Fnut 08 718356

REVIEW
published: 13 September 2021

doi: 10.3389/fnut.2021.718356
Inflammatory and
Microbiota-Related Regulation of the
Intestinal Epithelial Barrier
Giovanni Barbara 1,2*, Maria Raffaella Barbaro 1,2 , Daniele Fuschi 1,2 , Marta Palombo 1,2 ,
Francesca Falangone 3 , Cesare Cremon 1,2 , Giovanni Marasco 1,2 and
Vincenzo Stanghellini 1,2
1
IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy, 2 Department of Medical and Surgical Sciences,
University of Bologna, Bologna, Italy, 3 Medical-Surgical Department of Clinical Sciences and Translational Medicine,
University Sapienza, Rome, Italy
The intestinal epithelial barrier (IEB) is one of the largest interfaces between the
environment and the internal milieu of the body. It is essential to limit the passage of
harmful antigens and microorganisms and, on the other side, to assure the absorption
of nutrients and water. The maintenance of this delicate equilibrium is tightly regulated
as it is essential for human homeostasis. Luminal solutes and ions can pass across the
Edited by:
IEB via two main routes: the transcellular pathway or the paracellular pathway. Tight
Pinyi Lu, junctions (TJs) are a multi-protein complex responsible for the regulation of paracellular
Frederick National Laboratory for
permeability. TJs control the passage of antigens through the IEB and have a key role
Cancer Research (NIH), United States
in maintaining barrier integrity. Several factors, including cytokines, gut microbiota, and
Reviewed by:
Markus Xie, dietary components are known to regulate intestinal TJs. Gut microbiota participates
Genentech, United States in several human functions including the modulation of epithelial cells and immune
Matthew Snelson,
Monash University, Australia
system through the release of several metabolites, such as short-chain fatty acids
Sandrine Ménard, (SCFAs). Mediators released by immune cells can induce epithelial cell damage and TJs
INSERM U1220 Institut de Recherche
dysfunction. The subsequent disruption of the IEB allows the passage of antigens into
en Santé Digestive, France
the mucosa leading to further inflammation. Growing evidence indicates that dysbiosis,
*Correspondence:
Giovanni Barbara immune activation, and IEB dysfunction have a role in several diseases, including irritable
[email protected] bowel syndrome (IBS), inflammatory bowel disease (IBD), and gluten-related conditions.
Here we summarize the interplay between the IEB and gut microbiota and mucosal
Specialty section:
This article was submitted to immune system and their involvement in IBS, IBD, and gluten-related disorders.
Nutritional Immunology,
Keywords: intestinal epithelial barrier, mucosal immune system, gut microbiota, IBS, IBD, celiac disease, non-
a section of the journal
celiac gluten sensitivity
Frontiers in Nutrition
Received: 31 May 2021

Accepted: 12 August 2021
Published: 13 September 2021
INTRODUCTION
Citation: The gastrointestinal (GI) tract, with a surface area of about 40 m2 , is one of the largest interfaces
Barbara G, Barbaro MR, Fuschi D, between the environment and the internal milieu of the body (1, 2). The intestinal epithelial
Palombo M, Falangone F, Cremon C,
barrier (IEB) is a structure that receives and reacts to several stimuli in a dynamic way (3), The
Marasco G and Stanghellini V (2021)
Inflammatory and Microbiota-Related
IEB is essential as the first line of defense, limiting the passage of harmful microorganisms and
Regulation of the Intestinal Epithelial antigens, and at the same time, it has to assure the correct absorption of nutrients, water, and
Barrier. Front. Nutr. 8:718356. ions. This delicate equilibrium is reached through the interaction of several elements: the mucus,
doi: 10.3389/fnut.2021.718356 the outer layer, followed by a single cell layer of epithelial cells and, finally, the lamina propria
Frontiers in Nutrition | www.frontiersin.org 1 September 2021 | Volume 8 | Article 718356

Barbara et al. Inflammation, Microbiota, and Permeability
where immune cells, such as dendritic cells, plasma cells, mucus and are characterized by mucin domains, rich in serine,
macrophages, lymphocytes, reside (1). The intestinal epithelium, threonine, and proline amino acids, that are abundantly O-
furthermore, includes five cell lineages: absorptive enterocytes, glycosylated (21, 22). This post-translational modification gives
the most abundant epithelial cells, the goblet cells producing these proteins the property to be soluble in water and to form
mucus (4), the tuft cells producing IL-25 (5), the enteroendocrine a gel. In addition, the carbohydrates hide the protein core,
cells producing hormones, and Paneth cells, which produce preserving it from degradation. The glycan residues can bind the
antimicrobial peptides or lectins (4). The dysregulation of the lectin-like proteins of immune cells, giving the mucus an active
IEB is implicated in the pathogenesis of several intestinal immunological role. In addition, mucin 2 (MUC2), the principal
[e.g., celiac disease, inflammatory bowel disease (IBD), irritable gel-forming mucin in the intestine, can influence dendritic cells
bowel syndrome (IBS), colon carcinoma], and extra-intestinal and epithelial ones (23), contributing to oral tolerance [i.e.,
diseases (e.g., chronic liver disease, type 1 diabetes, obesity). The the unresponsiveness of the immune system induced by oral
hypothesis is that, for all these disorders, the IEB dysfunction, and administrated innocuous antigens, including that derived from
consequent increase of intestinal permeability (i.e., a functional food (24) and gut homeostasis (25)]. Although mucus is present
feature of the IEB, measurable by analyzing flux rates across throughout the intestine, it has peculiar properties in the different
the intestinal wall) (6), facilitate the entrance of antigens tracts (26). In the small intestine, there is a single layer of mucus
and/or microorganisms into the lamina propria with subsequent that is more permeable than elsewhere to contribute to nutrients’
activation of the immune system and the initiation and/or uptake (27). In addition, in this tract, mucus is discontinuous
maintenance of inflammatory responses (7, 8). to support the release of digestive enzymes (27–30), it is not
In the present review, we will summarize current evidence tightly attached to the epithelial cells, and it is mixed with
on the interplay between the IEB and immune system and antibacterial substances (31–33) which contribute to avoiding the
microbiota and their involvement in GI pathological conditions contact between bacteria and epithelium (29, 34–36). In the large
including IBS, IBD, and gluten-related disorders. intestine, the mucus is divided into two layers: the inner and
the outer ones. The inner layer is organized in lamellar layers
made up of MUC2 multimers anchored to the epithelium and
THE INTESTINAL EPITHELIAL BARRIER
not accessible to bacteria (22, 27). In humans, at a distance of
Mucus 200 µm from the epithelium, the action of proteases changes the
The mucus layer covers the luminal surface of the GI tract structure of the inner mucus, producing the outer one. The outer
and is the first line of defense against mechanical, chemical, layer (i.e., non-attached to the epithelium) is less dense than the
and biological insults. It protects epithelial cells from bacteria, inner mucus, has larger pores, and is the place where commensal
digestive enzymes, and dangerous substances coming from the bacteria live (37–39).
outside including environmental pollutants, food antigens, toxins Some years ago, Kamphuis et al., proposed a new model of
(9, 10). In addition, it provides lubrication for food passage mucus. They characterized the colonic mucus barrier in rodents
and removes bacteria and debris by flowing them away in the by using histological and FISH techniques. They demonstrated
intestinal stream. Over then acting as a physical barrier, it is also that in the distal colon, mucus covers the feces instead of
essential in the maintenance of intestinal homeostasis as small epithelial cells confining the microbiota to the feces. On the other
molecules, gases, ions, and water diffuse through it to reach the side, this organization is lost in the proximal colon, suggesting
epithelium (11, 12). It is continuously secreted in the GI tract that mucus organization depends on the presence of colonic
principally by goblet cells, but also from epithelial cells and glands content (40).
(12). Interestingly, the density of goblet cells increases distally The high polysaccharide content of the mucus represents a
within the GI tract and reaches the peak in the colon, likely in source of energy for bacteria, although only a subset of gut
parallel with the increase of microbiota (13, 14). microbiota can hydrolyze mucus carbohydrates in physiological
Mucus is made up of water (90–95%) (11, 15) proteins, lipids conditions (41, 42). Interestingly, in the case of a diet poor in
(1–2%), and electrolytes (16). Proteins, principally produced by fibers, there is a change in the microbiota composition, with
goblet cells, include mucins, which lend the mucus its gel-like an increase in the abundance of mucus-degrading bacteria that
properties. Mucus comprises also antimicrobial peptides and are capable to use glycosylated residues as a source of energy
immunoglobulin-A (IgA), giving the mucus a pivotal role in (43). Gut microbiota and its metabolites have a key role in
innate defense (17–19). IgA are the most abundant isotype in the formation and correct folding of the mucus. As a matter
humans and are secreted in the lumen where they are essential to of fact, germ-free mice showed a similar organization of the
prevent infections and to assure homeostasis with gut microbiota mucus layer to conventionally raised (Convr) mice, but the inner
(20). The mucins are responsible for the gel aspect of the mucus was more penetrable, and small intestinal mucus was
tightly attached to the epithelium. Following the colonization
Abbreviations: IEB, Intestinal epithelial barrier; GI, Gastrointestinal; TJs, tight of germ-free mice intestine with Convr microbiota, colonic
junctions; IBS, irritable bowel syndrome; IBD, inflammatory bowel diseases; inner mucus became impermeable, and small intestinal mucus
MUC2, mucin 2; AJs, adherens junctions; JAM-A, junctional adhesion molecule- acquired the typical characteristic of being easily detachable (44).
A; ZO, zonula occludens; CD, celiac disease; NCGS, non-celiac gluten sensitivity;
PAR-2, Proteinase-activated receptor 2; SCFAs, short-chain fatty acids; TLRs,
The mechanisms through which microbiota can influence mucus
Toll-like receptors; FGIDs, Functional Gastrointestinal Disorders; HLAs, human production and properties are still a matter of study. One possible
leucocyte antigens; GFD, gluten-free diet; UC, ulcerative colitis. way is that gut microbiota can influence mucin glycosylation

(21) and the expression of glycosyltransferase. On the other has different specificity for cations or anions as well as selectivity
hand, the gut-microbiota composition is influenced by mucus for ionic size. The characteristics of each claudin are shown in
glycosylation pattern, which differs among species, establishing Table 1.
an equilibrium that ensures nutrients to microbiota and avoids Occludin is a transmembrane protein with a molecular weight
mucus degradation (45). The role of mucus as a barrier is crucial of around 65 kDa. It presents a long C-terminal cytoplasmic
for the maintenance of health. Reduction or abnormalities in domain, two loops, and a short N-terminal cytoplasmic portion
the mucus production or in the glycosylation of the mucins are (64). The carboxy-terminal of occludin contains the binding
associated with gut inflammation and ulcerative colitis (46, 47) site for zonula occludens (ZO)-1. Occludin is a phosphorylated
as well as in the colonization of the inner mucus by bacteria in protein and it has been reported that its phosphorylation
both patients with ulcerative colitis and in the murine model of correlates with the localization at the TJs (105). ZO-1 (∼220
colitis (48). Qualitative and quantitative changes in the mucus kDa), ZO-2 (∼160 kDa), and ZO-3 (∼130 kDa) are scaffold
layer in response to inflammation, have been demonstrated also proteins, localized to the cytoplasm (106). ZO-1, -2, and -3 have
in Crohn’s disease (49–52) and colorectal cancer (53, 54). Finally, three PDZ domains and a guanylate kinase-like domain (GUK)
mucus is the first barrier for pathogens to enter the intestinal (107). PDZ1 binds the C-terminus of claudins (106) while the
mucosa and start an infectious (55). Lipopolysaccharide (LPS) GUK domain interacts with occludin (107). C-terminal regions
expressed on the outer membrane of Gram-negative bacteria, of ZOs interact with actin and serve as scaffolds linking TJ
lipoic acid on the membrane of Gram-positive bacteria and strands with the cytoskeleton (108–110). The association of the
flagellin, can activate MUC2 expression by the activation of toll- cytoskeleton with the TJ structure is crucial for the regulation
like receptors (TLRs) as reported in animal studies and in studies and maintenance of TJs function (111). Junctional adhesion
using cell lines, including goblet cell line and HT-29 (56–61). In molecules (JAM, ∼40 kDa) are transmembrane molecules
conclusion, on the basis of the above evidence, the integrity of localized to apical cell-cell contacts and associated with TJs.
the mucus and the correct balance between mucus production by They are members of the immunoglobulin superfamily and
goblet cells and mucus degradation by intestinal microbiota, are include 3 transmembrane proteins JAM-A, -B, and -C (also called
essential for the maintenance of a health state. JAM-1,−2, and−3) characterized by a short N-terminal portion,
two extracellular immunoglobulin-like loops, a transmembrane
Tight Junctions portion, a short cytoplasm fragment containing phosphorylation
Beneath the mucus layer, there is a columnar monolayer sites and a C-terminal PDZ domain involved in cell-cell adhesion
of intestinal epithelial cells that represents an additional (67, 112). The latter domain is involved in the binding of ZO-1
line of interface, between the outside environment and and is fundamental for protein-protein interactions (112–114).
intestinal mucosa. Among the JAM proteins, JAM-A is the best characterized in
Alterations of the IEB allow the excessive passage of food the regulation of TJ barrier function. It’s expressed in intestinal
and microbiota antigens which elicit immune activation involved epithelial cells and has also been implicated in cell proliferation
in the pathogenesis of the intestinal and systemic disease (e.g., and migration (115–118). The characteristics of ZO and JAM
diabetes, obesity, non-alcoholic liver diseases). The functioning proteins are shown in Table 2.
of the IEB depends on the presence of a series of intercellular Cingulin is a cytoplasmic protein with a molecular weight
junctions composed by the apical junctional complex (AJC), of 140–160 kDa. It has a structural role, binding ZOs and
including tight junctions (TJs) and adherens junctions (AJs), cytoskeletal proteins (125), and a signaling one, being involved
and desmosomes. Under physiological conditions, only water in the control of epithelial proliferation (114, 126). TJs are
and solutes like electrolytes can cross the epithelium through linked to microtubules and microfilaments of the cytoskeleton.
the paracellular way. TJs, the principal regulators of paracellular An important role in the regulation of TJ opening/closing is
permeability (62), are a network of proteins located at the apex attributed to the microfilaments of actin and myosin (127, 128).
of the lateral membrane of epithelial cells, including claudins Myosin is mainly involved in the regulation of TJ assembly
(63), tight junction-associated marvel proteins (TAMPs) such as and tone (1, 129), while actin binds to the cytoplasmic scaffold
occludin (64), junctional adhesion molecule-A (JAM-A) (65), proteins (130). In addition, actin polymerizing proteins and
and intracellular scaffold proteins, such as zonula occludens regulators of actin, are central in TJ changes (114).
(ZO), and tricellulin (66). The composition and stability of the IEB depend not only
Claudins are transmembrane proteins that form two on TJs but also on their interaction with AJs and desmosomes
extracellular loops interacting with their counterparts from the (131, 132). AJs establish cell-cell contacts, which are essential
neighboring cell (67, 68). for TJs maturation and maintenance. E-cadherin is the main
Claudins are a group of proteins with molecular weights transmembrane protein involved in AJ assembly (133). Its
ranging from 21 to 34 kDa (68–70). Intestinal claudins exist in intracellular domain is associated with p120, b-catenin, and a-
two functionally different classes: sealing claudins, responsible catenin, forming a complex that is bound to actin filaments (134).
for the tightness, and pore-forming claudins (71). Sealing tight Moreover, regulating the organization of the underlying actin
junction proteins include claudins-1, -3, -4, -5, -7, -8, -11, -14, cytoskeleton, it establishes a hub for cell signaling and regulation
-18, and -19 (68) and form a selective barrier to macromolecules of gene transcription (135).
and ions, whereas claudins-2, -10a/-10b, -15, -16, and -17 form Desmosomes provide mechanical strength to the intercellular
selective pores to ions and water (72). Each pore-forming claudin cell-cell contact in the epithelium. Their composition

TABLE 1 | Characteristics of claudins and their changes in intestinal diseases.
Claudin Size (kDa) Localization Functions Ions Interactions (68) Role in disease
(68) permeability
1 22.8 Ubiquitary (63) Barrier forming ↓ Cations It plays a general role in ↓ In UC (73–75), food
preventing the loss of water and allergy (76), liver cirrhosis
macromolecules (77), and IBS-D (78)
2 24.4 Intestinal crypts (79), Pore forming ↑ Cations It is involved in the regulation of ↑ UC (83), celiac disease
Proximal renal tubule (80), Na+ , Cl− , Ca2+ and water (84), IBS-D (85)
choroid plexus (81), ↑↓ Crohn’s disease (86)
Human ovarian surface epithelium (82)
3 23.3 Human gallbladder (87) Barrier forming ↓ Cations It is involved in the reduction of ↓ Crohn’s disease, acute
Brain capillary endothelium (88) paracellular permeability of large colitis (90)
Tighter segments of nephron (89) molecules and in the formation ↑ Celiac disease (84)
Liver/intestinal epithelial cells (79) of the blood-brain barrier
4 22.1 Kidney and lung (68) Barrier forming - It can act as a Na+ barrier or, ↓ Acute colitis (73, 83)
Human gallbladder (87) interacting with claudin-8, as an ↑ NCGS (92)
Stomach, small intestine and colon (91) anion (Cl− ) pore. In the colon
strengthens tight junctions
5 31.6 Endothelial tissue: endothelial cells (93) Barrier forming ↓ Cations It is involved in permeability of ↓ Acute colitis, Crohn’s
and brain capillary (94) small molecules (≈800 Da) disease (86), Celiac disease
Epithelial tissue: Human ovarian surface (84, 96)
epithelium (82)
Human colon epithelium (95)
7 22.4 Epithelial tissue: Duodenum, jejunum, Barrier forming ↓ Anions It plays a role in the regulation of ↓ UC (83),
ileum, colon (97) Na+ , Cl− , K+ and water Celiac disease (84, 96)
Human palatine tonsillar epithelium (98)
Nephron segments primarily at the
basolateral membrane (99)
8 24.8 Epithelial tissue: Duodenum, jejunum, Barrier forming ↓ Cations It can act as a Na+ barrier or ↓ Crohn’s disease (86)
ileum, colon (100) Cl− pore, depending on the cell
Distal nephron (99) type
12 27.1 Brain endothelial cells (94) - ↑ Cations It increases permeability to ↑↓ Crohn’s disease (101)
Duodenum, jejunum, ileum, colon (97) Ca2+
15 24.4 Kidney endothelial cells (89) Pore forming ↑ Cations It can act as a Na+ channel or ↑ Celiac disease (84, 96)
Intestine (duodenum, jejunum, ileum, Cl− barrier, depending on the
colon) (97) cell type; it is involved in
paracellular K+ absorption and
Na+ secretion
18-2 27.7 Stomach (102) Barrier forming ↓ Cations It acts as selective barrier ↓ Gastric cancer (104)
and bone cells (103) against Na+ and H+ , protecting
the epithelium from low pH
TABLE 2 | Characteristics of zonula occludens (ZO) proteins and junctional adhesion molecules (JAM) and their changes in intestinal diseases.
Tight junction protein Size (kDa) Interactions Role in disease
ZO-1 ∼220 kDa Claudin, JAM-A, occludin, F-actin, ZO-2,-3, cingulin ↓ Crohn’s disease (119)
IBS-D (120), IBS-A (121)
Celiac disease (122)
ZO-2 ∼160 kDa Claudin, occludin, F-actin, ZO-1,-3, cingulin ↓ IBS-D (120)
ZO-3 ∼130 kDa Claudin, occludin, ZO-1, cingulin ↓ IBS-D (120)
JAM-A ∼40 kDa Occludin, JAM-A, ZO-1, cingulin ↓ In IBD (75, 83, 123)
IBS-D and IBS-A (124)
JAM-B ∼40 kDa JAM-C, ZO-1 -
JAM-C ∼40 kDa JAM-B, JAM-C, ZO-1 -
includes two subtypes of transmembrane cadherins, bind intermediate filaments providing junction stability
desmogleins, and desmocollins. These proteins through to mechanical stress due to peristaltic movement of the
the binding with plakophilin and desmoplakin (136) can gut (137).

