Comprehensive Gastro-Intestinal Solutions

Genesis Laboratory Management, LLC (Genesis Lab) is a state-of-the-art CAP accredited and CLIA certified laboratory providing molecular diagnostic and anatomic pathology solutions for gastrointestinal diseases. From the beginning, our goal has been to advance the current knowledge, fill in the gaps that exist in the diagnosis and treatment of Gastrointestinal (GI) diseases, and improve clinical management outcomes.

Approximately 375 million episodes of diarrheal illness occur in the United States annually. Healthcare providers experience an overwhelming 73 million consultations resulting in 1.8 million hospitalizations. Mortality figures are in excess of 3,000 deaths with over $6 billion of associated medical care and lost productivity (1).

This is an integrated multiplex PCR based test for the simultaneous detection of 22 of the most commonly diagnosed diarrhea pathogens in humans (13 bacterial species including toxigenic C. difficile A/B, five viruses and four parasites). This panel test is performed on a BioFire FilmArray platform, which is 100% sensitive for 12/22 targets and over 94.5% sensitive for the remainder. Integrated multiplex PCR and bead array technology offer a highly sensitive and specific method of gastrointestinal pathogen detection. The specificity is greater than 97% for all panel targets. This DPP panel has been shown to have a much higher (at least 4.4-fold) detection rate than conventional methods and has also been shown to improve clinical management, reduce or eliminate hospital stay and to lower healthcare cost significantly. (1). The turnaround time (TAT) for this test is 1 hour after the sample is received in our lab and our staff reports the positive results to the referring practices immediately after completion. The samples are usually sent by overnight Federal Express by the patients in the provided pre-paid envelope and hence the results are known in most instances within 24 hours to the physician and the patient.For a list of pathogens tested click here. 

References:

  1. 1. Clinton, L. K., Enomoto, T., Ying, C., Kim, W., &Bankowski, M. J. (2014). Test Performance of the FilmArray Gastrointestinal Panel ( BioFire) From a Clinical Trial Study in Hawaii[Pamphlet]. Boston, MA: Mbankowski@dlslab.com.
C. difficile carrier state is common (about 10% of adults and a much higher incidence in infants and children). Detection of toxigenic C. difficile on PCR does not automatically imply that C. difficile infection (CDI) is causing a particular case of diarrhea as many studies show that other pathogens may be responsible for acute diarrhea in many C. difficile carriers. To provide more information in such scenario, our lab reflexes all samples detected to have C. difficile on FilmArray® testing to a further C. difficile Toxin A/B rapid enzyme immunoassay (EIA) test to help differentiate the presence of C. difficile infection (CDI) from a carrier state. Most clinical and laboratory experts agree that testing for stool Toxin A/B should be a part of making a diagnosis of CDI. However, it seems to be rarely performed in most commercial laboratories in such situations(1).

References:

  1. 1. Sharp, S. E., Ruden, L. O., Pohl, J. C., Hatcher, P. A., Jayne, L. M., & Ivie, W. M. (2010). Evaluation of the C.Diff Quik Chek Complete Assay, a New Glutamate Dehydrogenase and A/B Toxin Combination Lateral Flow Assay for Use in Rapid, Simple Diagnosis of Clostridium difficile Disease. Journal of Clinical Microbiology,48(6), 2082-2086. doi:10.1128/jcm.00129-10

Various immunoassays (ELISA based) can be performed from the same sample collection, either individually or collectively and are part of the comprehensive panel. These immunoassays offer multiple clues to the etiology of the diarrhea symptoms in addition to testing for the infections.

