growth and survival, and expression of the NMDA receptor subunit 2a in the cortex and hippocampus compared with specic pathogen free controls. A role for the microbiota in anxiety-like behaviors is also suggested by the benecial effects of probiotics in reducing these. For example, administration of a combination of Lactobacillus helveticus R0052 and B. longum R0175 reduced anxiety-like behavior in rats83; whereas chronic treatment with the probiotic L. rhamnosus (JB-1) reduced levels of stress-induced corticosterone and depressive behaviors in the forced swim test. The L. rhamnosus (JB-1)-treated animals also showed altered expression of GABAB1b and

GABAA a2 mRNA in cortical and subcortical regions which may be mediated by the vagus nerve, as the vagotomized mice did not display the neurochemical and behavioral effects of this bacterium.81 The gut microbiota may also modulate pain perception, as specic Lactobacillus strains were shown to induce the expression of l-opioid and cannabinoid receptors in intestinal epithelial cells and mimic the effects of morphine in promoting analgesia.84 The role of gut-microbiotabrain communication in functional disorders such as IBS is the subject of ongoing research. It has been proposed that changes in gut ora inuence behavior and provide a basis for a novel unifying hypothesis that accommodates both gut dysfunction and the behavioral changes that characterize many IBS patients. There are a number of animal studies that highlight the bidirectional relationship between gut microbiota and the brain in terms of the impact of each on behavior.85,86 Stress can change the composition of the microbiota and such changes are associated with increased vulnerability to inammatory stimuli in the GI tract. In turn, experimental perturbation of the microbiota has been shown to alter behavior, with germ-free mice displaying Central neurochemistry and behavior suggestive of reduced anxiety compared with conventional mice.87 It has also been observed in animal models that administration of probiotic Lactobacillus and Bidobacterium species confer antidepressant and anxiolytic effects that appear to be mediated via vagal pathways.81,83 These observations suggest that targeting the gutmicrobiotabrain axis may provide a means of correcting stress-related disorders often comorbid with conditions such as IBS and inammatory bowel disease87,88 (Fig. 4).

Gut microbiota: implications for future health care

Metagenomics has the potential to provide a tool to stratify individuals according to their gut microbiota prole and may help identify predictors of disease relapse and/or chronicity. In this way, metagenomics may play a future role in diagnosis, prognostication, and in the optimization of therapy possibly being used to distinguish between closely related syndromes, or to predict or determine the intensity and type of medical care required. The potential marriage of culture-independent metagenomic methods with the eld of gnotobiotics (rearing germ-free animals and assessing exposure to microbial species or consortia) may hold the key to improved understanding of the interrelationships between diet, nutritional status, and gut microbial interactions and communication within the

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Figure 4 Gut-microbiotabrain bidirectional communication (base on Figure 6 from Collins).85

Summary and future implications: microbiota and braingut communication in health and disease 1 What is currently known about this topic Gut microbiota play a pivotal role in gutbrain communication. Gut microbiota activate neural afferent circuits and can stimulate immune and inammatory responses and signals that inuence behavior and perception. Many of the symptoms of functional disorders such as IBS involve a central component that may involve microbiota-gutbrain communications. 2 Future directions/impact on clinical practice in the foreseeable future Implications of the microbiome in understanding altered brain gut signaling in health and disease, in particular whether manipulation of the gut microbiome may have therapeutic implications in stress-related disorders. human host that extend beyond intestinal health to broader aspects of human health and well-being. There is a need for continued focus on how manipulation of gut microbiota might offer a new approach to the prevention and management of a host of clinical symptoms, syndromes, and disorders. Rational deployment of antibiotics, probiotics, and prebiotics, alone or in synergy, may provide an effective means of sustaining changes in the human microbiome that would help in the management of conditions as diverse as acute gastroenteritis, antibiotic-associated diarrhea and colitis, constipation, inammatory bowel disease, irri-

table bowel syndrome, necrotizing enterocolitis, diabetes, obesity, and a variety of other disorders and diseases. Future studies will no doubt improve our understanding of the cause and effect relationship between diseases described above and the gut microbiome. Future areas of improved knowledge are likely to include: the identication of the implications of perturbations of the gut microbiome in early life to disease susceptibility in later life; whether the metagenome predicts risk for specic human diseases such as IBD or GI cancers; effects of the microbiome on the pharmacology of medicines, including whether microbiota inuences pharmacokinetics and drug toxicity; implications of the microbiome in understanding altered brain gut signaling in health and disease, in particular whether manipulation of the gut microbiome may have therapeutic implications in stress-related disorders; harnessing of the microbiome to develop new narrow-spectrum antibiotics. These possibilities highlight the importance of understanding the impact of interactions between the gut microbiome and the host in terms of metabolic and immune functions and the potential to improve human health through disease management, risk reduction, stratied medicine, and thus providing a signicant challenge for scientists in the 21st century.

ACKNOWLEDGMENTS
This work is supported by the Gut Microbiota & Health section of the European Society of Neurogastroenterology and Motility (ESNM) and through an unrestricted educational grant from Danone. The ESNM working Team was led by Professor Qasim Aziz. All team members contributed equally to the manuscript

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and therefore the order is alphabetical. Support in manuscript preparation by Winnie McFadzean is acknowledged.

FUNDING
This work is supported by Gut Microbiota & Health section of the European Society of Neurogastroenterology and Motility and through a unrestricted grant from Danone.

grants from Science Foundation Ireland to the Alimentary Pharmabiotic Centre. He is a non-executive director of Alimentary Health which holds patents in the area of the gut microbiota, has consulted with and had research support from Procter and Gamble and received honoraria for speaking engagements from Danone, Yakult, Yakult Korea and Megapharma.

AUTHOR CONTRIBUTION
The working team was led by Professor Qasim Aziz and all authors contributed to specic sections of the manuscript. Final editing was performed by Professor Q Aziz and Professor E Quigley.

DISCLOSURE
QA has been on the advisory board for Danone and Protexin; AE has been on the advisory board for Danone, EQ is supported by

REFERENCES
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