FIGURE 1 | Schematic representation of the junctional complex in intestinal epithelium. Molecules can cross the intestinal epithelial monolayer through the intercellular
space (paracellular route) or through the cells (transcellular route). The junctional complex involved in paracellular pathway includes tight junctions, adherens junctions,
gap junctions and desmosomes. Tight junctions are composed of transmembrane proteins such as claudins, occludin, junctional adhesion molecule (JAM), and
zonula occludens proteins (ZOs). ZOs, act as scaffold proteins, connecting claudins and occludin to cytoskeletal actin.
Zonulin, the pre-haptoglobin 2, is an endogenous modulator the phospholipid bilayer by simple diffusion. Small hydrophilic
of intestinal permeability. compounds and nutrients mainly use channels and transporters
The binding of gliadin to the chemokine receptor C-X-C located on cellular membranes to cross the cell membrane (144).
Motif Chemokine Receptor 3 (CXCR3) on epithelial cells, likely Some channels belong to the group of the ligand-gated channels,
induces the release of zonulin through a MyD88-dependent which requires the binding of a ligand to the receptor region to
pathway. Zonulin disassembles tight junctions, through the modify their conformation and be opened or closed (145, 146).
transactivation of EGF receptor via proteinase-activated receptor Carrier-mediated transport involves the binding of the target
2 (PAR-2) activation (138, 139). Interestingly, zonulin serum molecules to the receptor portion of the transporters, which in
levels are altered in conditions characterized by IEB alterations, turn produces a conformational change in the carrier and allows
including celiac disease (CD), type 1 diabetes, and non-celiac the translocation of the compound (147).
gluten sensitivity (NCGS) (138, 140, 141). It is to note that Larger molecules, such as proteins and bacterial products,
zonulin belongs to a family of structurally and functionally penetrate by the mechanism of receptor-mediated endocytosis,
related proteins named “zonulin family peptides” that can which implies the invagination of the plasma membrane and the
affect intestinal permeability. In addition, it cannot be excluded subsequent formation of vesicles, as a consequence of proteins
that different members of this family could be detected by or peptides binding to specific cell surface receptors (148).
commercially available enzyme-linked immunosorbent assay The substances thus incorporated are transported through the
(ELISA) kit (142). cytoplasm by transcytosis. This transport is essential for antigen
surveillance in the GI tract (149).
Transcellular and Paracellular Pathways Endocytosis in epithelial cells occurs differently depending on
Luminal solutes and ions can pass across the IEB via two main the substance interacting with the epithelium. Immunoglobulins
pathways: the transcellular pathway (i.e., through the cells) or and viruses penetrate the epithelium via clathrin-mediated
the paracellular pathway (i.e., between the cells) (Figure 1). endocytosis. This is a highly specific receptor-mediated process
The transcellular transport implicates the passage across the in which molecules, after binding the receptor, are internalized
cell membrane, which generically occurs by passive transport, via clathrin-coated vesicles (150). Transcytosis is a mechanism
passive diffusion by efflux pumps, active transport, or endocytosis through which IgA can cross the IEB and arrives into the lumen.
(143). Apolar compounds like soluble lipids can pass through In particular, epithelial cells express the polymeric IgA-receptor

(pIgA-R) that binds IgA. The extracellular portion of pIgA-R deeply modulate epithelial cells and the immune system (38)
is cleaved at the apical side and released into the lumen with through the production of a series of metabolites. Microbial
IgA (151), and the so generated secretory IgA (SIgA) complexes metabolites can be classified as metabolites generated by the host
play multiple protective roles (152). Bacterial and food antigens and then modified by the gut microbes into the lumen, such
delivery across the intestinal epithelium takes place throughout as secondary bile acids, dietary product-derived metabolites,
the transcellular pathway. At the level of Peyer’s patches, SIgA can such as compound K, or de novo synthesized metabolites
mediate antigens selective translocation, first binding them and such as short-chain fatty acids (SCFAs). SCFAs including
then promoting their apical-to-basal transepithelial migration via butyrate, acetate, and propionate, profoundly influence aspects
M cells, dendritic cells, and T cells (20, 153–156). Whereas, the of GI physiology, such as contractility, visceral pain, epithelial
food allergens translocation throughout the intestinal epithelium, proliferation, barrier function, host immunity, but also bacterial
during the initial phase, involves transcytosis of IgE-allergen pathogenesis (179–181).
complexes mediated by the CD23 IgE receptor in epithelial cells SCFAs can modulate the expression profile of epithelial
(157, 158). Indeed, the IgE-allergen complexes binding to the cells, enhancing the production of proteins involved in the
CD23, located at the apical side of polarized epithelial cells, biosynthesis of mucin (182). Specifically, butyrate enhances
promote IgE-allergen-CD23 migration toward the basolateral MUC2 expression both activating the MUC2 promoter and
surface of the cells with AP2-dependent endocytosis via clathrin- enhancing histone acetylation by HDAC inhibition in cell
coated (159, 160). cultures (183). Moreover, the intestinal epithelial cells express
Phagocytosis is another pathway that allows the uptake of receptors activated by SCFAs. These are members of the G-
antigens. In particular, enterocytes are able to carry out TLR- protein coupled receptors (GPR) and include GPR41, GPR43,
mediated phagocytosis to internalizing gram-negative bacteria and GPR109a. The SCFAs binding to GPR41 and GPR43
(161). Moreover, phagocytosis is a route through which bacteria, stimulates colonic epithelium to releases chemokines and
viruses, and particles can enter enterocytes, after binding to cytokines (184). The butyrate depending activation of GPR109a
different receptors (162, 163). Through the non-specific process enhances IL-18 excretion in epithelial cells, protecting the colon
of micropinocytosis, extracellular fluids are internalized, as well against inflammation and carcinogenesis (185). Other microbial
as dissolved molecules, viruses, and apoptotic cell fragments. metabolites that significantly influence the maintenance of gut
Finally, there is the mechanism mediated by lipid rafts/caveolae, barrier integrity include indole derivatives, bile acid metabolites,
that seems to be involved in the internalization of some conjugated fatty acids, polyamines, and polyphenolic derivatives.
enterotoxins and viruses into enterocytes (151). This mechanism Their role in regulating gut barrier function was recently assessed
involves the invagination of cholesterol-rich areas of the plasma in an extensive review (186).
membrane that contain a coating protein, caveolin (164). TLRs are single-pass membrane-spanning receptors playing
TJs are responsible for the sealing of the paracellular space a key role in the innate immune system (187). They are
between cells and, therefore, strictly limiting the transport of expressed on the membranes of immune and non-immune
hydrophilic molecules (165–167). TJs have the so-called “gate and cells, including epithelial cells, and recognize molecules that are
fence” function as they regulate the size and charge selectivity broadly shared by microbes. In particular, TLR recognition of
of the paracellular pathway. Indeed, TJs allow the paracellular microbial fractions improves the IEB function, the secretion of
transport of some medium-sized hydrophilic molecules, ions, mucus, and the production of antimicrobial peptides, promoting
or positively charged molecules but prevent the transport immune tolerance toward the gut microbiota. The role of
of proteins, such as antigenic macromolecules, lipids, and epithelial TLRs in gut homeostasis and disease was recently
microbial-derived peptides (168). reviewed (188).
Bacteria-epithelial cell interactions play an essential role
in regulating epithelial permeability through the modulation
GUT MICROBIOTA-EPITHELIAL BARRIER of TJs expression and assembly (189). Animal studies clearly
INTERPLAY underlined the interplay between the intestinal microbiota
and the IEB homeostasis. Germ-free mice had a higher
The human gut harbors a community of about 1014 colonic expression of claudin-1 and occludin as compared
microorganisms resulting from thousands of years of co- with conventional mice, with lower paracellular uptake of
evolution with the host, with an intricate and mutually beneficial a standard probe, suggesting that commensal microbiota
relationship (169). Indeed, gut microbiota participates in controls colonic TJs proteins and paracellular permeability
digestive functions, shapes the host immune system (170, 171) (190). Interestingly, transplantation of fecal microbiota from
modulates host metabolisms, and influences local and systemic healthy humans restores the IEB features of conventional
processes, such as vitamin intake and nutrient transformation mice within a week. In particular, colonization reestablishes
(172, 173). The intestinal microbial population also protects physiological colonic paracellular permeability, maturation of
against pathogens, by competing with them for nutrient uptake colonic barrier structure, and reduces systemic microbial
and regulating host immunity (174–178). To avoid aberrant antigen exposure (190). Altogether these data suggest that
immune responses, the IEB separates microbes and immune gut microbiota is crucial in preserving the integrity of the
cells, leading to the establishment of host-commensal mutualism IEB, thus preventing the systemic spreading of potentially
(171). Despite this physical separation, gut microbiota can harmful antigens.

Specific gut microbiota components may differently modulate this is virtually unknown at this time. Strategies to improve
the IEB permeability. For example, colonization of germ-free the relationship between host and intestinal microbiota to
mice with Bacteroides thetaiotaomicron (191) or Escherichia coli enhance epithelial mucosal permeability include the use of
Nissle 1917 (EcN) (192) led to up-regulation of genes encoding probiotics and dietary interventions, although there is still
for proteins such as small proline-rich protein-2 (sprr2a) and uncertainty on the potential benefits (6). In this context, we have
ZO-1 involved in improving cellular adhesion. Interestingly, recently demonstrated that Lactobacillus paracasei CNCM I-1572
we have recently demonstrated that the increase in paracellular modulates gut microbiota structure and function and reduces
permeability elicited by supernatants obtained from patients intestinal immune activation in patients with IBS. Interestingly,
with IBS could be ameliorated by EcN (193). Furthermore, the most robust result was obtained for a marked reduction
EcN treatment abolished the correlations between increased of interleukin 15 (IL-15) that affects the integrity of the IEB,
permeability induced by IBS supernatants with abdominal pain suggesting that this probiotic may play an important role in the
and distension referred by IBS patients, paving the way to further restoration of mucosal integrity (201).
explore clinical applicability of this probiotic in IBS human
studies (193). In contrast, other bacteria had no impact on IEB
permeability or could impair the IEB. For the latter, not only GUT IMMUNE SYSTEM-EPITHELIAL
pathogens, such as enterohemorrhagic Escherichia coli (EHEC) BARRIER INTERPLAY
O157:H7 (194), enterotoxigenic Escherichia coli (ETEC) K88 and
Salmonella typhimurium SL1344 (195), but also non-pathogenic The integrity of the IEB depends on the delicate balance
commensal bacteria, such as Escherichia coli C25 (196), can between differentiation and renewal of intestinal epithelial cells,
be involved. the response to signals coming from the lumen including
Growing evidence indicated that microbiota dysbiosis, microbiota and their end products, and nutritional factors
occurring when the diversity, composition, and/or functions of introduced with daily diet as well as signals coming from
the intestinal microbiome are disrupted, could contribute to the mucosal immune system (202). Several factors, including
the alteration of the IEB with implications in the development, cytokines, proteases, growth factors, gut microbiota, and dietary
progression, and symptom flare-up of several diseases. Among components are known to regulate intestinal TJs opening (6).
these, inflammatory conditions, such as IBD, and functional Immune dysregulation in several disorders of the gastrointestinal
bowel disorders, such as IBS, are both characterized by a well- tract such as IBD, celiac disease, colonic cancer, and IBS is
established microbiota dysbiosis associated with impairment often associated with impaired IEB integrity or dysfunction.
of intestinal permeability. The interplay between the host, Indeed, the IEB may represent the target of mediators released
and in particular the semipermeable multi-layer ecosystem by inflammatory cells in the lamina propria. This elicits
where intestinal epithelial cells exert a critical role, and the epithelial cell damage and TJ dysfunction, mucus structural and
gut microbiota is constantly challenged by numerous factors, functional alterations, ultimately leading to increased intestinal
including genetics, age, environment, food, and immunological permeability (6). Disruption of the IEB would then allow the
factors. A recent report of the Rome Foundation on the Intestinal passage of antigens, bacterial products in the mucosa leading
Microenvironment and Functional Gastrointestinal Disorders to further inflammation hence creating a self-maintaining
(FGIDs) provided an excellent overview of the importance pathological inflammatory process (6). The involvement of
of the environment, including food, diet, microbiota, and its the immune system in conditions affecting the gastrointestinal
metabolic interactions, in the pathophysiology and symptom tract can be greatly different for magnitude as well as the
generation of patients with FGIDs (197). Patients with IBD type of immune cells. Conditions characterized by mucosal
display a loss of biodiversity (mostly Firmicutes) and stability, inflammation often show the involvement of both innate as well
while an increase of Proteobacteria such as Enterobacteriaceae, as adaptive immunity.
Bilophila, and certain members of Bacteroidetes [for review, Intestinal epithelial cells and mononuclear phagocytes sense
see (198)]. In addition, Akkermansia muciniphila, a mucolytic bacteria or their products mainly through pattern recognition
commensal, is generally reduced in the gut of these patients, with receptors such as TLRs (166). Downstream of activation of innate
a consequent increase of the overall mucosal bacteria population responses is the production of cytokines, including the IL-1
(42). Furthermore, patients with IBD display a reduction in family cytokines such as IL-1 and IL-18 which lead to pro-
SCFA-producing bacteria such as Faecalibacterium prausnitzii inflammatory effects in the context of intestinal inflammation.
(199) that is well-known to have anti-inflammatory properties IL-1 can further promote Th17 cell differentiation and IFN-
through its ability to produce butyrate, allowing for T regulatory γ production from T cells (203) and its two isoforms (IL-1α
cell and T helper 17 regulation (200). Altogether, these changes and -β) seem to be involved in epithelial repair/regeneration
may lead to a loss or reduction of key functions necessary (204). IL-1R1 is a receptor expressed on different cell types of
for maintaining IEB integrity, potentially resulting in increased the colon such as innate lymphoid cells (ILCs) and GREM+
immune responses and the diffusion of pathogens into the mesenchymal cells (205). Cox et al. demonstrated that in a mice
intestinal tissues. In addition, bacterial translocation induces model of DSS-induced colitis, the binding of IL-1α/β to IL-1R1
the production of inflammatory cytokines, which promote the in ILCs induces the production of IL-22, a cytokine involved
disassembly of TJs, enhancing IEB permeability. However, if in progenitor cell proliferation. Conversely, in a model of C.
these changes are a cause or consequence of these diseases, rodentium infection, the activation of IL-1R1 occurs both in ILCs