  • Calprotectin – A measure of neutrophilic activity in the stool which is increased in various inflammatory conditions. An elevated value can be used to differentiate Inflammatory Bowel Disease (IBD) from Irritable Bowel Syndrome (IBS) and serial quantitative values can be used to measure activity of Inflammatory Bowel Disease (IBD).
  • Lactoferrin – It is similar to Calprotectin in most respects, but the measurement of Lactoferrin may be more stable in samples that are transported and stored for a prolonged period. (1)
  • EDN/ EPX (Eosinophilic derived neurotoxin or Eosinophilic protein X) – This is a measure of intestinal eosinophilic activity. Fecal EDN is considered to be the best of the cytotoxic granule proteins for assessment of gut eosinophilic inflammation. Elevated levels can be seen in food allergies (both IgE mediated and non-IgE mediated e.g. Celiac Disease). Higher levels can also be seen in eosinophilic gastroenteritis, parasitic diseases, or any other inflammatory conditions. (2) (3)
  • Anti-Gliadin Antibody (IgA) and tissue-Transglutaminase Antibody (t-TTG, IgA) – Elevated levels of these antibodies in the stool can be an indication of underlying Celiac Disease. (4) Overall sensitivity for finding elevated celiac antibodies in stool is low, especially if IgA deficiency is present, while the specificity is fairly high. The detection of any of these antibodies in stool should prompt testing for serum and biopsy evidence of Celiac Disease. (5)
  • Anti-Saccharomyces cerevisiae antibody (ASCA) – These antibodies present in 50-70% of patients with Crohn’s Disease and have been traditionally used to differentiate Crohn’s from Ulcerative Colitis. The frequency of elevated ASCA in the stool is as high as the serum in patients who produce this antibody. Additionally, the presence of ASCA may serve as a predictor marker in the development of Crohn’s Disease prior to onset.
  • Zonulin – This is a protein that can be used as a measure of intestinal permeability. Clinical studies show that Zonulin levels correlate with the “gold standard” Lactulose-Mannitol test for intestinal permeability. Fecal Zonulin has been shown to be an excellent biomarker of impaired gut barrier function. Increased intestinal permeability has been linked to many chronic gastrointestinal conditions. Additionally, activation of the Zonulin pathway has been implicated in the pathogenesis of Celiac Disease and metabolic disorders. Elevated levels are a non-specific finding and need to be correlated with clinical symptoms, but typically would not be seen in functional diarrhea. (6) (7)
  • Elastase – This quantitative test is used to measure levels of Fecal Elastase, a protein digesting pancreatic enzyme and is an excellent marker for Exocrine Pancreatic Insufficiency (EPI).
  • Fecal Bile Acids – Choleretic Diarrhea (caused by Bile Acid malabsorption) is a common occurrence after biliary surgery or after terminal ileal resection. In addition, it is also a common cause of ongoing diarrhea in many patients with inflammatory bowel disease (IBD) even if the bowel inflammation is controlled. Measurement of Fecal Bile Acids to distinguish choleretic diarrhea from other causes of chronic diarrhea has long been a sought after tool in the GI community. Genesis Lab has recently completed validation of this key test and it will be included in our immunoassays panel in the near future. Currently, we are the ONLY lab in the country offering such a valuable test. This has the potential to save a large amount of money being spent on unnecessary testing and very expensive medications to treat IBD when the cause of diarrhea may not be active inflammation. (8) (9)
 

References:

  1. 1. Fecal Lactoferrin Testing. (n.d.). Retrieved from https://www.gastroenterologyandhepatology.net/archives/december-2018/fecal-lactoferrin-testing/
  2. 2. Peterson, C. G., Eklund, E., Taha, Y., Raab, Y., & Carlson, M. (2002). A new method for the quantification of neutrophil and eosinophil cationic proteins in feces: Establishment of normal levels and clinical application in patients with inflammatory bowel disease. The American Journal of Gastroenterology, 97(7), 1755-1762. doi:10.1111/j.1572-0241.2002.05837.x
  3. 3. Saitoh, O. (1999). Fecal eosinophil granule-derived proteins reflect disease activity in inflammatory bowel disease. The American Journal of Gastroenterology, 94(12), 3513-3520. doi:10.1016/s0002-9270(99)00699-1
  4. 4. Rubio-Tapia, A., Hill, I. D., Kelly, C. P., Calderwood, A. H., & Murray, J. A. (2013). ACG Clinical Guidelines: Diagnosis and Management of Celiac Disease. The American Journal of Gastroenterology, 108(5), 656-676. doi:10.1038/ajg.2013.79
  5. 5. Tang, V., Valim, C., Moman, R., Richman, A., Zhou, J., Ramgopal, V., . . . Rufo, P. A. (2017). Assessment of Fecal ASCA Measurement as a Biomarker of Crohn Disease in Pediatric Patients. Journal of Pediatric Gastroenterology and Nutrition, 64(2), 248-253. doi:10.1097/mpg.0000000000001244
  6. 6. Wang, W., Uzzau, S., Goldblum, S., & Fasano, A. (2000, December 15). Human zonulin, a potential modulator of intestinal tight junctions. Retrieved from http://jcs.biologists.org/content/113/24/4435
  7. 7. Scheffler, L., Crane, A., Heyne, H., Tonjes, A., Schleinitz, D., Ihling, C. H., . . . Heiker, J. T. (2018). Widely Used Commercial ELISA Does Not Detect Precursor of Haptoglobin2, but Recognizes Properdin as a Potential Second Member of the Zonulin Family. Frontiers in Endocrinology, 9. doi:10.3389/fendo.2018.00022
  8. 8. Ruiz-Cerulla, A., Rodriguez-Moranta, F., Rodriguez-Alonso, L., Arajol, C., Ortega, T. L., Maisterra, S., . . . Guardiola, J. (2014). P275 Bile acid malabsorption involvement in Crohns disease symptoms. Its relationship with ROME III criteria. Journal of Crohns and Colitis, 8. doi:10.1016/s1873-9946(14)60396-2
  9. 9. Vitek, L. (2015). Bile Acid Malabsorption in Inflammatory Bowel Disease. Inflammatory Bowel Diseases, 21(2), 476-483. doi:10.1097/mib.0000000000000193
The following tests are all performed using the long-established usual methods and can be performed from the same sample if requested.
  • Stool sample stained with Sudan III for Fecal fat testing

1. Fecal Fat Stool Test, Semi-Quantitative – Fecal fat measures the amount of fat within a stool sample. Excess fat known as steatorrhea, can be tested for this, ultimately aiding in the determination of malabsorption and/or digestive disease. We test for both the presence of neutral fats and split fats in stool. Neutral fats (e.g.,monoglycerides, diglycerides, triglycerides) seen in excess is suggestive of steatorrhea, impaired synthesis or secretion of pancreatic enzymes or bile. An increase in split fats is suggestive of impaired absorption of nutrients. These neutral/split fats should be rare in normal stool samples. In order to test the stool sample we stain the stool with Sudan III for Fecal fat testing. Both fecal fat preparations are resulted in an semi-quantitative manner ranging from 0-3+ depending on microscopic criteria. Both tests are examined microscopically under 400x for evaluation.

  • Stool sample stained with Trichrome, Positive for Giardia lamblia

2. Ova & Parasites, Wet Mount & Concentrated Permanent Trichrome Stain – Ova & Parasite stool test is a microscopic exam to help diagnose the appearance of eggs, trophozoites and/or helminths found within stool. Parasitic infections often occur in the lower digestive tract, which may cause diarrhea. This test is performed on a stool sample with fresh stool for wet mount and Proto-fix preserved sample for concentrated Trichrome (permanent) stain. This test is microscopically evaluated under oil immersion field by experienced technologists. Ova & parasites are reported if identified, NEGATIVE or POSITIVE; however, life cycles may prevent a diagnosis and have a higher yield of identification in molecular studies, such as in our Diarrhea Pathogen Panel.

  • Stool sample stained with Trichrome for WBC stool Test 3+.

3. Fecal White Blood Cell (WBC) – White Blood Cell stool testing or Fecal Leukocyte test helps diagnose inflammatory diarrhea. This type of diarrhea may be an indication of an infection by bacteria, result of ulcerative colitis or inflammatory bowel disease. This test is performed on a stool sample with a microscopic evaluation using Trichrome stain. Fecal Leukocytes are rarely seen in diarrhea caused by other parasites or viruses. When leukocytes are seen in moderation with regular fecal background material it may indicate infection or other inflammatory processes. An increase in Fecal Leukocytes is a response to infection with microorganisms that may invade tissue or produce toxins, which cause tissue damage. This could also be suggestive of shigellosis and salmonellosis (erythrocytes) and sometimes amebiasis.

4. Fecal Immunohistochemical Test (FIT) – This test is used for the detection of human hemoglobin.

5. Fecal Osmolality and Electrolytes – This test is used for the differentiation of secretory and osmotic diarrhea.

  • Helicobacter pylori. (1)
  • Listeria monocytogenes.
The above pathogens are detected by using Real-Time PCR methods to detect nucleic acid sequences in human derived specimens. They are over 99% sensitive and specific for diagnosis of these organisms. In Development: Next Gen Sequencing (NGS) based determination of antibiotic resistance for H pylori, C. difficile and other pathogens.  