and in GREM+ mesenchymal cells, inducing the production by mast cells upon degranulation, was abundantly increased
of R-spondin 3 (RSPO3), an intestinal stem cell self-renewal in mucosal biopsy supernatants of patients with IBS compared
activator. The IL-1R1-dependent response thus appears to reveal to healthy controls (229–231). Interestingly, the application
a damage-specific reparative capacity, which opens the door to of mucosal biopsy supernatants of IBS patients elicited a
IL-1-based therapeutic approaches (206). marked increase in paracellular permeability in Caco-2 epithelial
Other important cytokines in the orchestration of innate cell monolayers (193). The importance of proteases in the
immunity-related intestinal inflammation, include IL-6, IL-33, pathogenesis of IEB dysfunction described in IBS is further
TNF-α (202). The release of TNF-α and IFN-γ in the intestinal supported by the evidence that transfer of fecal supernatants
mucosa has been associated with IEB disruption in patients with from patients with diarrhea-predominant IBS evoked increased
IBD (207–210) as well as IBS (211). In line with this concept, mucosal permeability in mice and mucosal factors obtained
incubation of intestinal epithelial cell monolayers with TNF-α from IBS evoked IEB dysfunction and TJ disruption in isolated
and IFN-γ elicits profound changes of claudins, occludin, ZO- epithelial monolayers (228). The effect of fecal supernatants on
1, JAM-A, leading to increased epithelial permeability (212). the epithelial barrier was absent in mice lacking PAR-2 (232).
During intestinal inflammation, TJs show strand breaks, and These results suggest that mucosal or luminal mediators impact
changes in TJ proteins composition and function as well as negatively IEB by increasing epithelial permeability through a
impaired structure and remodeling of apical junctions (213). protease, PAR-2-dependent pathway and open new avenues for
During inflammatory processes neutrophils, mast cells, and therapeutic intervention (232).
macrophages release proteases (214). Besides degrading the Contrary to the long-lasting belief that IBS is not associated
extracellular matrix and proteins, proteases act as signaling with organic changes, there is now growing evidence supporting
molecules via specific receptors (215). Proteases may deeply that structural, although subtle, changes may be found in the
influence the integrity of the IEB either through excessive gastrointestinal tract of large subgroups of these patients (197).
proteolysis determined by direct cleavage of intercellular junction The observation that IBS can develop after an episode of acute
proteins, or by a functional TJ opening elicited by the infectious gastroenteritis further supports the organic as opposed
activation of protease-activated receptors (216). Mast cells are to the functional nature of this condition (233). Many studies
very proficient producers of proteases and mast cell activation showed that the intestinal mucosa of IBS patients contains larger
has been proposed as underlying pathogenetic mechanisms in numbers of immune cells and evidence of a higher state of
different gastrointestinal disorders, including IBS (217, 218). activation of the immune system (218). Interestingly, growing
evidence supports the concept that IEB dysfunction may be key
CLINICAL IMPLICATIONS in the initiation and progression of immune activation and that
this may eventually contribute to brain-gut axis dysfunction and
Irritable Bowel Syndrome symptom generation (228, 234). Accordingly, this evidence has
Differently from IBD and celiac disease, IBS is not associated generated a new dogma in the pathophysiology of IBS. More in
with overt mucosal inflammation, and evidence supporting detail, microenvironmental factors (e.g., food, microbiota, bile
the potential role of cytokines in these patients has been so acids) would permeate in excess through a leaky IEB, allowing
far controversial (Figure 2) (219–221). However, we previously amplification of signaling from the lumen to deeper mucosal and
reported that IBS is associated with a marked increase in IFN-γ muscle layers, including overstimulation of the mucosal immune
gene and IFN-γ protein expression in the colonic mucosa (211), system (197). These factors may determine abnormal signaling
a finding also supported by evidence of increased IFN-γ release to neural circuits (intrinsic primary afferent nerves and extrinsic
in the lumen (222). As IFN-γ is known to increase paracellular primary afferent nerves), which in turn may affect intestinal
permeability through disruption of TJs (223). This cytokine physiology and sensory perception (197).
could well be involved in increased paracellular permeability Nonetheless, evidence indicates that there is a poor correlation
described in patients with IBS (224). In addition to IFN-γ, other between pathogenetic mechanisms and symptom generation
players could be of relevance in the dysregulation of TJs. IL-9 is in IBS. More likely, only the combination of peripheral (i.e.,
abundantly produced by mast cells as well as innate lymphoid intestinal) factors, in conjunction with central nervous system
cells and T helper cells. Evidence suggests that IL-9 amplifies mechanisms is necessary for the full expression of symptom
intestinal mastocytosis involved in several inflammatory diseases perception. For this reason, IBS, like many other functional
of the gastrointestinal tract (225). Recently, it has been shown that gastrointestinal disorders, is now better defined with the new
IL-9 modulates IEB function, modifying TJs proteins expression. term of Disorders of Gut-Brain Interaction (DGBI). On the
In particular, IL-9 increases intestinal permeability through the same line, a single phenomenon is insufficient to explain
upregulation of claudin-2 expression in an experimental model the complexity of the protean symptom experience of IBS.
of ulcerative colitis (226). This concept is further supported by One example in line with these concepts was our previous
recent studies showing that in murine models of colitis, the demonstration that the number of mucosal mast cells was
TJ protein claudin-1 showed lower expression levels in IL-9 increased in the colonic mucosa of patients with IBS (229).
knock-out mice (227). However, this phenomenon alone was not correlated to any
We have previously shown that the permeability of colonic symptom experienced by the patients. Nonetheless, when
biopsies was significantly higher in patients with IBS compared this parameter was associated with the presence of activated
to healthy subjects (228). Tryptase, a key serine protease released mast cells in close proximity with nerve endings in the

FIGURE 2 | Alteration of IEB in irritable bowel syndrome, inflammatory bowel disease and celiac disease. (A) In irritable bowel syndrome (IBS), tryptase, histamine, and
interferon-γ (IFN-γ) are increased and can contribute to TJ disruption. In addition, IL-9 is produced by innate lymphoid cells, T helper cells and mast cells. This latter
(Continued)

FIGURE 2 | cell population has a key role in IBS pathophysiology, and can modify TJ protein expression. In addition, immune mediators, including histamine,
serotonin and proteases evoke sensory afferent over-stimulation and contribute to symptom generation. In celiac disease (CD), intestinal epithelial cells recognize
gluten peptides through CXCR3, which increases IEB permeability through zonulin release and its transactivation of epidermal growth factor receptor (EGFR) and
protease activated receptor 2 (PAR-2). Transcytosis of gluten peptides occurs after peptide recognition by secretory immunoglobulin A (SIgA). A reduction in the
expression of E-cadherin and β-catenin was found in intestinal biopsies of CD patients. Active tissue transglutaminase2 (tTG2) deamidates gluten peptides,
contributing to the development of a cell mediated pro-inflammatory immune response. (B) Genetics, environment, diet, immune system dysregulation and dysbiosis
represent some of the complex mechanisms responsible for inflammatory bowel diseases (IBD). Inflammation down-regulates TJs proteins contributing to IEB
alteration. In IBD patients has been reported an upregulation of the pore-forming claudin-2 and downregulation of occludin. Channel-forming claudins are
up-regulated by cytokines including TNF-α and IL-13, leading to an increased permeability for ions and water. Occludin is down-regulated by inflammatory processes
(e.g., TNF-α and IFN-γ), leading to increased paracellular permeability for macromolecules. Moreover, it has been shown a downregulation of claudin-5 and -8 in
Crohn’s disease and claudin-4 and -7 in Ulcerative Colitis (UC). In Crohn’s disease, the stimulation of NOD2, a sensor of Gram-positive bacteria, induces the
production of pro-inflammatory mediators, which concur to IEB dysfunction. Differently from UC, in Crohn’s disease the mucus layer is thicker, suggesting an increase
in MUC2 expression and goblet cells hyperplasia. In patients with Crohn’s disease, intestinal epithelial cells (IECs) failed to produce thymic stromal lymphopoietin
(TSLP), with consequent inability to control IL-12, produced by dendritic cells and involved in the development of Thelper 2 cells, resulting in alteration of intestinal
homeostasis. Compared to UC, in which the antimicrobial peptides (AMPs) system seems to be adequately induced, Crohn’s disease is characterized by lower levels
of AMPs. Contrasting evidence are available on the role of smoking in UC and Crohn’s disease.
mucosa of the intestine, we found a stringent correlation with with altered permeability following gluten ingestion as a possible
abdominal pain (229). In addition, there is wide redundancy common shape.
in pathogenetic mechanisms, and the different pathogenetic CD is a chronic systemic disorder triggered by the abnormal
mechanisms influence each other and therefore should be always response of human immunity to gluten ingestion in genetically
considered in context. For example, on one hand, changes in pre-disposed individuals (238). The activation of the immune
gut microbiota can promote IEB dysfunction which can lead system against gluten peptides begins after their transfer to
to mucosal inflammation. On the other hand, inflammatory the lamina propria where they are deamidated by the tissue
mediators can increase mucosal permeability and influence gut transglutaminase enzyme and subsequently bounded to human
microbiota. This generates a vicious and integrated circle that leucocyte antigens (HLAs) expressed by antigen-presenting cells
cannot be separated into fully independent compartments. (APCs), which activate the inflammatory cascade (Figure 2) (239,
With all the above considerations in mind, one of the 240). However, the presence of gluten and genetic background
most common observations in the studies evaluating the gut does not fully explain CD pathogenesis. Indeed, in studies on
IEB and IBS relates to the correlation between increased twins, in one-fourth of cases, only one twin developed CD
intestinal permeability and abdominal pain (234). The link (241). Mounting evidence suggests that CD onset is favored
between epithelial permeability and pain likely reflects the under the influence of triggering environmental factors, such as
abovementioned redundancy of the system involving the gut viral infections and dysbiosis (242–247) which activate innate
microbiota overstimulating the immune system through a leaky immunity leading to IEB disruption (248). Several studies suggest
IEB, leading to the release of immune mediators, such as that the primum movens for CD onset depends on an increased
histamine, tryptase, serotonin, polyunsaturated fatty acids (12- intestinal permeability, which leads to gluten passage from
hydroperoxyeicosatetraenoic acid, 15-hydroxyeicosatetraenoic the lumen to the mucosal layer and innate cytotoxic immune
acid, 5-hydroxyeicosatetraenoic acid, 5-oxoeicosatetraenoic acid, activation on epithelial cells further enhancing gluten migration
and leukotriene B4) (235, 236) known to evoke sensory afferent (249). Although the IEB has been extensively investigated
over-stimulation and pain (230). in the context of CD pathogenesis, to date is still unclear
Although some tantalizing findings have been reported, the whether the IEB impairment is a cause or consequence of
final proof to demonstrate the key role of increased intestinal CD. On the other hand, in the last decades a novel clinically
permeability in IBS has yet to be provided. There is a need entity has been defined in patients without CD complaining
for longitudinal studies that include assessment of the IEB extraintestinal and gastrointestinal symptoms referring to a clear
function over time and its correlation with symptoms in benefit by avoiding gluten from their diet and/or symptom
well-characterized IBS populations. In addition, further studies worsening upon gluten reintroduction, namely NCGS (141). The
assessing the role of IEB modulation in IBS are now needed. In pathophysiology of NCGS is incompletely known, although some
this perspective, a recent study using a medical device containing evidence suggests a role for permeability alterations, microbiota
xyloglucan, pea protein and tannins from grape seed extract, and changes, and immune activation (141). The Salerno criteria are
xylo-oligosaccharides, acting together to protect and reinforce the gold standard to diagnose NCGS. These criteria imply a
the IEB, effectively controlled diarrhea and alleviated clinical double-blind placebo-controlled gluten challenge (250), which
symptoms in patients with IBS-D (237). is cumbersome and unfeasible to perform in clinical practice.
In addition, there are no available biomarkers for NCGS. For
Gluten-Related Disorders all these reasons, diagnosis is currently based on self-reported
Gluten-related disorders comprise distinct clinical entities, symptoms by patients. There is a great overlap in symptoms
including celiac disease (CD), wheat-associated allergy, and between NCGS and IBS which makes a challenge the differential
NCGS, characterized by distinct pathophysiological pathways, diagnosis between these two conditions. We have recently

reported that zonulin serum levels are significantly increased Structural changes consisting of dilatation, destruction, and
in NCGS compared to IBS. In addition, the combination reduced number of TJ strands were found in CD patients
of zonulin levels, gender, and abdominal symptoms, can from ancillary (261) to more recent studies using transmission
differentiate NCGS from IBS with a diagnostic accuracy of electron microscopy of duodenal biopsies (262). In CD has
89% (141). been widely reported an increased expression of pore-forming
Studies carried out using epithelial cell lines and animal proteins such as occludin and claudin-2, together with a decrease
models showed that gliadin was able to induce apoptosis of pore-sealing proteins such as claudin-3 and -4 and ZO-1
of intestinal epithelial cells through a direct toxic effect (84, 262–264). Claudin-2 expression is also induced by TNF-
(251), including enterocyte atrophy, villi shortening, decreased α, which in turn is upregulated in CD (86) and responsible
epithelial disaccharidase activity, increased expression of HLA for increased transcellular permeability in CD. These alterations
molecules, and intraepithelial inflammatory activation. Among are simultaneous to the loss of the penta-laminar ultrastructure
other effects, gliadin fraction p31-43 is able to mimic epidermal and dilatation of TJs found in CD (262). As matter of fact, the
growth factors in human intestinal epithelial cell lines, finally overexpression of pore-forming and under-expression of pore-
leading to barrier defects (252). This peptide is usually detoxified sealing TJ proteins is responsible for the dilatation of TJs (262).
during the transport in healthy subjects, whereas in active CD CD patients have been found to have also alterations in
patients most of these peptides are transported intact in the adherence junction protein expression. A reduction in the
serosal compartment; this process may be explained by the expression of E-cadherin and β-catenin was found using
binding between gluten peptides with anti-gliadin secretory IgA transcription analysis in both intestinal biopsies of CD patients
finally forming large complexes in the intestinal lumen which and Caco-2 cells (265). Moreover, an impaired interaction
in turn bind the CD71 receptor, namely the endocytic receptor between ZO-1, mostly not phosphorylated in CD patients,
for transferrin, thus activating the transport across enterocytes and β-catenin has been reported, finally, leading to an absent
escaping lysosomal degradation (156). It is unclear whether connection between β-catenin and occludin in CD patients
this process is involved in CD development since it has been (263). On the other hand, β-catenin has been reported to be
postulated that the entrance of IgA-gliadin complexes may break highly phosphorylated in CD, thus not binding E-cadherin
local immune tolerance (253). However, it is more likely that this which in turn is free to bind intra-epithelial lymphocytes
process may perpetuate the immune reaction against gluten once responsible for inflammatory activation (263). Together with
the disease started. Besides, the effect of gliadin on the enterocyte barrier impairment, epithelial polarization may also affect
actin cytoskeleton was studied on rat intestinal epithelial (IEC- permeability since it regulates the function of proteins partition
6) cell cultures, finding that it was able to reversible stimulate defective-3 (PARD-3) and protein phosphatase-2 (PP-1) which
tyrosine phosphorylation of actin filaments resulting in filaments are involved in tight junctions formation (266).
polymerization, cytoskeleton reorganization, and tight junction Although these alterations are not specific for CD and
opening (254). Other authors suggested that gliadin was able to may merely depend on mucosal inflammation, tight junctions’
bind the mono-sialic ganglioside 1 (GM1) or the receptors for abnormalities have been found even in asymptomatic and first-
the proinflammatory chemokine 3 (CXCR3) in mouse models, degree relatives of CD patients, thus underlying a possible genetic
leading to the release of zonulin which in turn decreases electrical background for permeability defects in CD (267). Supporting this
resistance of epithelial layers, finally resulting in increased hypothesis, polymorphisms in tight junctions encoding genes,
epithelial permeability (139, 255). Indeed, zonulin release can such as PAR-3, membrane-associated guanylate kinase WW, and
induce cytoskeleton reorganization and zonula occludens-1 and PDZ domain containing 2 (MAGI-2) and myosin IXb (MYO9B)
occludin downregulation (139, 256). More interestingly, the have been found in CD patients (268–270). A subsequent
receptors for the proinflammatory chemokine CXCR3 were study did not confirm a direct causal relationship between
also activated by the overexpression of its chemokine ligand genetic polymorphisms and increased intestinal permeability
10 (CXCL10), which in turn is upregulated in vitro by viral (271). However, more recent studies evaluating CD loci showed
infections (256). a possible role of other genes involved in barrier functions and
Macroscopic alterations in intestinal permeability have been cell-cell adhesion (272–274).
studied since the 60s (257) using tests able to measure the To date, the only effective treatment for CD is a gluten-free
absorption of two inert probes of different dimensions by the diet (GFD). GFD is able to partially restore TJs abnormalities
IEB (257). The first probe was mannitol, which was taught to found in CD since TJs numbers remained low in crypts (261).
get through the IEB freely; the second was lactulose, which Other studies found a normalization of ZO-1 (264) expression
was able to get through the IEB only when its integrity was after gluten removal in vitro and of claudin expression (262)
lost. An increased ratio between urinary lactulose/mannitol after 6 months of GFD. In parallel, in vitro models showed
concentrations 6 and 12 h after oral administration indicated that β-catenin and E-cadherin alterations were reversible after
increased intestinal permeability, which has been extensively gluten removal (265, 275). These microscopic findings were
reported in CD patients (258–260). These alterations were further confirmed by the recovery of a normal lactulose/mannitol
also correlated to villus atrophy and intraepithelial lymphocyte ratio after histological mucosal healing due to long-term GFD
count. Indeed, a further study showed that permeability increase (276). This evidence additionally confirmed that most intestinal
was dependent on the release of IFN-γ by intraepithelial permeability alterations were reversible, thus excluding the
lymphocytes (207). previous hypothesis of a causal role for genetic background.

Additional or alternative therapeutic options to GFD focused UC. Studies that involve Israeli populations, for example, have
on the reduction of intestinal permeability have been proposed consistently failed to demonstrate a positive association between
for CD patients. Gluten detoxification through proteolysis or smoking and Crohn’s disease, yet these same studies have shown
gliadin sequestrants has been proposed for overcoming the a protective relationship between smoking and the development
gliadin-related toxic effect across the epithelium (277, 278). A of UC (300). Conversely, a recent paper showed current smokers
randomized controlled trial carried out in 2007 aimed to improve compared to never-smokers had an ∼2-fold risk of UC and
intestinal permeability using larazotide acetate (AT-1001), which Crohn’s disease (303).
is an inhibitor of paracellular permeability derived from a protein Another study analyzed systemic concentrations of key
secreted by Vibrio cholerae and analogs of human zonulin chemokines and cytokines in IBD patients with a different
(279). The authors concluded that larazotide acetate reduced range of disease activity compared to levels found in healthy
IEB permeability assessed by lactulose/mannitol permeability donors (304). The result shows that there was a significant
test, proinflammatory cytokine production, and gastrointestinal increase of chemokines including macrophage migration factor
symptoms in CD after gluten exposure (279). Two further phase (MIF), CCL25, CCL23, CXCL5, CXCL13, CXCL10, CXCL11,
II trials (280, 281) with larazotide acetate failed in finding an MCP1, and CCL21 in IBD patients as compared to normal
improvement in intestinal permeability, whereas the last trial healthy donors. Further, has been reported an increase in
published (282) underlined possible usefulness in refractory the inflammatory cytokines IL-16, IFN-γ, IL-1β, and TNF-
CD, defined as malabsorption and continued villous atrophy α in IBD patients when compared to healthy donors (P <
on duodenal biopsies despite strict avoidance of gluten for a 0.05). These data clearly indicate an increase in circulating
minimum of 12 months (283). Another promising approach for levels of specific chemokines and cytokines that are known
reducing intestinal permeability is the use of probiotics, which to modulate systemic levels through immune cells, results in
however deserve further studies (244, 284). affecting local intestinal inflammation and tissue damage in IBD
patients (304). More recently it has been studied the role of
Inflammatory Bowel Diseases antimicrobial peptides (AMPs) in IBD patients. Between this
Dysfunctional IEB has been implicated as a pathogenic factor group of molecules, the most important ones are produced
in IBD in the last 30 years (285, 286). IBD includes a spectrum in the gut epithelium and are α-defensins HD5 and HD6,
of disorders such as Crohn’s disease and ulcerative colitis produced by the small-intestinal Paneth cells, and ß-defensins
(UC), representing chronic remittent or progressive conditions (constitutive HBD1 and inducible HBD2 and HBD3), mostly
determined by non-specific inflammation and intestinal in the gastric and colonic epithelium (305). The changes in
tissue damage. It has been characterized by exaggerated and the microbiome composition and the bacterial contamination
inappropriate mucosal immune responses that can involve of the mucosa as well as the inner layer of the mucus may
the entire mucosal wall, as in Crohn’s disease, or be confined well be mediated by defects in this chemical defense (306).
to the submucosa, as in UC (287). The pathogenesis of IBD Compared to ulcerative colitis, in which the AMP system seems
is complex and multifactorial and it is not fully understood, to be adequately induced, colonic Crohn’s disease is characterized
involving a complex dysregulated interaction between different by low HBD1, regulated by peroxisome proliferator-activated
factors (Figure 2). Particularly genetic pre-disposition, gut receptor gamma (PPARγ), and a compromised induction of
microbiota, and innate and adaptive immune responses HBD2 and HBD3 (307, 308). Considering the important role
represent fundamental elements (288). Some authors suggest played by the intestinal epithelium, which establishes a tightly
that the alteration of the balance between these three components regulated barrier, its integrity defects are frequently reported
would be responsible for the triggering of the inflammatory during intestinal inflammation (309). Microscopic analysis of
environment needed to induce IBD (289). Otherwise many intestinal tissue from IBD patients reveals a decrease in goblet
researchers reported that many other factors are involved in cells (50), reduction thickness of mucus layer, and defective
the pathogenesis of IBD such as dysfunction of intercellular defensin production (310), with an altered composition of some
transport mechanisms (290, 291), associated with factors components such as mucins and phosphatidylcholine (311). The
responsible for the exacerbation in IBD (i.e., cigarette smoking, alteration of the mucus protective barrier plays a key role in
diet, stress, microbial dysbiosis, and food additives) (292–297). the onset of IBD (312). A recent case-control study reported
In fact, urbanization of societies is associated with changes in that mucus abnormalities contribute to UC pathogenesis,
diet, antibiotic use, hygiene status, microbial exposures, and demonstrating how core mucus structural components were
pollution, which have been implicated as potential environmental reduced in active UC (313). These alterations were associated
risk factors for IBD (298). Although these factors have been with attenuation of the goblet cell secretory response to microbial
explored, the data available are still inconclusive (299). It is still a challenge and occurred independently of local inflammation.
matter of debate the role of smoking in IBD. Evidence reported Another important mechanism involved in the alteration of the
in literature shows smoking is associated with opposing risks in mucus protective barrier in IBD is the invasion by bacteria
Crohn’s disease and UC (300–302). directly in contact with the epithelium and their penetration
A meta-analysis focused on the effects of smoking behaviors into the crypts and epithelial cells (314). This mechanism has
and IBD has demonstrated that different races may have varying been demonstrated in mice lacking MUC2 mucin (27). In these
degrees of susceptibility to IBD (300). Smoking may play differing animal models, bacterial invasion induces the response of the
roles in the development of Crohn’s disease compared with colonic immune system resulting in inflammation, spontaneous