References:

 
  1. 1. Belda, S., Saez, J., Santibanez, M., Rodriguez, J. C., Galiana, A., Sola-Vera, J., … & Sillero, C. (2012). Quantification of Helicobacter pylori in gastric mucosa by real-time polymerase chain reaction: comparison with traditional diagnostic methods. Diagnostic microbiology and infectious disease, 74(3), 248-252.
Congenital Sucrase-Isomaltase Deficiency (CSID) is a disorder that affects a person’s ability to digest certain sugars. A person with this condition cannot break down the sugars sucrose and maltose. Sucrose (a sugar found in fruits and also known as table sugar) and maltose (the sugar found in grains) are called disaccharides because they are made up of two simple sugars. Disaccharides are broken down into simple sugars during digestion by intestinal disaccharidase.Sucrose is broken down into glucose and another simple sugar called fructose. Maltose is broken down into two glucose molecules. People with CSID cannot break down sucrose, maltose, and other compounds made from these sugar molecules (carbohydrates). CSID usually becomes apparent after an infant is weaned and starts to consume fruits, juices, and grains. After ingestion of sucrose or maltose, an affected child will typically experience stomach cramps, bloating, excess gas production, and diarrhea. These digestive problems can lead to failure to gain weight and grow at the expected rate (failure to thrive) and malnutrition. Most affected children are better able to tolerate sucrose and maltose as they get older (1). The prevalence of CSID is estimated to be 1 in 5,000 people of European descent. This condition is much more prevalent in the native populations of Greenland, Alaska, and Canada, where as many as 1 in 20 people may be affected. The disease is often missed or misdiagnosed, and may be confused with a number of other diseases if not tested for specifically. Examples of differential diagnosis are congenital intestinal malformations, infectious and post-infectious disease, lactose intolerance, endocrine disorders, pseudomembranous colitis, celiac disease, and cystic fibrosis. New Research Links Genetic Defects in Carbohydrate Digestion to Irritable Bowel Syndrome (2) Irritable Bowel Syndrome (IBS) affects a large portion of the general population. New research coordinated by Karolinska Institutet now shows a link between Defective Sucrase-Isomaltase gene variants and IBS. IBS is the most common gastrointestinal disorder. More than 10% of the population suffer from recurrent symptoms including abdominal pain, gas, diarrhea, and constipation. What causes IBS is largely unknown, and this hampers the development of effective treatment for many patients. Now an international research team led by Karolinska Institutet in Sweden have identified defective sucrase-isomaltase gene variants that increase the risk of IBS. The study is published in the scientific journal, GUT. By screening 1,887 study participants from multiple centers in Sweden, Italy and the US, they found that rare defective SI mutations were twice more common among IBS cases than healthy controls, and a common variant with reduced enzymatic activity was also associated with increased risk of IBS(3). The Gold Standard The Gold Standard for diagnosis of CSID has been distal duodenal biopsies which are analyzed for Disaccharidase (Sucrase, Isomaltase, Lactase, and Palatinase activity). Genesis Laboratory Management, LLC (Genesis Lab) is one of the only 11 or so labs in the country that specialize in analyzing Disaccharidase Assays in-house. Most larger labs, including LabCorp, outsource Disaccharidase assays to one of the 11 labs that perform this testing. There are no commercially available “kits” that can be used to perform such an assay. The sample transport and storage is tedious, requires timeliness and an exact amount of dry ice. The sample analysis is exact and precise, with many minute measurements. A larger lab cannot provide such personal attention to detail as many samples are compromised during transport, storage, or analysis. Thereby, this creates a great inconvenience and frustration to the clinician and the patient. As a result, Disaccharidase Deficiency is significantly under-diagnosed.

At Genesis Lab we spent over a year developing and validating our own Disaccharidase Assay by investing considerable resources. We have clinically validated our methods by comparing our results to that of other labs. We have been offering Disaccharidase testing in New Jersey with pickups arranged through our couriers. We have been receiving great reviews and feedback from happy and satisfied GI providers. Please contact us at 732-686-9291 to arrange for setting up Disaccharidase testing at your healthcare facility.