colitis, diarrhea, rectal and colon prolapse, rectal bleeding, and of Gram-positive bacteria (muramyl dipeptide, MDP) whose
an increased risk of colon cancer development. Differently from stimulation determines the production of pro-inflammatory
UC, in Crohn’s disease, the mucus layer is thicker, suggesting mediators (338–341). Moreover, it was shown that mutations in
an increase in MUC2 expression and goblet cells hyperplasia. the NOD2 gene increased susceptibility to intestinal permeability
Nevertheless, the structure of MUC2 is altered due to a reduction in the healthy relatives compared to control subjects (342).
in the oligosaccharide chain length by 50%, leading to a loss The intestinal microbiota has an important role as a regulator
of mucus viscoelastic properties and consequently a loss of of epithelial–immune cell communication and patients with IBD
protective function (315). Furthermore, indirect data suggest often show dysbiosis (309). In fact in IBD have been documented
that barrier defect might precede the onset of disease (316) changes in the commensal gut microbiota, represented by
and up to 40% of first-degree relatives of patients with Crohn’s reduced complexity of commensals bacteria that are beneficial
disease demonstrate an altered small intestinal permeability for the host or a greater representation of a specific phylum
(317). Moreover, it was shown that patients that had increased (343). Currently, it is not clear if these disorders are the cause
intestinal permeability were at greater risk of successive disease or consequence of the manifestation of IBD. The cause of
relapse (318, 319). this condition seems to be disturbances in the recognition of
The mechanisms involved in the proper functioning of the pathogens microorganisms in the human intestine determined by
IEB include the transport of molecules across the intestinal alterations in the expression of pathogen recognition receptors,
mucosa through two distinct mechanisms: paracellular diffusion which include the already mentioned NOD2 (336, 340) and
through TJs between adjacent intestinal epithelial cells and also TLRs and Rig-I like receptors. Intestinal epithelial cells
transcellular transport involving the transcytosis of materials, (IECs) and innate immune cells, such as dendritic cells and
eventually mediated by membrane receptors. In IBD patients macrophages, are equipped with these receptors to distinguish
has been observed increased paracellular permeability with between components of pathogens and beneficial commensals
abnormal TJ structure and a down-regulation and redistribution (344). IECs have also the role to produce thymic stromal
of many TJ proteins or other adherents junctions (320, lymphopoietin (TSLP), IL-2 cytokine member, in response to
321). Both paracellular hyperpermeability [demonstrated by commensals, such as Gram-negative Escherichia coli or Gram-
abnormal TJ expression and upregulation of myosin light positive Lactobacillus rhamnosous (345). Interestingly it was
chain kinase (MLCK) activity (86, 322–324)] and transcellular shown that in patients with Crohn’s disease, IECs failed to
hyperpermeability [represented by bacterial internalization to produce TSLP, with consequent inability to control IL-12,
epithelia (325)] were documented in mucosal biopsies of patients produced by dendritic cells and involved in the development of
with Crohn’s disease and UC. Disruptions of TJ proteins could Thelper 2 cells, resulting in alteration of intestinal homeostasis
lead to an alteration of the IEB, allowing entry of luminal (346). These dysregulated epithelial-immune cell communication
bacteria. In fact in IBD has been reported an upregulation of support the evidence of disturbed microbiota in patients with
the pore-forming claudin-2 and down-regulation of occludin, IBD (309).
particularly claudin-5 and -8 in Crohn’s disease and claudin-4 Despite the involvement of immune intrinsic and barrier
and -7 in UC (83, 86, 326). Increased expression of claudin- intrinsic dysfunction in the pathogenesis of IBD, none of these
2 determines an increased number of pores responsible for the mechanisms alone would be able to explain all the characteristics
paracellular movement of small molecules, characteristic of both of IBD. At the same time, data available in the literature,
UC and Crohn’s disease (1). This rupture in the IEB can result do not fully support defect in the IEB as a primary etiologic
in inflammatory infiltrate resulting in a production of cytokines factor leading to the manifestation of IBD and it is unclear
and other mediators that can further contribute to the impaired whether increased intestinal permeability is a consequence of the
functioning of the IEB. Different proinflammatory cytokines are inflammatory process (347, 348) or anticipates and contributes
implicated in IEB dysfunction through the increased intestinal to intestinal inflammation (317). Considering that current
permeability along paracellular pathways (327). In particular anti-inflammatory therapy (steroids and immunosuppressant
cytokines such as TNF-α, IL-4, IL-13, interferon-γ (IFN-γ), drugs) remains unsatisfactory due to substantial side effects and
IL-1β, IL-9, and IL-6 increase intestinal permeability, whereas uncontrolled relapses (349), understand the interaction between
has been shown that IL-10 has a protective role, maintain IEB gut microbiota and IEB, particularly at the early subclinical
function (321, 328–330). This is supported by the fact that phase of inflammatory disease, could be used to identify novel
IFN-γ and TNF-α are elevated in the mucosa of IBD patients therapeutic approaches in chronic intestinal inflammation.
contributing to a pro-inflammatory cascade and IEB disruption
(75, 331).
Regarding the important role of genetic susceptibility in IBD THERAPEUTIC IMPLICATIONS
patients, most genetic loci that confer susceptibility to Crohn’s
disease and UC, have been linked to defects in IEB function (332– Although several dietary factors, such as gluten, bile acids,
335). The first Crohn’s disease susceptibility gene identified was fructose, ethanol, and emulsifiers are well-known agents
NOD2/CARD15 (336). It was demonstrated that patients with damaging the IEB, other dietary components, such as fibers,
a mutation of NOD2 have altered cell-cell epithelial contacts SCFAs, glutamine, and vitamin D, may improve the IEB.
(337). Furthermore, epithelial cells with mutated NOD2, have Similarly, prebiotics, symbiotics, and probiotics may act on IEB
an inappropriate response to a sensor of a cell wall component function fortifying it. Recent extensive reviews have analyzed

the effects of nutrients and supplements on IEB function (350, Faecalibacterium prausnitzii) and Roseburia (in particular the
351). Now, we will focus on nutritional approaches exerting species Roseburia intestinalis) (365, 366). Sources for butyrate
a protective effect on the IEB, in particular on those that are production include sugars, lactate, acetate, and amino acids,
better defined and studied such as glutamine, vitamin D, and such as lysine (367). Although a lack of dietary fibers and
SCFAs, particularly butyrate. Interestingly, these approaches have SCFAs production can compromise both IEB integrity and
been proposed in the management of patients with IBS or IBD, mucus production, altering gut permeability, the role of SCFAs
conditions characterized by altered IEB function. in DGBI pathophysiology is controversial (368). Similarly,
Glutamine is an essential amino acid in humans and one of although in vitro studies suggested that butyrate can improve
the main energy sources for rapidly dividing epithelial cells of paracellular permeability (183, 185), its role in restoring human
the gastrointestinal tract (352). Its depletion during illness or intestinal permeability in clinical practice is very poorly defined.
infection leads to intestinal epithelial cells atrophy resulting in Preliminary data suggest that supplementation of sodium
increased intestinal permeability (352). Pioneer studies assessing butyrate may improve IBS symptoms, particularly abdominal
the effect of enteral supplement with glutamine granules on pain (369). In a recent proof-of-concept study performed in 40
intestinal IEB function in severely burned patients, showed that patients with IBS, we showed that Lactobacillus paracasei CNCM
this compound can improve intestinal mucosal permeability, I-1572 improves IBS symptoms through a significant reduction in
decrease plasma endotoxin levels, reduce hospital stay and costs genus Ruminococcus associated with a reduction of IL-15, linked
(353, 354). A recent randomized controlled trial (RCT) assessing with the modulation of IEB, and a significant increase in the
the efficacy and safety of oral glutamine supplementation in fecal SCFAs acetate and butyrate (201). However, if nutritional
patients with post-infection IBS with diarrhea and increased butyrate exerts a protective effect on the IEB and may be effective
intestinal permeability, showed that this treatment significantly in the management of patients with common gastrointestinal
improves all IBS symptoms and IEB function (355). However, disorders, this should be demonstrated in ad hoc studies.
due to the small sample size and the suboptimal experimental
study design with significant methodological limitations, these CONCLUSIONS
results require caution and need to be replicated in larger well-
performed clinical trials. IEB dysfunction is a common element of numerous intestinal
Vitamin D is a group of fat-soluble secosteroids responsible and extra-intestinal diseases. Several factors can alter IEB
for increasing intestinal absorption of electrolytes including including gut microbiota metabolites and immune system
calcium, magnesium, and phosphate (356). Among the many mediators. The intricate relationship among all these elements
other biological effects, vitamin D may activate the innate is still a matter of study. If IEB dysfunction is a cause
and modulate the adaptive immune systems with antibacterial, or a consequence of the pathogenesis of common diseases
antiviral, and anti-inflammatory effects (357, 358). Vitamin D including IBS, IBD, CD and the emerging NCGS is a challenge
receptors are expressed by both epithelial and a large number of for the researcher. Solving this dilemma and deciphering the
immune cells in the gastrointestinal tract (357, 358). Although in underlying molecular mechanisms will open the way to the
vitro studies showed that vitamin D is involved in the regulation development of new therapies and the optimization of the
of IEB function throughout the modulation of the expression diagnostic process.
of TJ molecules (357, 359, 360), few randomized controlled
intervention studies have investigated its clinical efficacy or AUTHOR CONTRIBUTIONS
mechanisms of action in gastrointestinal diseases. Low levels of
vitamin D are associated with IBD. A recent systematic review GB and VS designed the review. GB, MRB, DF, MP, FF, CC,
and meta-analysis of vitamin D therapy in patients with IBD and GM performed literature search and drafted the manuscript.
and vitamin D deficiency has shown that this supplementation All authors critically revised and approved the final version of
is effective not only for the correction of vitamin D levels the manuscript.
but also for improving scores of clinical disease activity and
biochemical markers (361). Although the mechanism of action is FUNDING
virtually unknown at this time, preliminary clinical data suggest
that vitamin D supplementation in Crohn’s disease patients in This study was supported in part by the Italian Ministry
remission may have a prominent role in intestinal permeability of Education, University and Research and funds from the
maintenance over time (362). University of Bologna (RFO) to GB. GB was a recipient of the
SCFAs are essential molecules involved not only in host european grant HORIZON 2020-SC1-BHC-2018-2020/H2020-
metabolism and immunity but also in IEB function (180, 363, SC1-2019-Two-Stage-RTD-DISCOVERIE PROJECT. GB was a
364). In addition, they are an energy source for intestinal recipient of an educational grant from Fondazione del Monte
cells and serve as signaling molecules with a beneficial role di Bologna e Ravenna, and Fondazione Carisbo, Bologna,
in intestinal homeostasis (180, 363, 364). Among SCFAs, Italy. MRB was a recipient of a grant from the Italian
butyrate is considered the most beneficial. Butyrate can be Ministry of Health (Ricerca Finalizzata GR-2018-12367062).
produced by a wide variety of bacteria and the most important The funders had no role in study design, data collection
butyrate-producing microorganisms in the human gut belong and analysis, decision to publish, or preparation of the
to the genera Faecalibacterium (in particular the species manuscript.

REFERENCES 26. Ermund A, Gustafsson JK, Hansson GC, Keita Å V. Mucus properties and
goblet cell quantification in mouse, rat and human ileal Peyer’s patches. PLoS
1. Turner JR. Intestinal mucosal barrier function in health and disease. Nat Rev ONE. (2013) 8:e83688. doi: 10.1371/journal.pone.0083688
Immunol. (2009) 9:799–809. doi: 10.1038/nri2653 27. Johansson MEV, Holmén Larsson JM, Hansson GC. The two mucus layers
2. Helander HF, Fändriks L. Surface area of the digestive tract-revisited. Scand of colon are organized by the MUC2 mucin, whereas the outer layer is a
J Gastroenterol. (2014) 49:681–9. doi: 10.3109/00365521.2014.898326 legislator of host-microbial interactions. Proc Natl Acad Sci USA. (2011)
3. Camilleri M. Leaky gut: mechanisms, measurement and clinical implications 108:4659–65. doi: 10.1073/pnas.1006451107
in humans. Gut. (2019) 68:1516–26. doi: 10.1136/gutjnl-2019-318427 28. Atuma C, Strugala V, Allen A, Holm L. The adherent gastrointestinal mucus
4. Yen TH, Wright NA. The gastrointestinal tract stem cell niche. Stem Cell Rev. gel layer: thickness and physical state in vivo. Am J Physiol Gastrointest Liver
(2006) 2:203–12. doi: 10.1007/s12015-006-0048-1 Physiol. (2001) 280:G922–9. doi: 10.1152/ajpgi.2001.280.5.g922
5. Von Moltke J, Ji M, Liang HE, Locksley RM. Tuft-cell-derived IL-25 regulates 29. Ermund A, Schütte A, Johansson MEV, Gustafsson JK, Hansson GC. Studies
an intestinal ILC2-epithelial response circuit. Nature. (2016) 529:221– of mucus in mouse stomach, small intestine, and colon. I. Gastrointestinal
5. doi: 10.1038/nature16161 mucus layers have different properties depending on location as well as
6. Bischoff SC, Barbara G, Buurman W, Ockhuizen T, Schulzke JD, Serino over the Peyer’s patches. Am J Physiol Gastrointest Liver Physiol. (2013)
M, et al. Intestinal permeability - a new target for disease prevention and 305:G341–7. doi: 10.1152/ajpgi.00046.2013
therapy. BMC Gastroenterol. (2014) 14:189. doi: 10.1186/s12876-014-0189-7 30. Birchenough GMH, Johansson MEV, Gustafsson JK, Bergström JH, Hansson
7. Salvo-Romero E, Alonso-Cotoner C, Pardo-Camacho C, Casado- GC. New developments in goblet cell mucus secretion and function. Mucosal
Bedmar M, Vicario M. The intestinal barrier function and its Immunol. (2015) 8:712–9. doi: 10.1038/mi.2015.32
involvement in digestive disease. Rev Esp Enfermedades Dig. (2015) 31. Ouellette AJ. Paneth cells and innate mucosal immunity. Curr Opin
107:686–96. doi: 10.17235/reed.2015.3846/2015 Gastroenterol. (2010) 26:547–53. doi: 10.1097/MOG.0b013e32833dccde
8. Meddings J. The significance of the gut barrier in disease. Gut. (2008) 32. Heazlewood CK, Cook MC, Eri R, Price GR, Tauro SB, Taupin D, et al.
57:438–40. doi: 10.1136/gut.2007.143172 Aberrant mucin assembly in mice causes endoplasmic reticulum stress and
9. Hansson GC. Mucus and mucins in diseases of the intestinal and respiratory spontaneous inflammation resembling ulcerative colitis. PLoS Med. (2008)
tracts. J Intern Med. (2019) 285:479–90. doi: 10.1111/joim.12910 5:54. doi: 10.1371/journal.pmed.0050054
10. Gillois K, Lévêque M, Théodorou V, Robert H, Mercier-Bonin M. Mucus: an 33. Renner M, Bergmann G, Krebs I, End C, Lyer S, Hilberg F, et al.
underestimated gut target for environmental pollutants and food additives. DMBT1 confers mucosal protection in vivo and a deletion variant
Microorganisms. (2018) 6:53. doi: 10.3390/microorganisms6020053 is associated with Crohn’s disease. Gastroenterology. (2007) 133:1499–
11. Johansson MEV, Hansson GC. Immunological aspects of intestinal mucus 509. doi: 10.1053/j.gastro.2007.08.007
and mucins. Nat Rev Immunol. (2016) 16:639–49. doi: 10.1038/nri.2016.88 34. Hooper LV, MacPherson AJ. Immune adaptations that maintain homeostasis
12. Cone RA. Barrier properties of mucus. Adv Drug Deliv Rev. (2009) 61:75– with the intestinal microbiota. Nat Rev Immunol. (2010) 10:159–
85. doi: 10.1016/j.addr.2008.09.008 69. doi: 10.1038/nri2710
13. König J, Wells J, Cani PD, García-Ródenas CL, MacDonald T, Mercenier A, 35. Meyer-Hoffert U, Hornef MW, Henriques-Normark B, Axelsson
et al. Human intestinal barrier function in health and disease. Clin Transl LG, Midtvedt T, Pütsep K, et al. Secreted enteric antimicrobial
Gastroenterol. (2016) 7:e196. doi: 10.1038/ctg.2016.54 activity localises to the mucus surface layer. Gut. (2008)
14. Kim YS, Ho SB. Intestinal goblet cells and mucins in health and disease: 57:764–71. doi: 10.1136/gut.2007.141481
recent insights and progress. Curr Gastroenterol Rep. (2010) 12:319– 36. Van Der Waaij LA, Harmsen HJM, Madjipour M, Kroese FGM,
30. doi: 10.1007/s11894-010-0131-2 Zwiers M, Van Dullemen HM, et al. Bacterial population analysis
15. Hansson GC. Mucins and the Microbiome. Annu Rev Biochem. (2020) of human colon and terminal ileum biopsies with 16S rRNA-based
89:769–93. doi: 10.1146/annurev-biochem-011520-105053 fluorescent probes: commensal bacteria live in suspension and have no
16. Bansil R, Turner BS. The biology of mucus: composition, direct contact with epithelial cells. Inflamm Bowel Dis. (2005) 11:865–
synthesis and organization. Adv Drug Deliv Rev. (2018) 71. doi: 10.1097/01.mib.0000179212.80778.d3
124:3–15. doi: 10.1016/j.addr.2017.09.023 37. Johansson MEV, Phillipson M, Petersson J, Velcich A, Holm L, Hansson
17. LAMONT JT. Mucus: the front line of intestinal mucosal defense. Ann N Y GC. The inner of the two Muc2 mucin-dependent mucus layers in
Acad Sci. (1992) 664:190–201. doi: 10.1111/j.1749-6632.1992.tb39760.x colon is devoid of bacteria. Proc Natl Acad Sci USA. (2008) 105:15064–
18. Kim JJ, Khan WI. Goblet cells and mucins: role in innate defense in enteric 9. doi: 10.1073/pnas.0803124105
infections. Pathogens. (2013) 2:55–70. doi: 10.3390/pathogens2010055 38. Johansson MEV, Sjövall H, Hansson GC. The gastrointestinal mucus system
19. Strugnell RA, Wijburg OLC. The role of secretory antibodies in infection in health and disease. Nat Rev Gastroenterol Hepatol. (2013) 10:352–
immunity. Nat Rev Microbiol. (2010) 8:656–67. doi: 10.1038/nrmicro2384 61. doi: 10.1038/nrgastro.2013.35
20. Huus KE, Petersen C, Finlay BB. Diversity and dynamism 39. Li H, Limenitakis JP, Fuhrer T, Geuking MB, Lawson MA, Wyss M, et al. The
of IgA–microbiota interactions. Nat Rev Immunol. (2021) outer mucus layer hosts a distinct intestinal microbial niche. Nat Commun.
21:514–25. doi: 10.1038/s41577-021-00506-1 (2015) 6:8292. doi: 10.1038/ncomms9292
21. Pelaseyed T, Hansson GC. Membrane mucins of the intestine at a glance. J 40. Kamphuis JBJ, Mercier-Bonin M, Eutamène H, Theodorou V. Mucus
Cell Sci. (2020) 133:jcs240929. doi: 10.1242/JCS.240929 organisation is shaped by colonic content; a new view. Sci Rep. (2017)
22. Etienne-Mesmin L, Chassaing B, Desvaux M, De Paepe K, Gresse R, 7:8527. doi: 10.1038/s41598-017-08938-3
Sauvaitre T, et al. Experimental models to study intestinal microbes–mucus 41. Hoskins LC, Boulding ET. Mucin degradation in human colon ecosystems. J
interactions in health and disease. FEMS Microbiol Rev. (2019) 43:457– Clin Invest. (1981) 67:163–72. doi: 10.1172/jci110009
89. doi: 10.1093/femsre/fuz013 42. Png CW, Lindén SK, Gilshenan KS, Zoetendal EG, McSweeney CS, Sly LI,
23. Pelaseyed T, Bergström JH, Gustafsson JK, Ermund A, Birchenough GMH, et al. Mucolytic bacteria with increased prevalence in IBD mucosa augment
Schütte A, et al. The mucus and mucins of the goblet cells and enterocytes in vitro utilization of mucin by other bacteria. Am J Gastroenterol. (2010)
provide the first defense line of the gastrointestinal tract and interact with 105:2420–8. doi: 10.1038/ajg.2010.281
the immune system. Immunol Rev. (2014) 260:8–20. doi: 10.1111/imr.12182 43. Desai MS, Seekatz AM, Koropatkin NM, Kamada N, Hickey CA, Wolter
24. Pabst O, Mowat AM. Oral tolerance to food protein. Mucosal Immunol. M, et al. A dietary fiber-deprived gut microbiota degrades the colonic
(2012) 5:232–9. doi: 10.1038/mi.2012.4 mucus barrier and enhances pathogen susceptibility. Cell. (2016) 167:1339–
25. Shan M, Gentile M, Yeiser JR, Walland AC, Bornstein 53.e21. doi: 10.1016/j.cell.2016.10.043
VU, Chen K, et al. Mucus enhances gut homeostasis 44. Johansson MEV, Jakobsson HE, Holmén-Larsson J, Schütte A, Ermund
and oral tolerance by delivering immunoregulatory A, Rodríguez-Piñeiro AM, et al. Normalization of host intestinal mucus
signals. Science. (2013) 342:447–53. doi: 10.1126/science.12 layers requires long-term microbial colonization. Cell Host Microbe. (2015)
37910 18:582–92. doi: 10.1016/j.chom.2015.10.007