Treatment The treatment of CSID involves a strict and life-long “table-sugar” (sucrose) free diet. However, this is very difficult to adhere to today as much of the processed food we can buy contains sucrose. It is especially difficult for children to adhere to a diet free from sucrose. In the USA there is an approved pharmaceutical enzyme replacement therapy which can be used to compensate for the lack of an endogenous functioning enzyme. Such supplementation allows a more normal diet, including some intake of sucrose without the development of symptoms.  

References:

 
  1. 1. Treem, W. R. (2012). Clinical Aspects and Treatment of Congenital Sucrase – Isomaltase Deficiency. Journal of Pediatric Gastroenterology and Nutrition,55(2), S7-S14.
  2. 2. Henstrom, M., Diekmann, L., Bonfiglio, F., Hadizadeh, F., Kuech, E., Von Kockritz-Blickwede, M., . . . D\’Amato, M. (2018, February). Functional variants in the sucrase-isomaltase gene associate with increased risk of irritable bowel syndrome. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27872184
  3. 3. Karolinska Institutet. (2016, November 21). New research links genetic defects in carbohydrate digestion to irritable bowel syndrome. ScienceDaily. Retrieved May 10, 2019 from www.sciencedaily.com/releases/2016/11/161121093514.htm
 

References:

 
  1. 1. Bonino JA, Sharma P. (2005). Barrett’s esophagus. Current Opinion Gastroenterology, (21),461-465.
  2. 2. Cameron AJ, Ott BJ, Payne WS.(1985) The incidence of adenocarcinoma in columnar-lined (Barrett’s) esophagus. New England Journal of Medicine,(313),857-859.
  3. 3. Riegman PH, Vissers KJ, Alers JC, et al.,(2001) Genomic alterations in malignant transformation of Barrett’s esophagus. Cancer Research, (61),3164-3170.
  4. 4. Walch, A. K., Zitzelberger, H. F., Bruch, J., Keller, G., Angermeier, D., Aubele, M. M., . . . Werner, M. (2000). Chromosomal Imbalances in Barrett’s Adenocarcinoma and the Metaplasia-Dysplasia-Carcinoma Sequence. The American Journal of Pathology,156(2), 555-556. Retrieved from https://www.sciencedirect.com/science/article/pii/S0002944010647608
  5. 5. Falk, G. W., Skacel, M., Gramlich, T. L., Casey, G., Goldblum, J. R., & Tubbs, R. R. (2004). Fluorescence in situ hybridization of cytologic specimens from Barrett’s esophagus: A pilot feasibility study. Gastrointestinal Endoscopy,60(2), 280-284. doi:10.1016/s0016-5107(04)01687-6
  6. 6. Galipeau PC, Prevo LJ, Sanchez CA, Longton GM, Reid BJ.(1999). Clonal expansion and loss of heterozygosity at chromosomes 9p and 17p in premalignant esophageal (Barrett’s) tissue. JNCI: Journal of the National Cancer Institute, (91), 2087-2095.
  7. 7. Brankley, S. M., Wang, K. K., Harwood, A. R., Miller, D. V., Legator, M. S., Lutzke, L. S., . . . Halling, K. C. (2006). The Development of a Fluorescence in Situ Hybridization Assay for the Detection of Dysplasia and Adenocarcinoma in Barrett’s Esophagus. The Journal of Molecular Diagnostics,8(2), 260-267. doi:10.2353/jmoldx.2006.050118
  8. 8. Riegman, P. H., Burgart, L. J., Wang, K. K., Wink-Godschalk, J. C., Dinjens, W. N., Siersema, P. D., . . . Van Dekken, H. (2002). Allelic Imbalance of 7q32.3-q36.1 during Tumorigenesis in Barrett’s Esophagus. Cancer Research,62, 1531-1533. Retrieved from http://cancerres.aacrjournals.org/content/62/5/1531.full-text.pdf
  9. 9. Barrett, M. T., Sanchez, C. A., Prevo, L. J., Wong, D. J., Galipeau, P. C., Paulson, T. G., . . . Reid, B. J. (1999). Evolution of neoplastic cell lineages in Barrett oesophagus. Nature Genetics,22(1), 106-109. doi:10.1038/8816
  10. 10. Wong, D., Prevo, L., Galipeau, P., Paulson, T., Blount, P., & Reid, B. (2001). Clonal cell populations with p16 lesions arise early and expand within Barretts metaplastic epithelium. Gastroenterology,120(5), 8284-82849. doi:10.1016/s0016-5085(01)80390-5
  11. 11.Fritcher, E. G., Brankley, S. M., Kipp, B. R., Voss, J. S., Campion, M. B., Morrison, L. E., . . . Halling, K. C. (2008). A comparison of conventional cytology, DNA ploidy analysis, and fluorescence in situ hybridization for the detection of dysplasia and adenocarcinoma in patients with Barrett’s esophagus. Human Pathology,39(8), 1128-1135. doi:10.1016/j.humpath.2008.02.003