45. Schroeder BO. Fight them or feed them: how the intestinal mucus 65. Martìn-Padura I, Lostaglio S, Schneemann M, Williams L, Romano M,
layer manages the gut microbiota. Gastroenterol Rep. (2019) 7:3– Fruscella P, et al. Junctional adhesion molecule, a novel member of
12. doi: 10.1093/gastro/goy052 the immunoglobulin superfamily that distributes at intercellular junctions
46. Fu J, Wei B, Wen T, Johansson MEV, Liu X, Bradford E, et al. Loss of intestinal and modulates monocyte transmigration. J Cell Biol. (1998) 142:117–
core 1-derived O-glycans causes spontaneous colitis in mice. J Clin Invest. 27. doi: 10.1083/jcb.142.1.117
(2011) 121:1657–66. doi: 10.1172/JCI45538 66. Ikenouchi J, Umeda K, Tsukita S, Furuse M, Tsukita S. Requirement of ZO-
47. Larsson JMH, Karlsson H, Crespo JG, Johansson MEV, Eklund L, Sjövall 1 for the formation of belt-like adherens junctions during epithelial cell
H, et al. Altered O-glycosylation profile of MUC2 mucin occurs in active polarization. J Cell Biol. (2007) 176:779–86. doi: 10.1083/jcb.200612080
ulcerative colitis and is associated with increased inflammation. Inflamm 67. Günzel D, Fromm M. Claudins and other tight junction proteins. Compr
Bowel Dis. (2011) 17:2299–307. doi: 10.1002/ibd.21625 Physiol. (2012) 2:1819–52. doi: 10.1002/cphy.c110045
48. Johansson MEV, Gustafsson JK, Holmen-Larsson J, Jabbar KS, Xia L, Xu H, 68. Günzel D, Yu ASL. Claudins and the modulation of
et al. Bacteria penetrate the normally impenetrable inner colon mucus layer tight junction permeability. Physiol Rev. (2013) 93:525–
in both murine colitis models and patients with ulcerative colitis. Gut. (2014) 69. doi: 10.1152/physrev.00019.2012
63:281–91. doi: 10.1136/gutjnl-2012-303207 69. Suzuki T. Regulation of the intestinal barrier by nutrients: the role of tight
49. Strugala V, Dettmar PW, Pearson JP. Thickness and continuity junctions. Anim Sci J. (2020) 91:e13357. doi: 10.1111/asj.13357
of the adherent colonic mucus barrier in active and quiescent 70. Cong X, Kong W. Endothelial tight junctions and their regulatory
ulcerative colitis and Crohn’s disease. Int J Clin Pract. (2008) signaling pathways in vascular homeostasis and disease. Cell Signal. (2020)
62:762–9. doi: 10.1111/j.1742-1241.2007.01665.x 66:109485. doi: 10.1016/j.cellsig.2019.109485
50. Pullan RD, Thomas GAO, Rhodes M, Newcombe RG, Williams GT, Allen A, 71. Shen L, Weber CR, Raleigh DR, Yu D, Turner JR. Tight junction pore
et al. Thickness of adherent mucus gel on colonic mucosa in humans and its and leak pathways: a dynamic duo. Annu Rev Physiol. (2011) 73:283–309.
relevance to colitis. Gut. (1994) 35:353–9. doi: 10.1136/gut.35.3.353 doi: 10.1146/annurev-physiol-012110-142150
51. Buisine MP, Desreumaux P, Leteurtre E, Copin MC, Colombel JF, Porchet N, 72. Van Itallie CM, Anderson JM. Claudins and epithelial
et al. Mucin gene expression in intestinal epithelial cells in Crohn’s disease. paracellular transport. Annu Rev Physiol. (2006) 68:403–
Gut. (2001) 49:544–51. doi: 10.1136/gut.49.4.544 29. doi: 10.1146/annurev.physiol.68.040104.131404
52. Buisine MP, Desreumaux P, Debailleul V, Gambiez L, Geboes K, Ectors N, 73. Heller F, Florian P, Bojarski C, Richter J, Christ M, Hillenbrand B, et al.
et al. Abnormalities in mucin gene expression in Crohn’s disease. Inflamm Interleukin-13 is the key effector Th2 cytokine in ulcerative colitis that affects
Bowel Dis. (1999) 5:24–32. doi: 10.1097/00054725-199902000-00004 epithelial tight junctions, apoptosis, and cell restitution. Gastroenterology.
53. Nakamori S, Ota DM, Cleary KR, Shirotani K, Irimura T. (2005) 129:550–64. doi: 10.1016/j.gastro.2005.05.002
MUC1 mucin expression as a marker of progression and 74. Ivanov AI, Nusrat A, Parkos CA. The epithelium in inflammatory
metastasis of human colorectal carcinoma. Gastroenterology. (1994) bowel disease: potential role of endocytosis of junctional
106:353–61. doi: 10.1016/0016-5085(94)90592-4 proteins in barrier disruption. Novartis Found Symp. (2004)
54. Ajioka Y, Allison LJ, Jass JR. Significance of MUC1 and MUC2 263:115–24. doi: 10.1002/0470090480.ch9
mucin expression in colorectal cancer. J Clin Pathol. (1996) 49:560– 75. Kucharzik T, Walsh S V., Chen J, Parkos CA, Nusrat A. Neutrophil
4. doi: 10.1136/jcp.49.7.560 transmigration in inflammatory bowel disease is associated with differential
55. McGuckin MA, Lindén SK, Sutton P, Florin TH. Mucin dynamics and enteric expression of epithelial intercellular junction proteins. Am J Pathol. (2001)
pathogens. Nat Rev Microbiol. (2011) 9:265–78. doi: 10.1038/nrmicro2538 159:2001–9. doi: 10.1016/S0002-9440(10)63051-9
56. Dharmani P, Srivastava V, Kissoon-Singh V, Chadee K. Role of intestinal 76. Pizzuti D, Senzolo M, Buda A, Chiarelli S, Giacomelli L, Mazzon E, et al.
mucins in innate host defense mechanisms against pathogens. J Innate In vitro model for IgE mediated food allergy. Scand J Gastroenterol. (2011)
Immun. (2009) 1:123–35. doi: 10.1159/000163037 46:177–87. doi: 10.3109/00365521.2010.525716
57. Hayashi F, Smith KD, Ozinsky A, Hawn TR, Yi EC, Goodlett DR, 77. Assimakopoulos SF, Tsamandas AC, Tsiaoussis GI, Karatza E,
et al. The innate immune response to bacterial flagellin is mediated Triantos C, Vagianos CE, et al. Altered intestinal tight junctions’
by Toll-like receptor 5. Nature. (2001) 410:1099–103. doi: 10.1038/3507 expression in patients with liver cirrhosis: a pathogenetic
4106 mechanism of intestinal hyperpermeability. Eur J Clin Invest. (2012)
58. Birchenough GMH, Nystrom EEL, Johansson MEV, Hansson GC. A sentinel 42:439–46. doi: 10.1111/j.1365-2362.2011.02609.x
goblet cell guards the colonic crypt by triggering Nlrp6-dependent Muc2 78. Bertiaux-Vandaële N, Youmba SB, Belmonte L, Lecleire S, Antonietti M,
secretion. Science. (2016) 352:1535–42. doi: 10.1126/science.aaf7419 Gourcerol G, et al. The expression and the cellular distribution of the
59. Wang S, Ahmadi S, Nagpal R, Jain S, Mishra SP, Kavanagh K, et al. tight junction proteins are altered in irritable bowel syndrome patients with
Lipoteichoic acid from the cell wall of a heat killed Lactobacillus paracasei differences according to the disease subtype. Am J Gastroenterol. (2011)
D3-5 ameliorates aging-related leaky gut, inflammation and improves 106:2165–73. doi: 10.1038/ajg.2011.257
physical and cognitive functions: from C. elegans to mice. GeroScience. (2020) 79. Rahner C, Mitic LL, Anderson JM. Heterogeneity in expression and
42:333–52. doi: 10.1007/s11357-019-00137-4 subcellular localization of claudins 2, 3, 4, and 5 in the rat liver, pancreas,
60. Lee KD, Guk SM, Chai JY. Toll-like receptor 2 and Muc2 expression on and gut. Gastroenterology. (2001) 120:411–22. doi: 10.1053/gast.2001.21736
human intestinal epithelial cells by gymnophalloides seoi adult antigen. J 80. Reyes JL, Lamas M, Martin D, Namorado MDC, Islas S, Luna J, et al. The
Parasitol. (2010) 96:58–66. doi: 10.1645/GE-2195.1 renal segmental distribution of claudins changes with development. Kidney
61. Kamdar K, Johnson AMF, Chac D, Myers K, Kulur V, Truevillian K, Int. (2002) 62:476–87. doi: 10.1046/j.1523-1755.2002.00479.x
et al. Innate recognition of the microbiota by TLR1 promotes epithelial 81. Wolburg H, Wolburg-Buchholz K, Liebner S, Engelhardt B. Claudin-
homeostasis and prevents chronic inflammation. J Immunol. (2018) 1, claudin-2 and claudin-11 are present in tight junctions of choroid
201:230–42. doi: 10.4049/jimmunol.1701216 plexus epithelium of the mouse. Neurosci Lett. (2001) 307:77–80.
62. Anderson JM, Van Itallie CM. Physiology and function of doi: 10.1016/S0304-3940(01)01927-9
the tight junction. Cold Spring Harb Perspect Biol. (2009) 82. Zhu Y, Brännström M, Janson PO, Sundfeldt K. Differences in expression
1:a002584. doi: 10.1101/cshperspect.a002584 patterns of the tight junction proteins, claudin 1, 3, 4 and 5, in human ovarian
63. Furuse M, Fujita K, Hiiragi T, Fujimoto K, Tsukita S. Claudin-1 surface epithelium as compared to epithelia in inclusion cysts and epithelial
and−2: novel integral membrane proteins localizing at tight junctions ovarian tumours. Int J Cancer. (2006) 118:1884–91. doi: 10.1002/ijc.21506
with no sequence similarity to occludin. J Cell Biol. (1998) 141:1539– 83. Oshima T, Miwa H, Joh T. Changes in the expression of
50. doi: 10.1083/jcb.141.7.1539 claudins in active ulcerative colitis. J Gastroenterol Hepatol. (2008)
64. Furuse M, Hirase T, Itoh M, Nagafuchi A, Yonemura S, Tsukita S, et al. 23:3–7. doi: 10.1111/j.1440-1746.2008.05405.x
Occludin: a novel integral membrane protein localizing at tight junctions. 84. Nagy Szakál D, Gyorffy H, Arató A, Cseh Á, Molnár K, Papp M, et al.
J Cell Biol. (1993) 123:1777–88. doi: 10.1083/jcb.123.6.1777 Mucosal expression of claudins 2, 3 and 4 in proximal and distal part of