One of our main focuses has been to develop various stool tests that can help clinicians differentiate Functional Diseases from Non-Functional GI illnesses. Abdominal pain, bloating, and diarrhea are common symptoms shared by most GI illnesses. As such, the ability to differentiate between the Functional and Non-Functional etiologies is difficult and often requires a variety of expensive and sometimes unfruitful lab tests. This can be frustrating for both the patient and physician. Also, it can be needlessly more expensive for the insurance company paying the bills. With this in mind, Genesis Lab developed a comprehensive diarrhea panel that combines a selection of FDA approved and Laboratory Development Tests (LDT’s) which have demonstrated the ability to decisively differentiate between Functional and Non-Functional GI disorders.

Specialized Stool Testing

In addition to performing all traditional stool tests performed at most major labs, we perform several stool molecular and immunoassay based tests that can differentiate between various diseases affecting the GI tract. Many of these are uniquely offered at Genesis Lab and are not being performed at larger laboratories. Genesis Lab has partnered with many developmental stage stool testing labs around the world and helped with refining testing methods, validations, and clinical applications. By our estimates, we are currently the largest stool testing lab in the country doing close to 20,000 various types of stool tests every month. We proudly claim that “WE ARE #1 IN THE BUSINESS OF #2.”

Rapid Turnaround Time (TAT)

We have taken the lead to develop and improve patient compliance with stool testing and to reduce turnaround time (TAT). This has significantly increased the number of patients undergoing stool testing recommended by their physicians. We have created a very user-friendly take-home kit for sample collection. Our preassembled kit is handed to the patient at the time of the office visit. The kit has all of the tools needed for a quick and seamless sample collection at home. The kit includes a prepaid Federal Express envelope for the sample to be delivered to the lab overnight. All of the physician ordered tests can be run from the two collection vials included in the kit. The turnaround time (TAT) for the Diarrhea Pathogen Panel (DPP) is 24 hours or less after collection and all other test results are reported within 72 hours. Traditionally for stool testing, patients visit a lab to pick up sample collection vials after getting a prescription from the physician’s office. Then, they must visit the lab again after collecting the sample at home without the use of any stool collection equipment provided by the lab. Needless to say, most patients never complete this lengthy process and forgo these very important tests requested by their physicians. Our own research (2019 Genesis Lab Patient Satisfaction Survey)(2) indicates that the compliance rate of stool testing with traditional labs is less than 20%, while close to 60% of patients submit a sample when our kit is given out by the physician. Delayed and missed diagnosis can clearly add to worsening of illness and increased expenditure. In addition to the test we already perform, Genesis Lab’s portfolio of fecal markers in the making are geared to further differentiate between Functional and Non-functional GI disorders. These include Alpha-1 Antitrypsin, Beta defensin 2, Lysozyme, and Secretory IgA. These are all under varying stages of development and could be included in our future offerings if they demonstrate clinical utility.


References:

  1. 1. Guerrant, R. L., Van Gilder, T., Steiner, T. S., Thielman, N. M., L. S., Tauxe, R. V., . . . Pickering, L. K. (2001). Practice Guidelines For The Management Of Infectious Diarrhea. Infectious Diseases in Clinical Practice,10(3), 175-177. doi:10.1097/00019048-200103000-00028
  2. 2. Genesis Laboratory Management Patient Satisfaction Survey