duodenum in children with coeliac disease. Virchows Arch. (2010) 456:245– homeodomain transcription factor, encodes lung- and stomach-specific
50. doi: 10.1007/s00428-009-0879-7 isoforms through alternative splicing. Mol Cell Biol. (2001) 21:7380–
85. Martínez C, Lobo B, Pigrau M, Ramos L, González-Castro AM, Alonso C, 90. doi: 10.1128/mcb.21.21.7380-7390.2001
et al. Diarrhoea-predominant irritable bowel syndrome: an organic disorder 103. Linares GR, Brommage R, Powell DR, Xing W, Chen ST, Alshbool FZ, et al.
with structural abnormalities in the jejunal epithelial barrier. Gut. (2013) Claudin 18 is a novel negative regulator of bone resorption and osteoclast
62:1160–8. doi: 10.1136/gutjnl-2012-302093 differentiation. J Bone Miner Res. (2012) 27:1553–65. doi: 10.1002/jbmr.1600
86. Zeissig S, Bürgel N, Günzel D, Richter J, Mankertz J, Wahnschaffe 104. Sanada Y, Oue N, Mitani Y, Yoshida K, Nakayama H, Yasui W. Down-
U, et al. Changes in expression and distribution of claudin 2, 5 and regulation of the claudin-18 gene, identified through serial analysis of gene
8 lead to discontinuous tight junctions and barrier dysfunction in expression data analysis, in gastric cancer with an intestinal phenotype. J
active Crohn’s disease. Gut. (2007) 56:61–72. doi: 10.1136/gut.2006.0 Pathol. (2006) 208:633–42. doi: 10.1002/path.1922
94375 105. Wong V. Phosphorylation of occludin correlates with occludin localization
87. Laurila JJ, Karttunen T, Koivukangas V, Laurila PA, Syrjälä H, Saarnio J, et al. and function at the tight junction. Am J Physiol Cell Physiol. (1997)
Tight junction proteins in gallbladder epithelium: different expression in 273:C1859–67. doi: 10.1152/ajpcell.1997.273.6.c1859
acute acalculous and calculous cholecystitis. J Histochem Cytochem. (2007) 106. Umeda K, Ikenouchi J, Katahira-Tayama S, Furuse K, Sasaki H, Nakayama
55:567–73. doi: 10.1369/jhc.6A7155.2007 M, et al. ZO-1 and ZO-2 independently determine where claudins are
88. Wolburg H, Wolburg-Buchholz K, Kraus J, Rascher-Eggstein G, Liebner polymerized in tight-junction strand formation. Cell. (2006) 126:741–
S, Hamm S, et al. Localization of claudin-3 in tight junctions of the 54. doi: 10.1016/j.cell.2006.06.043
blood-brain barrier is selectively lost during experimental autoimmune 107. González-Mariscal L, Quirós M, Díaz-Coránguez M. ZO proteins and
encephalomyelitis and human glioblastoma multiforme. Acta Neuropathol. redox-dependent processes. Antioxidants Redox Signal. (2011) 15:1235–
(2003) 105:586–92. doi: 10.1007/s00401-003-0688-z 53. doi: 10.1089/ars.2011.3913
89. Kiuchi-Saishin Y, Gotoh S, Furuse M, Takasuga A, Tano Y, Tsukita S. 108. Jesaitis LA, Goodenough DA. Molecular characterization and tissue
Differential expression patterns of claudins, tight junction membrane distribution of ZO-2, a tight junction protein homologous to ZO-1 and
proteins, in mouse nephron segments. J Am Soc Nephrol. (2002) 13:875– the Drosophila discs-large tumor suppressor protein. J Cell Biol. (1994)
86. doi: 10.1681/asn.v134875 124:949–61. doi: 10.1083/jcb.124.6.949
90. Mennigen R, Nolte K, Rijcken E, Utech M, Loeffler B, Senninger N, et al. 109. Fanning AS, Jameson BJ, Jesaitis LA, Anderson JM. The tight junction
Probiotic mixture VSL#3 protects the epithelial barrier by maintaining protein ZO-1 establishes a link between the transmembrane protein
tight junction protein expression and preventing apoptosis in a murine occludin and the actin cytoskeleton. J Biol Chem. (1998) 273:29745–
model of colitis. Am J Physiol Gastrointest Liver Physiol. (2009) 296:G1140– 53. doi: 10.1074/jbc.273.45.29745
9. doi: 10.1152/ajpgi.90534.2008 110. Itoh M, Morita K, Tsukita S. Characterization of ZO-2 as a MAGUK
91. Oshima T, Miwa H. Gastrointestinal mucosal barrier function and diseases. J family member associated with tight as well as adherens junctions with a
Gastroenterol. (2016) 51:768–78. doi: 10.1007/s00535-016-1207-z binding affinity to occludin and α catenin. J Biol Chem. (1999) 274:5981–
92. Sapone A, Lammers KM, Casolaro V, Cammarota M, Giuliano MT, De 6. doi: 10.1074/jbc.274.9.5981
Rosa M, et al. Divergence of gut permeability and mucosal immune gene 111. Fanning AS, Ma TY, Anderson JM. Isolation and functional characterization
expression in two gluten-associated conditions: Celiac disease and gluten of the actin binding region in the tight junction protein ZO-1. FASEB J.
sensitivity. BMC Med. (2011) 9:23. doi: 10.1186/1741-7015-9-23 (2002) 16:1835–7. doi: 10.1096/fj.02-0121fje
93. Morita K, Sasaki H, Furuse M, Tsukita S. Endothelial claudin: Claudin- 112. Mandell KJ, Parkos CA. The JAM family of proteins. Adv Drug Deliv Rev.
5/TMVCF constitutes tight junction strands in endothelial cells. J Cell Biol. (2005) 57:857–67. doi: 10.1016/j.addr.2005.01.005
(1999) 147:185–94. doi: 10.1083/jcb.147.1.185 113. Ebnet K. Junctional adhesion molecules (JAMs): cell adhesion receptors with
94. Nitta T, Hata M, Gotoh S, Seo Y, Sasaki H, Hashimoto N, et al. Size-selective pleiotropic functions in cell physiology and development. Physiol Rev. (2017)
loosening of the blood-brain barrier in claudin-5-deficient mice. J Cell Biol. 97:1529–54. doi: 10.1152/physrev.00004.2017
(2003) 161:653–60. doi: 10.1083/jcb.200302070 114. Van Itallie CM, Anderson JM. Architecture of tight junctions and
95. Amasheh S, Schmidt T, Mahn M, Florian P, Mankertz J, Tavalali S, et al. principles of molecular composition. Semin Cell Dev Biol. (2014) 36:157–
Contribution of claudin-5 to barrier properties in tight junctions of epithelial 65. doi: 10.1016/j.semcdb.2014.08.011
cells. Cell Tissue Res. (2005) 321:89–96. doi: 10.1007/s00441-005-1101-0 115. Laukoetter MG, Nava P, Lee WY, Severson EA, Capaldo CT, Babbin BA, et al.
96. Schumann M, Günzel D, Buergel N, Richter JF, Troeger H, May C, JAM-A regulates permeability and inflammation in the intestine in vivo. J
et al. Cell polarity-determining proteins Par-3 and PP-1 are involved in Exp Med. (2007) 204:3067–76. doi: 10.1084/jem.20071416
epithelial tight junction defects in coeliac disease. Gut. (2012) 61:220– 116. Severson EA, Lee WY, Capaldo CT, Nusrat A, Parkos CA. Junctional
8. doi: 10.1136/gutjnl-2011-300123 adhesion molecule a interacts with afadin and PDZ-GEF2 to activate raplA,
97. Fujita H, Chiba H, Yokozaki H, Sakai N, Sugimoto K, Wada T, regulate j31 integrin levels, and enhance cell migration. Mol Biol Cell. (2009)
et al. Differential expression and subcellular localization of claudin- 20:1916–25. doi: 10.1091/mbc.E08-10-1014
7,−8,−12,−13, and−15 along the mouse intestine. J Histochem Cytochem. 117. Nava P, Capaldo CT, Koch S, Kolegraff K, Rankin CR, Farkas AE, et al. JAM-
(2006) 54:933–44. doi: 10.1369/jhc.6A6944.2006 A regulates epithelial proliferation through Akt/β-catenin signalling. EMBO
98. Go M, Kojima T, Takano KI, Murata M, Ichimiya S, Tsubota H, et al. Rep. (2011) 12:314–20. doi: 10.1038/embor.2011.16
Expression and function of tight junctions in the crypt epithelium 118. Monteiro AC, Sumagin R, Rankin CR, Leoni G, Mina MJ, Reiter DM, et al.
of human palatine tonsils. J Histochem Cytochem. (2004) 52:1627– JAM-A associates with ZO-2, afadin, and PDZ-GEF1 to activate Rap2c
38. doi: 10.1369/jhc.4A6339.2004 and regulate epithelial barrier function. Mol Biol Cell. (2013) 24:2849–
99. Li WY, Huey CL, Yu AS. Expression of claudin-7 and−8 along 60. doi: 10.1091/mbc.E13-06-0298
the mouse nephron. Am J Physiol Renal Physiol. (2004) 286:F1063– 119. Hollander D, Vadheim CM, Brettholz E, Petersen GM, Delahunty T, Rotter
71.doi: 10.1152/ajprenal.00384.2003 JI. Increased intestinal permeability in patients with Crohn’s disease and
100. Turksen K, Troy TC. Claudin-6: a novel tight junction molecule is their relatives: a possible etiologic factor. Ann Intern Med. (1986) 105:883–
developmentally regulated in mouse embryonic epithelium. Dev Dyn. (2001) 5. doi: 10.7326/0003-4819-105-6-883
222:292–300. doi: 10.1002/dvdy.1174 120. Martínez C, Vicario M, Ramos L, Lobo B, Mosquera JL, Alonso C, et al. The
101. Lameris AL, Huybers S, Kaukinen K, Mäkelä TH, Bindels RJ, Hoenderop JG, jejunum of diarrhea-predominant irritable bowel syndrome shows molecular
et al. Expression profiling of claudins in the human gastrointestinal tract in alterations in the tight junction signaling pathway that are associated
health and during inflammatory bowel disease. Scand J Gastroenterol. (2013) with mucosal pathobiology and clinical manifestations. Am J Gastroenterol.
48:58–69. doi: 10.3109/00365521.2012.741616 (2012) 107:736–46. doi: 10.1038/ajg.2011.472
102. Niimi T, Nagashima K, Ward JM, Minoo P, Zimonjic DB, Popescu NC, 121. Wilcz-Villega E, Mcclean S, O’Sullivan M. Reduced E-cadherin expression
et al. claudin-18, a novel downstream target gene for the T/EBP/NKX2.1 is associated with abdominal pain and symptom duration in a study of

alternating and diarrhea predominant IBS. Neurogastroenterol Motil. (2014) 141. Barbaro MR, Cremon C, Wrona D, Fuschi D, Marasco G, Stanghellini V, et al.
26:316–25. doi: 10.1111/nmo.12262 Non-celiac gluten sensitivity in the context of functional gastrointestinal
122. Drago S, El Asmar R, Di Pierro M, Clemente MG, Tripathi A, Sapone disorders. Nutrients. (2020) 12:1–21. doi: 10.3390/nu12123735
A, et al. Gliadin, zonulin and gut permeability: effects on celiac and non- 142. Fasano A. Zonulin measurement conundrum: add confusion
celiac intestinal mucosa and intestinal cell lines. Scand J Gastroenterol. (2006) to confusion does not lead to clarity. Gut. (2020) 70:2007–8.
41:408–19. doi: 10.1080/00365520500235334 doi: 10.1136/gutjnl-2020-323367
123. Vetrano S, Rescigno M, Rosaria Cera M, Correale C, Rumio C, Doni 143. Misra A. Challenges in delivery of therapeutic genomics and proteomics.
A, et al. Unique role of junctional adhesion molecule-a in maintaining Amsterdam: Elsevier Inc. (2011). doi: 10.1016/C2010-0-65663-X
mucosal homeostasis in inflammatory Bowel disease. Gastroenterology. 144. Sugano K, Kansy M, Artursson P, Avdeef A, Bendels S, Di L, et al. Coexistence
(2008) 135:173–84. doi: 10.1053/j.gastro.2008.04.002 of passive and carrier-mediated processes in drug transport. Nat Rev Drug
124. Wilcz-Villega EM, McClean S, O’Sullivan MA. Mast cell tryptase Discov. (2010) 9:597–614. doi: 10.1038/nrd3187
reduces junctional adhesion molecule-A (JAM-A) expression in intestinal 145. Wang Y, DeMazumder D, Hill JA. Ionic fluxes and genesis
epithelial cells: implications for the mechanisms of barrier dysfunction of the cardiac action potential. Muscle. (2012) 1:67–
in irritable bowel syndrome. Am J Gastroenterol. (2013) 108:1140– 85. doi: 10.1016/B978-0-12-381510-1.00007-7
51. doi: 10.1038/ajg.2013.92 146. Horisberger JD, Chraïbi A. Epithelial sodium channel: a ligand-gated
125. Cordenonsi M, D’Atri F, Hammar E, Parry DAD, Kendrick-Jones J, Shore channel? Nephron Physiol. (2004) 96:37–41. doi: 10.1159/000076406
D, et al. Cingulin contains globular and coiled-coil domains and interacts 147. Mukherjee B, Satapathy BS, Bhattacharya S, Chakraborty R, Mishra VP.
with ZO-1, ZO-2, ZO-3, and myosin. J Cell Biol. (1999) 147:1569– Chapter 19 - Pharmacokinetic and pharmacodynamic modulations of
81. doi: 10.1083/jcb.147.7.1569 therapeutically active constituents from orally administered nanocarriers
126. Citi S, Paschoud S, Pulimeno P, Timolati F, De Robertis F, Jond L, et al. The along with a glimpse of their advantages and limitations. In: Grumezescu
tight junction protein cingulin regulates gene expression and rhoA signaling. AM, editor. Nano- and Microscale Drug Delivery Systems. Elsevier. (2017).
Ann N Y Acad Sci. (2009) 1165:88–98. doi: 10.1111/j.1749-6632.2009.04053.x p. 357–75. doi: 10.1016/B978-0-323-52727-9.00019-4
127. Suarez C, Kovar DR. Internetwork competition for monomers governs 148. Goldstein JL, Anderson RGW, Brown MS. Coated pits, coated
actin cytoskeleton organization. Nat Rev Mol Cell Biol. (2016) 17:799– vesicles, and receptor-mediated endocytosis. Nature. (1979)
810. doi: 10.1038/nrm.2016.106 279:679–85. doi: 10.1038/279679a0
128. Kim S, Coulombe PA. Emerging role for the cytoskeleton as an organizer 149. Garcia-Castillo MD, Chinnapen DJF, Lencer WI. Membrane transport
and regulator of translation. Nat Rev Mol Cell Biol. (2010) 11:75– across polarized epithelia. Cold Spring Harb Perspect Biol. (2017)
81. doi: 10.1038/nrm2818 9:a027912. doi: 10.1101/cshperspect.a027912
129. Al-Sadi RM, Ma TY. IL-1β Causes an Increase in Intestinal 150. Sandvig K, Kavaliauskiene S, Skotland T. Clathrin-independent endocytosis:
Epithelial Tight Junction Permeability. J Immunol. (2007) an increasing degree of complexity. Histochem Cell Biol. (2018) 150:107–
178:4641–9. doi: 10.4049/jimmunol.178.7.4641 18. doi: 10.1007/s00418-018-1678-5
130. Schwayer C, Shamipour S, Pranjic-Ferscha K, Schauer A, Balda M, Tada M, 151. Tuma PL, Hubbard AL. Transcytosis: crossing cellular barriers. Physiol Rev.
et al. Mechanosensation of tight junctions depends on ZO-1 phase separation (2003) 83:871–932. doi: 10.1152/physrev.00001.2003
and flow. Cell. (2019) 179:937–52.e18. doi: 10.1016/j.cell.2019.10.006 152. Mestecky J, Russell MW, Elson CO. Intestinal IgA: novel views on its
131. Holthöfer B, Windoffer R, Troyanovsky S, Leube RE. Structure function in the defence of the largest mucosal surface. Gut. (1999) 44:2–
and function of desmosomes. Int Rev Cytol. (2007) 264:65– 5. doi: 10.1136/gut.44.1.2
163. doi: 10.1016/S0074-7696(07)64003-0 153. Kadaoui KA, Corthésy B. Secretory IgA mediates bacterial
132. Hartsock A, Nelson WJ. Adherens and tight junctions: structure, function translocation to dendritic cells in mouse Peyer’s patches
and connections to the actin cytoskeleton. Biochim Biophys Acta Biomembr. with restriction to mucosal compartment. J Immunol. (2007)
(2008) 1778:660–9. doi: 10.1016/j.bbamem.2007.07.012 179:7751–7. doi: 10.4049/jimmunol.179.11.7751
133. Shapiro L, Weis WI. Structure and biochemistry of cadherins 154. Boullier S, Tanguy M, Kadaoui KA, Caubet C, Sansonetti P, Corthésy B, et al.
and catenins. Cold Spring Harb Perspect Biol. (2009) Secretory IgA-mediated neutralization of Shigella flexneri prevents intestinal
1:a003053. doi: 10.1101/cshperspect.a003053 tissue destruction by down-regulating inflammatory circuits. J Immunol.
134. Ivanov AI, Naydenov NG. Dynamics and regulation of epithelial adherens (2009) 183:5879–85. doi: 10.4049/jimmunol.0901838
junctions. Recent discoveries and controversies. Int Rev Cell Mol Biol. (2013) 155. Rey J, Garin N, Spertini F, Corthésy B. Targeting of secretory IgA to Peyer’s
303:27–99. doi: 10.1016/B978-0-12-407697-6.00002-7 patch dendritic and T cells after transport by intestinal M cells. J Immunol.
135. Takeichi M. Dynamic contacts: rearranging adherens junctions to drive (2004) 172:3026–33. doi: 10.4049/jimmunol.172.5.3026
epithelial remodelling. Nat Rev Mol Cell Biol. (2014) 15:397–410. 156. Matysiak-Budnik T, Moura IC, Arcos-Fajardo M, Lebreton C, Ménard S,
doi: 10.1038/nrm3802 Candalh C, et al. Secretory IgA mediates retrotranscytosis of intact gliadin
136. Nekrasova OE, Amargo EV, Smith WO, Chen J, Kreitzer GE, Green peptides via the transferrin receptor in celiac disease. J Exp Med. (2008)
KJ. Desmosomal cadherins utilize distinct kinesins for assembly into 205:143–54. doi: 10.1084/jem.20071204
desmosomes. J Cell Biol. (2011) 195:1185–203. doi: 10.1083/jcb.2011 157. Bevilacqua C, Montagnac G, Benmerah A, Candalh C, Brousse N, Cerf-
06057 Bensussan N, et al. Food allergens are protected from degradation during
137. Hatzfeld M, Keil R, Magin TM. Desmosomes and intermediate filaments: CD23-mediated transepithelial transport. Int Arch Allergy Immunol. (2004)
their consequences for tissue mechanics. Cold Spring Harb Perspect Biol. 205:143–54. doi: 10.1159/000080653
(2017) 9:a029157. doi: 10.1101/cshperspect.a029157 158. Kaiserlian D, Lachaux A, Grosjean I, Graber P, Bonnefoy JY. Intestinal
138. Tripathi A, Lammers KM, Goldblum S, Shea-Donohue T, Netzel-Arnett S, epithelial cells express the CD23/FcεRII molecule: enhanced expression in
Buzza MS, et al. Identification of human zonulin, a physiological modulator enteropathies. Immunology. (1993) 80:90–5.
of tight junctions, as prehaptoglobin-2. Proc Natl Acad Sci USA. (2009) 159. Montagnac G, Yu LCH, Bevilacqua C, Heyman M, Conrad DH,
106:16799–804. doi: 10.1073/pnas.0906773106 Perdue MH, et al. Differential role for CD23 splice forms in apical to
139. Lammers KM, Lu R, Brownley J, Lu B, Gerard C, Thomas K, et al. basolateral transcytosis of IgE/allergen complexes. Traffic. (2005) 6:230–
Gliadin induces an increase in intestinal permeability and zonulin release 42. doi: 10.1111/j.1600-0854.2005.00262.x
by binding to the chemokine receptor CXCR3. Gastroenterology. (2008) 160. Montagnac G, Mollà-Herman A, Bouchet J, Yu LCH, Conrad DH, Perdue
135:194–204.e3. doi: 10.1053/j.gastro.2008.03.023 MH, et al. Intracellular trafficking of CD23: differential regulation in humans
140. Sapone A, De Magistris L, Pietzak M, Clemente MG, Tripathi A, Cucca F, and mice by both extracellular and intracellular exons. J Immunol. (2005)
et al. Zonulin upregulation is associated with increased gut permeability in 174:5562–72. doi: 10.4049/jimmunol.174.9.5562
subjects with type 1 diabetes and their relatives. Diabetes. (2006) 55:1443–9. 161. Neal MD, Leaphart C, Levy R, Prince J, Billiar TR, Watkins S,
doi: 10.2337/db05-1593 et al. Enterocyte TLR4 Mediates Phagocytosis and Translocation of

Bacteria Across the Intestinal Barrier. J Immunol. (2006) 176:3070– 184. Kim MH, Kang SG, Park JH, Yanagisawa M, Kim CH. Short-chain fatty
9. doi: 10.4049/jimmunol.176.5.3070 acids activate GPR41 and GPR43 on intestinal epithelial cells to promote
162. Conner SD, Schmid SL. Regulated portals of entry into the cell. Nature. inflammatory responses in mice. Gastroenterology. (2013) 145:396–406.e1-
(2003) 422:37–44. doi: 10.1038/nature01451 10. doi: 10.1053/j.gastro.2013.04.056
163. Günther J, Seyfert HM. The first line of defence: insights into mechanisms 185. Singh N, Gurav A, Sivaprakasam S, Brady E, Padia R, Shi H, et al. Activation
and relevance of phagocytosis in epithelial cells. Semin Immunopathol. of Gpr109a, receptor for niacin and the commensal metabolite butyrate,
(2018) 40:555–65. doi: 10.1007/s00281-018-0701-1 suppresses colonic inflammation and carcinogenesis. Immunity. (2014)
164. Hommelgaard AM, Roepstorff K, Vilhardt F, Torgersen ML, 40:128–39. doi: 10.1016/j.immuni.2013.12.007
Sandvig K, van Deurs B. Caveolae: stable membrane domains 186. Ghosh S, Whitley CS, Haribabu B, Jala VR. Regulation of intestinal barrier
with a potential for internalization. Traffic. (2005) 6:720– function by microbial. Cell Mol Gastroenterol Hepatol. (2021) 11:1463–
4. doi: 10.1111/j.1600-0854.2005.00314.x 82. doi: 10.1016/j.jcmgh.2021.02.007
165. Maloy KJ, Powrie F. Intestinal homeostasis and its breakdown 187. Abreu MT. Toll-like receptor signalling in the intestinal epithelium: how
in inflammatory bowel disease. Nature. (2011) 474:298– bacterial recognition shapes intestinal function. Nat Rev Immunol. (2010)
306. doi: 10.1038/nature10208 10:131–43. doi: 10.1038/nri2707
166. Khor B, Gardet A, Xavier RJ. Genetics and pathogenesis of inflammatory 188. Burgueño JF, Abreu MT. Epithelial Toll-like receptors and their role in gut
bowel disease. Nature. (2011) 474:307–17. doi: 10.1038/nature10209 homeostasis and disease. Nat Rev Gastroenterol Hepatol. (2020) 17:263–
167. Suzuki T. Regulation of intestinal epithelial permeability by tight junctions. 78. doi: 10.1038/s41575-019-0261-4
Cell Mol Life Sci. (2013) 70:631–59. doi: 10.1007/s00018-012-1070-x 189. Allam-Ndoul B, Castonguay-Paradis S, Veilleux A. Gut microbiota
168. Berkes J, Viswanathan VK, Savkovic SD, Hecht G. Intestinal and intestinal trans-epithelial permeability. Int J Mol Sci. (2020) 21:1–
epithelial responses to enteric pathogens: effects on the tight 14. doi: 10.3390/ijms21176402
junction barrier, ion transport, and inflammation. Gut. (2003) 190. Hayes CL, Dong J, Galipeau HJ, Jury J, McCarville J, Huang X,
52:439–51. doi: 10.1136/gut.52.3.439 et al. Commensal microbiota induces colonic barrier structure
169. Bäckhed F, Ley RE, Sonnenburg JL, Peterson DA, Gordon JI. Host- and functions that contribute to homeostasis. Sci Rep. (2018)
bacterial mutualism in the human intestine. Science. (2005) 307:1915– 8:14184. doi: 10.1038/s41598-018-32366-6
20. doi: 10.1126/science.1104816 191. Hooper L V., Wong MH, Thelin A, Hansson L, Falk PG, Gordon
170. Hooper L V., Littman DR, Macpherson AJ. Interactions between JI. Molecular analysis of commensal host-microbial relationships in the
the microbiota and the immune system. Science. (2012) 336:1268– intestine. Science. (2001) 291:881–4. doi: 10.1126/science.291.5505.881
73. doi: 10.1126/science.1223490 192. Ukena SN, Singh A, Dringenberg U, Engelhardt R, Seidler U,
171. Kayama H, Okumura R, Takeda K. Interaction between the microbiota, Hansen W, et al. Probiotic Escherichia coli Nissle 1917 inhibits
epithelia, and immune cells in the intestine. Annu Rev Immunol. (2020) leaky gut by enhancing mucosal integrity. PLoS ONE. (2007)
38:23–48. doi: 10.1146/annurev-immunol-070119-115104 2:e1308. doi: 10.1371/journal.pone.0001308
172. Sonnenburg ED, Smits SA, Tikhonov M, Higginbottom SK, Wingreen NS, 193. Barbaro MR, Fuschi D, Cremon C, Carapelle M, Dino P, Marcellini MM,
Sonnenburg JL. Diet-induced extinctions in the gut microbiota compound et al. Escherichia coli Nissle 1917 restores epithelial permeability alterations
over generations. Nature. (2016) 529:212–5. doi: 10.1038/nature16504 induced by irritable bowel syndrome mediators. Neurogastroenterol Motil.
173. LeBlanc JG, Milani C, de Giori GS, Sesma F, van Sinderen D, Ventura M. (2018) 30:e13388. doi: 10.1111/nmo.13388
Bacteria as vitamin suppliers to their host: a gut microbiota perspective. Curr 194. Johnson-Henry KC, Donato KA, Shen-Tu G, Gordanpour M, Sherman PM.
Opin Biotechnol. (2013) 24:160–8. doi: 10.1016/j.copbio.2012.08.005 Lactobacillus rhamnosus strain GG prevents enterohemorrhagic Escherichia
174. Baümler AJ, Sperandio V. Interactions between the microbiota coli O157:H7-induced changes in epithelial barrier function. Infect Immun.
and pathogenic bacteria in the gut. Nature. (2016) 535:85– (2008) 76:1340–8. doi: 10.1128/IAI.00778-07
93. doi: 10.1038/nature18849 195. Yu Q, Yuan L, Deng J, Yang Q. Lactobacillus protects the integrity of
175. Buffie CG, Pamer EG. Microbiota-mediated colonization intestinal epithelial barrier damaged by pathogenic bacteria. Front Cell Infect
resistance against intestinal pathogens. Nat Rev Immunol. (2013) Microbiol. (2015) 5:26. doi: 10.3389/fcimb.2015.00026
13:790–801. doi: 10.1038/nri3535 196. Zareie M, Riff J, Donato K, McKay DM, Perdue MH, Soderholm JD, et al.
176. Gensollen T, Iyer SS, Kasper DL, Blumberg RS. How colonization by Novel effects of the prototype translocating Escherichia coli, strain C25 on
microbiota in early life shapes the immune system. Science. (2016) 352:539– intestinal epithelial structure and barrier function. Cell Microbiol. (2005)
44. doi: 10.1126/science.aad9378 7:1782–97. doi: 10.1111/j.1462-5822.2005.00595.x
177. Thaiss CA, Zmora N, Levy M, Elinav E. The microbiome and innate 197. Barbara G, Feinle-Bisset C, Ghoshal UC, Santos J, Vanner SJ, Vergnolle
immunity. Nature. (2016) 535:65–74. doi: 10.1038/nature18847 N, et al. The intestinal microenvironment and functional gastrointestinal
178. Stecher B, Hardt WD. Mechanisms controlling pathogen colonization of the disorders. Gastroenterology. (2016) 150:1305–18.e8. doi: 10.1053/j.gastro.201
gut. Curr Opin Microbiol. (2011) 14:82–91. doi: 10.1016/j.mib.2010.10.003 6.02.028
179. Keeney KM, Finlay BB. Enteric pathogen exploitation of the microbiota- 198. Lee M, Chang EB. Inflammatory Bowel Diseases (IBD) and the
generated nutrient environment of the gut. Curr Opin Microbiol. (2011) microbiome—searching the crime scene for clues. Gastroenterology.
14:92–8. doi: 10.1016/j.mib.2010.12.012 (2021) 160:524–37. doi: 10.1053/j.gastro.2020.09.056
180. Litvak Y, Byndloss MX, Bäumler AJ. Colonocyte metabolism shapes the gut 199. Machiels K, Joossens M, Sabino J, De Preter V, Arijs I, Eeckhaut V,
microbiota. Science. (2018) 362:eaat9076. doi: 10.1126/science.aat9076 et al. A decrease of the butyrate-producing species Roseburia hominis and
181. van Thiel IAM, de Jonge WJ, Chiu IM, van den Wijngaard RM. Microbiota- Faecalibacterium prausnitzii defines dysbiosis in patients with ulcerative
neuroimmune cross talk in stress-induced visceral hypersensitivity of colitis. Gut. (2014) 63:1275–83. doi: 10.1136/gutjnl-2013-304833
the bowel. Am J Physiol Gastrointest Liver Physiol. (2020) 318:G1034– 200. Zhou L, Zhang M, Wang Y, Dorfman RG, Liu H, Yu T, et al. Faecalibacterium
41. doi: 10.1152/ajpgi.00196.2019 prausnitzii produces butyrate to maintain Th17/treg balance and to
182. Chowdhury SR, King DE, Willing BP, Band MR, Beever JE, Lane ameliorate colorectal colitis by inhibiting histone deacetylase 1. Inflamm
AB, et al. Transcriptome profiling of the small intestinal epithelium Bowel Dis. (2018) 24:1926–40. doi: 10.1093/ibd/izy182
in germfree versus conventional piglets. BMC Genomics. (2007) 201. Cremon C, Guglielmetti S, Gargari G, Taverniti V, Castellazzi AM,
8:215. doi: 10.1186/1471-2164-8-215 Valsecchi C, et al. Effect of Lactobacillus paracasei CNCM I-1572 on
183. Burger-van Paassen N, Vincent A, Puiman PJ, van der Sluis M, Bouma J, symptoms, gut microbiota, short chain fatty acids, and immune activation
Boehm G, et al. The regulation of intestinal mucin MUC2 expression by in patients with irritable bowel syndrome: a pilot randomized clinical trial.
short-chain fatty acids: implications for epithelial protection. Biochem J. United Eur Gastroenterol J. (2018) 6:604–13. doi: 10.1177/20506406177
(2009) 420:211–9. doi: 10.1042/BJ20082222 36478

202. Friedrich M, Pohin M, Powrie F. Cytokine networks in the 221. McKernan DP, Gaszner G, Quigley EM, Cryan JF, Dinan TG.
pathophysiology of inflammatory Bowel disease. Immunity. (2019) Altered peripheral toll-like receptor responses in the irritable
50:992–1006. doi: 10.1016/j.immuni.2019.03.017 bowel syndrome. Aliment Pharmacol Ther. (2011) 33:1045–
203. Coccia M, Harrison OJ, Schiering C, Asquith MJ, Becher B, Powrie F, et al. IL- 52. doi: 10.1111/j.1365-2036.2011.04624.x
1β mediates chronic intestinal inflammation by promoting the accumulation 222. Darkoh C, Comer L, Zewdie G, Harold S, Snyder N, DuPont HL.
of IL-17A secreting innate lymphoid cells and CD4 + Th17 cells. J Exp Med. Chemotactic chemokines are important in the pathogenesis of irritable
(2012) 209:1595–609. doi: 10.1084/jem.20111453 bowel syndrome. PLoS ONE. (2014) 9:e93144. doi: 10.1371/journal.pone.00
204. Lee YS, Yang H, Yang JY, Kim Y, Lee SH, Kim JH, et al. Interleukin-1 93144
(IL-1) signaling in intestinal stromal cells controls KC/ CXCL1 secretion, 223. Wang F, Graham WV, Wang Y, Witkowski ED, Schwarz BT,
which correlates with recruitment of IL-22- secreting neutrophils at early Turner JR. Interferon-γ and tumor necrosis factor-α synergize to
stages of Citrobacter rodentium infection. Infect Immun. (2015) 83:3257– induce intestinal epithelial barrier dysfunction by up-regulating
67. doi: 10.1128/IAI.00670-15 myosin light chain kinase expression. Am J Pathol. (2005)
205. Song A, Zhu L, Gorantla G, Berdysz O, Amici SA, Guerau-De-Arellano 166:409–19. doi: 10.1016/S0002-9440(10)62264-X
M, et al. Salient type 1 interleukin 1 receptor expression in peripheral 224. Hanning N, Edwinson AL, Ceuleers H, Peters SA, De Man JG, Hassett
non-immune cells. Sci Rep. (2018) 8:723. doi: 10.1038/s41598-018-19248-7 LC, et al. Intestinal barrier dysfunction in irritable bowel syndrome: a
206. Cox CB, Storm EE, Kapoor VN, Chavarria-Smith J, Lin DL, systematic review. Therap Adv Gastroenterol. (2021) 14:1756284821993586.
Wang L, et al. IL-1R1-dependent signaling coordinates epithelial doi: 10.1177/1756284821993586
regeneration in response to intestinal damage. Sci Immunol. (2021) 225. Renga G, Moretti S, Oikonomou V, Borghi M, Zelante T, Paolicelli
6:eabe8856. doi: 10.1126/sciimmunol.abe8856 G, et al. IL-9 and mast cells are key players of Candida albicans
207. Madara JL, Stafford J. Interferon-γ directly affects barrier function of commensalism and pathogenesis in the gut. Cell Rep. (2018) 23:1767–
cultured intestinal epithelial monolayers. J Clin Invest. (1989) 83:724– 78. doi: 10.1016/j.celrep.2018.04.034
7. doi: 10.1172/JCI113938 226. Gerlach K, Hwang Y, Nikolaev A, Atreya R, Dornhoff H, Steiner S, et al. T H
208. Adams RB, Planchon SM, Roche JK. IFN-gamma modulation of epithelial 9 cells that express the transcription factor PU.1 drive T cell-mediated colitis
barrier function. Time course, reversibility, and site of cytokine binding. J via IL-9 receptor signaling in intestinal epithelial cells. Nat Immunol. (2014)
Immunol. (1993) 150:2356–63. 15:676–86. doi: 10.1038/ni.2920
209. Schmitz H, Fromm M, Bentzel CJ, Scholz P, Detjen K, Mankertz, J, et al. 227. Gerlach K, McKenzie AN, Neurath MF, Weigmann B. IL-9 regulates
Tumor necrosis factor-alpha (TNFalpha) regulates the epithelial barrier in intestinal barrier function in experimental T cell-mediated colitis.
the human intestinal cell line HT-29/B6. J Cell Sci. (1999) 112(Pt 1):137–46. Tissue Barriers. (2015) 3:e983777. doi: 10.4161/21688370.2014.9
210. Bruewer M, Luegering A, Kucharzik T, Parkos CA, Madara JL, Hopkins 83777
AM, et al. Proinflammatory cytokines disrupt epithelial barrier function 228. Piche T, Barbara G, Aubert P, Des Varannes SB, Dainese R, Nano JL,
by apoptosis-independent mechanisms. J Immunol. (2003) 171:6164– et al. Impaired Intestinal barrier integrity in the colon of patients with
72. doi: 10.4049/jimmunol.171.11.6164 irritable bowel syndrome: involvement of soluble mediators. Gut. (2009)
211. Barbaro MR, Di Sabatino A, Cremon C, Giuffrida P, Fiorentino M, Altimari 58:196–201. doi: 10.1136/gut.2007.140806
A, et al. Interferon-γ is increased in the gut of patients with irritable bowel 229. Barbara G, Stanghellini V, De Giorgio R, Cremon C, Cottrell GS, Santini
syndrome and modulates serotonin metabolism. Am J Physiol Gastrointest D, et al. Activated mast cells in proximity to colonic nerves correlate
Liver Physiol. (2016) 310:G439–47. doi: 10.1152/ajpgi.00368.2015 with abdominal pain in irritable Bowel syndrome. Gastroenterology. (2004)
212. Zolotarevsky Y, Hecht G, Koutsouris A, Gonzalez DE, Quan C, Tom J, et al. 126:693–702. doi: 10.1053/j.gastro.2003.11.055
A membrane-permeant peptide that inhibits MLC kinase restores barrier 230. Barbara G, Wang B, Stanghellini V, de Giorgio R, Cremon C, Di Nardo
function in in vitro models of intestinal disease. Gastroenterology. (2002) G, et al. Mast cell-dependent excitation of visceral-nociceptive sensory
123:163–72. doi: 10.1053/gast.2002.34235 neurons in irritable Bowel syndrome. Gastroenterology. (2007) 132:26–
213. Bhat AA, Uppada S, Achkar IW, Hashem S, Yadav SK, Shanmugakonar 37. doi: 10.1053/j.gastro.2006.11.039
M, et al. Tight junction proteins and signaling pathways in cancer 231. Gecse K, Róka R, Ferrier L, Leveque M, Eutamene H, Cartier C, et al.
and inflammation: a functional crosstalk. Front Physiol. (2019) Increased faecal serine protease activity in diarrhoeic IBS patients: a colonic
10:1942. doi: 10.3389/fphys.2018.01942 lumenal factor impairing colonic permeability and sensitivity. Gut. (2008)
214. Pham CTN. Neutrophil serine proteases: specific regulators of inflammation. 57:591–8. doi: 10.1136/gut.2007.140210
Nat Rev Immunol. (2006) 6:541–50. doi: 10.1038/nri1841 232. Pontarollo G, Mann A, Brandão I, Malinarich F, Schöpf M, Reinhardt C.
215. Dale C, Vergnolle N. Protease signaling to G protein-coupled receptors: Protease-activated receptor signaling in intestinal permeability regulation.
implications for inflammation and pain. J Recept Signal Transduct. (2008) FEBS J. (2020) 287:645–58. doi: 10.1111/febs.15055
28:29–37. doi: 10.1080/10799890801941913 233. Barbara G, Grover M, Bercik P, Corsetti M, Ghoshal UC,
216. Chin AC, Lee WY, Nusrat A, Vergnolle N, Parkos CA. Neutrophil-mediated Ohman L, et al. Rome foundation working team report on
activation of epithelial protease-activated receptors-1 and−2 regulates post-infection irritable Bowel syndrome. Gastroenterology. (2019)
barrier function and transepithelial migration. J Immunol. (2008) 181:5702– 156:46–58.e7. doi: 10.1053/j.gastro.2018.07.011
10. doi: 10.4049/jimmunol.181.8.5702 234. Edogawa S, Edwinson AL, Peters SA, Chikkamenahalli LL, Sundt W, Graves
217. Barbara G, Stanghellini V, De Giorgio R, Corinaldesi S, et al., Breen-Lyles M, Johnson S, Dyer R, et al. Serine proteases as luminal
R. Functional gastrointestinal disorders and mast cells: mediators of intestinal barrier dysfunction and symptom severity in IBS. Gut.
implications for therapy. Neurogastroenterol Motil. (2006) (2020) 69:62–73. doi: 10.1136/gutjnl-2018-317416
18:6–17. doi: 10.1111/j.1365-2982.2005.00685.x 235. Cenac N, Bautzova T, Le Faouder P, Veldhuis NA, Poole DP, Rolland C, et al.
218. Bashashati M, Moossavi S, Cremon C, Barbaro MR, Moraveji S, Quantification and potential functions of endogenous agonists of transient
Talmon G, et al. Colonic immune cells in irritable bowel syndrome: receptor potential channels in patients with irritable bowel syndrome.
a systematic review and meta-analysis. Neurogastroenterol Motil. (2018) Gastroenterology. (2015) 149:433–4.e7. doi: 10.1053/j.gastro.2015.04.011
30:10. doi: 10.1111/nmo.13192 236. Bautzova T, Hockley JRF, Perez-Berezo T, Pujo J, Tranter MM, Desormeaux
219. Bashashati M, Rezaei N, Shafieyoun A, Mckernan DP, Chang L, Öhman C, et al. 5-oxoETE triggers nociception in constipation-predominant irritable
L, Quigley EM, et al. Cytokine imbalance in irritable bowel syndrome: bowel syndrome through MAS-related G protein–coupled receptor D. Sci
a systematic review and meta-analysis. Neurogastroenterol Motil. (2014) Signal. (2018) 11:eaal2171. doi: 10.1126/scisignal.aal2171
26:1036–48. doi: 10.1111/nmo.12358 237. Trifan A, Burta O, Tiuca N, Petrisor DC, Lenghel A, Santos J. Efficacy and
220. Chang L, Adeyemo M, Karagiannidis I, Videlock EJ, Bowe C, Shih W, et al. safety of Gelsectan for diarrhoea-predominant irritable bowel syndrome:
Serum and colonic mucosal immune markers in irritable bowel syndrome. a randomised, crossover clinical trial. United Eur Gastroenterol J. (2019)
Am J Gastroenterol. (2012) 107:262–72. doi: 10.1038/ajg.2011.423 7:1093–101. doi: 10.1177/2050640619862721

238. Rubio-Tapia A, Murray JA. Updated guidelines by the European Society 258. Cobden I, Dickinson RJ, Rothwell J, Axon ATR. Intestinal permeability
for the Study of Coeliac Disease. United Eur Gastroenterol J. (2019) 7:581– assessed by excretion ratios of two molecules: results in coeliac disease. Br
2. doi: 10.1177/2050640619849370 Med J. (1978) 2:1060. doi: 10.1136/bmj.2.6144.1060
239. Schuppan D, Junker Y, Barisani D. Celiac disease: from 259. Oberhuber G, Vogelsang H. Gastrointestinal permeability in celiac disease
pathogenesis to novel therapies. Gastroenterology. (2009) [1]. Gastroenterology. (1998) 114:226. doi: 10.1016/S0016-5085(98)70661-4
137:1912–33. doi: 10.1053/j.gastro.2009.09.008 260. Van Elburg RM, Uil JJ, Mulder CJJ, Heymans HSA. Intestinal permeability
240. Harris LA, Park JY, Voltaggio L, Lam-Himlin D. Celiac disease: clinical, in patients with coeliac disease and relatives of patients with coeliac disease.
endoscopic, and histopathologic review. Gastrointest Endosc. (2012) 76:625– Gut. (1993) 34:354–7. doi: 10.1136/gut.34.3.354
40. doi: 10.1016/j.gie.2012.04.473 261. Schulzke JD, Bentzel CJ, Schulzke I, Riecken EO, Fromm M.
241. Greco L, Romino R, Coto I, Di Cosmo N, Percopo S, Maglio M, et al. Epithelial tight junction structure in the jejunum of children
The first large population based twin study of coeliac disease. Gut. (2002) with acute and treated celiac sprue. Pediatr Res. (1998)
50:624–8. doi: 10.1136/gut.50.5.624 43:435–41. doi: 10.1203/00006450-199804000-00001
242. Caminero A, McCarville JL, Galipeau HJ, Deraison C, Bernier SP, Constante 262. Goswami P, Das P, Verma AK, Prakash S, Das TK, Nag TC, et al. Are
M, et al. Duodenal bacterial proteolytic activity determines sensitivity to alterations of tight junctions at molecular and ultrastructural level different
dietary antigen through protease-activated receptor-2. Nat Commun. (2019) in duodenal biopsies of patients with celiac disease and Crohn’s disease?
10:1–14. doi: 10.1038/s41467-019-09037-9 Virchows Arch. (2014) 465:521–30. doi: 10.1007/s00428-014-1651-1
243. Di Biase AR, Marasco G, Ravaioli F, Dajti E, Colecchia L, Righi B, et al. 263. Ciccocioppo R, Finamore A, Ara C, Di Sabatino A, Mengheri E, Corazza
Gut microbiota signatures and clinical manifestations in celiac disease GR. Altered expression, localization, and phosphorylation of epithelial
children at onset: a pilot study. J Gastroenterol Hepatol. (2020) 36:446– junctional proteins in celiac disease. Am J Clin Pathol. (2006) 125:502–
54. doi: 10.1111/jgh.15183 11. doi: 10.1309/dtyr-a91g-8r0k-tm8m
244. Marasco G, Cirota GG, Rossini B, Lungaro L, Di Biase AR, Colecchia 264. Montalto M, Cuoco L, Ricci R, Maggiano N, Vecchio FM, Gasbarrini
A, et al. Probiotics, prebiotics and other dietary supplements for G. Immunohistochemical analysis of ZO-1 in the duodenal mucosa of
gut microbiota modulation in celiac disease patients. Nutrients. (2020) patients with untreated and treated celiac disease. Digestion. (2002) 65:227–
12:2674. doi: 10.3390/nu12092674 33. doi: 10.1159/000063817
245. Stene LC, Honeyman MC, Hoffenberg EJ, Haas JE, Sokol RJ, Emery L, et al. 265. Perry I, Tselepis C, Hoyland J, Iqbal TH, Scott D, Sanders A, et al. Reduced
Rotavirus infection frequency and risk of celiac disease autoimmunity in cadherin/catenin complex expression in celiac disease can be reproduced in
early childhood: a longitudinal study. Am J Gastroenterol. (2006) 101:2333– vitro by cytokine stimulation. Lab Invest. (1999) 79:1489–99.
40. doi: 10.1111/j.1572-0241.2006.00741.x 266. Schumann M, Siegmund B, Schulzke JD, Fromm M. Celiac
246. Zafeiropoulou K, Nichols B, Mackinder M, Biskou O, Rizou E, Karanikolou disease: role of the epithelial barrier. CMGH. (2017) 3:150–
A, et al. Alterations in intestinal microbiota of children with celiac disease 62. doi: 10.1016/j.jcmgh.2016.12.006
at time of diagnosis and on a gluten-free diet. Gastroenterology. (2020) 267. Mishra A, Prakash S, Sreenivas V, Das TK, Ahuja V, Gupta SD, et al.
159:2039–51.e20. doi: 10.1053/j.gastro.2020.08.007 Structural and functional changes in the tight junctions of asymptomatic and
247. Marasco G, Di Biase AR, Colecchia A. Microbial signatures in celiac serology-negative first-degree relatives of patients with celiac disease. J Clin
disease: still far from a final answer. Gastroenterology. (2020) 161:358– Gastroenterol. (2016) 50:551–60. doi: 10.1097/MCG.0000000000000436
9. doi: 10.1053/j.gastro.2020.10.059 268. Hunt KA, Zhernakova A, Turner G, Heap GAR, Franke L, Bruinenberg M,
248. Marasco G, Di Biase AR, Schiumerini R, Eusebi LH, Iughetti L, Ravaioli et al. Newly identified genetic risk variants for celiac disease related to the
F, et al. Gut microbiota and celiac disease. Dig Dis Sci. (2016) 61:1461– immune response. Nat Genet. (2008) 40:395–402. doi: 10.1038/ng.102
72. doi: 10.1007/s10620-015-4020-2 269. Wapenaar MC, Monsuur AJ, Van Bodegraven AA, Weersma RK,
249. Jabri B, Abadie V. IL-15 functions as a danger signal to regulate tissue- Bevova MR, Linskens RK, et al. Associations with tight junction genes
resident T cells and tissue destruction. Nat Rev Immunol. (2015) 15:771– PARD3 and MAGI2 in Dutch patients point to a common barrier
83. doi: 10.1038/nri3919 defect for coeliac disease and ulcerative colitis. Gut. (2008) 57:463–
250. Catassi C, Elli L, Bonaz B, Bouma G, Carroccio A, Castillejo G, et al. 7. doi: 10.1136/gut.2007.133132
Diagnosis of Non-Celiac Gluten Sensitivity (NCGS): the Salerno experts’ 270. Monsuur AJ, Bakker PIWD, Alizadeh BZ, Zhernakova A, Bevova MR,
criteria. Nutrients. (2015) 7:4966–77. doi: 10.3390/nu7064966 Strengman E, et al. Myosin IXB variant increases the risk of celiac disease
251. Giovannini C, Sanchez M, Straface E, Scazzocchio B, Silano M, De and points toward a primary intestinal barrier defect. Nat Genet. (2005)
Vincenzi M. Induction of apoptosis in Caco-2 cells by wheat gliadin 37:1341–4. doi: 10.1038/ng1680
peptides. Toxicology. (2000) 145:63–71. doi: 10.1016/S0300-483X(99)0 271. Wolters VM, Alizadeh BZ, Weijerman ME, Zhernakova A, van Hoogstraten
0223-1 IMW, Mearin ML, et al. Intestinal barrier gene variants may not
252. Barone MV, Gimigliano A, Castoria G, Paolella G, Maurano F, Paparo F, et al. explain the increased levels of antigliadin antibodies, suggesting other
Growth factor-like activity of gliadin, an alimentary protein: implications for mechanisms than altered permeability. Hum Immunol. (2010) 71:392–
coeliac disease. Gut. (2007) 56:480–8. doi: 10.1136/gut.2005.086637 6. doi: 10.1016/j.humimm.2010.01.016
253. Heyman M, Abed J, Lebreton C, Cerf-Bensussan N. Intestinal permeability 272. Kumar V, Gutierrez-Achury J, Kanduri K, Almeida R, Hrdlickova B,
in coeliac disease: insight into mechanisms and relevance to pathogenesis. Zhernakova D V., et al. Systematic annotation of celiac disease loci
Gut. (2012) 61:1355–64. doi: 10.1136/gutjnl-2011-300327 refines pathological pathways and suggests a genetic explanation for
254. Clemente MG, De Virgiliis S, Kang JS, Macatagney R, Musu MP, Di increased interferon-gamma levels. Hum Mol Genet. (2015) 24:397–
Pierro MR, et al. Early effects of gliadin on enterocyte intracellular 409. doi: 10.1093/hmg/ddu453
signalling involved in intestinal barrier function. Gut. (2003) 52:218– 273. Almeida R, Ricanõ-Ponce I, Kumar V, Deelen P, Szperl A, Trynka
23. doi: 10.1136/gut.52.2.218 G, et al. Fine mapping of the celiac disease-associated LPP locus
255. Alaedini A, Latov N. Transglutaminase-independent binding of gliadin to reveals a potential functional variant. Hum Mol Genet. (2014) 23:2481–
intestinal brush border membrane and GM1 ganglioside. J Neuroimmunol. 9. doi: 10.1093/hmg/ddt619
(2006) 177:167–72. doi: 10.1016/j.jneuroim.2006.04.022 274. Ciccocioppo R, Panelli S, Bellocchi MCC, Cangemi GC, Frulloni L, Capelli
256. Bondar C, Araya RE, Guzman L, Rua EC, Chopita N, Chirdo E, et al. The transcriptomic analysis of circulating immune cells in a celiac
FG. Role of CXCR3/CXCL10 axis in immune cell recruitment family unveils further insights into disease pathogenesis. Front Med. (2018)
into the small intestine in celiac disease. PLoS ONE. (2014) 5:182. doi: 10.3389/fmed.2018.00182
9:e0089068. doi: 10.1371/journal.pone.0089068 275. Dolfini E, Roncoroni L, Elli L, Fumagalli C, Colombo R, Ramponi S,
257. Careddu P, Chiumello G, Vaccari A, Bardare M, Zilocchi A. Effects of gluten et al. Cytoskeleton reorganization and ultrastructural damage induced by
on intestinal absorption and permeability during remission of celiac disease. gliadin in a three-dimensional in vitro model. World J Gastroenterol. (2005)
Boll Soc Ital Biol Sper. (1963) 1963:1235–8. 11:7597–601. doi: 10.3748/wjg.v11.i48.7597

276. Strobel S, Brydon WG, Ferguson A. Cellobiose/mannitol sugar permeability 295. Cipriani S, Mencarelli A, Chini MG, Distrutti E, Renga B, Bifulco G, et al.
test complements biopsy histopathology in clinical investigation of the The bile acid receptor GPBAR-1 (TGR5) modulates integrity of intestinal
jejunum. Gut. (1984) 25:1241–6. doi: 10.1136/gut.25.11.1241 barrier and immune response to experimental colitis. PLoS ONE. (2011)
277. Gass J, Bethune MT, Siegel M, Spencer A, Khosla C. Combination enzyme 6:e0025637. doi: 10.1371/journal.pone.0025637
therapy for gastric digestion of dietary gluten in patients with celiac sprue. 296. Chia-Hui Y. Microbiota dysbiosis and barrier dysfunction in inflammatory
Gastroenterology. (2007) 133:472–80. doi: 10.1053/j.gastro.2007.05.028 bowel disease: RSM Library Discovery Service. J Biomed Sci. (2018) 25:79.
278. Pinier M, Verdu EF, Nasser-Eddine M, David CS, Vézina A, doi: 10.1186/s12929-018-0483-8
Rivard N, et al. Polymeric binders suppress gliadin-induced 297. Gruber L, Lichti P, Rath E, Haller D. Nutrigenomics and nutrigenetics
toxicity in the intestinal epithelium. Gastroenterology. (2009) in inflammatory bowel diseases. J Clin Gastroenterol. (2012) 46:735–
136:288–98. doi: 10.1053/j.gastro.2008.09.016 47. doi: 10.1097/MCG.0b013e31825ca21a
279. Paterson BM, Lammers KM, Arrieta MC, Fasano A, Meddings JB. The safety, 298. Ananthakrishnan AN, Bernstein CN, Iliopoulos D, Macpherson A, Neurath
tolerance, pharmacokinetic and pharmacodynamic effects of single doses MF, Ali RAR, et al. Environmental triggers in IBD: a review of
of AT-1001 in coeliac disease subjects: a proof of concept study. Aliment progress and evidence. Nat Rev Gastroenterol Hepatol. (2018) 15:39–
Pharmacol Ther. (2007) 26:757–66. doi: 10.1111/j.1365-2036.2007.03413.x 49. doi: 10.1038/nrgastro.2017.136
280. Kelly CP, Green PHR, Murray JA, Dimarino A, Colatrella A, Leffler DA, 299. Ho SM, Lewis JD, Mayer EA, Plevy SE, Chuang E, Rappaport SM, et al.
et al. Larazotide acetate in patients with coeliac disease undergoing a gluten Challenges in IBD research: environmental triggers. Inflamm Bowel Dis.
challenge: a randomised placebo-controlled study. Aliment Pharmacol Ther. (2019) 25:S13–23. doi: 10.1093/ibd/izz076
(2013) 37:252–62. doi: 10.1111/apt.12147 300. Mahid SS, Minor KS, Soto RE, Hornung CA, Galandiuk S. Smoking
281. Leffler DA, Kelly CP, Abdallah HZ, Colatrella AM, Harris LA, Leon F, and inflammatory bowel disease: a meta-analysis. Mayo Clin Proc. (2006)
et al. A randomized, double-blind study of larazotide acetate to prevent 81:1462–71. doi: 10.4065/81.11.1462
the activation of celiac disease during gluten challenge. Am J Gastroenterol. 301. Calkins BM. A meta-analysis of the role of smoking in inflammatory bowel
(2012) 107:1554–62. doi: 10.1038/ajg.2012.211 disease. Dig Dis Sci. (1989) 34:1841–54. doi: 10.1007/BF01536701
282. Leffler DA, Kelly CP, Green PHR, Fedorak RN, Dimarino A, Perrow W, 302. Higuchi LM, Khalili H, Chan AT, Richter JM, Bousvaros A, Fuchs
et al. Larazotide acetate for persistent symptoms of celiac disease despite CS. A prospective study of cigarette smoking and the risk of
a gluten-free diet: a randomized controlled trial. Gastroenterology. (2015) inflammatory bowel disease in women. Am J Gastroenterol. (2012)
148:1311–9.e6. doi: 10.1053/j.gastro.2015.02.008 107:1399–406. doi: 10.1038/ajg.2012.196
283. Hujoel IA, Murray JA. Refractory celiac disease. Curr Gastroenterol Rep. 303. Pedersen KM, Çolak Y, Vedel-Krogh S, Kobylecki CJ, Bojesen SE,
(2020) 22:1–8. doi: 10.1007/s11894-020-0756-8 Nordestgaard BG. Risk of ulcerative colitis and Crohn’s disease in smokers
284. Jauregi-Miguel A. The tight junction and the epithelial barrier lacks causal evidence. Eur J Epidemiol. (2021) 10.1007/s10654-021-00763-3.
in coeliac disease. Int Rev Cell Mol Biol. (2021) 358:105– doi: 10.1007/s10654-021-00763-3
32. doi: 10.1016/bs.ircmb.2020.09.010 304. Singh UP, Singh NP, Murphy EA, Price RL, Fayad R, Nagarkatti M, et al.
285. Pearson ADJ, Eastham EJ, Laker MF, Craft AW, Nelson R. Intestinal Chemokine and cytokine levels in inflammatory bowel disease patients.
permeability in children with Crohn’s disease and Coeliac disease. Br Med Cytokine. (2016) 77:44–9. doi: 10.1016/j.cyto.2015.10.008
J. (1982) 285:20–21. doi: 10.1136/bmj.285.6334.20 305. Ostaff MJ, Stange EF, Wehkamp J. Antimicrobial peptides and gut
286. Ukabam SO, Clamp JR, Cooper BT. Abnormal small intestinal permeability microbiota in homeostasis and pathology. EMBO Mol Med. (2013) 5:1465–
to sugars in patients with Crohn’s disease of the terminal ileum and colon. 83. doi: 10.1002/emmm.201201773
Digestion. (1983) 27:70–4. doi: 10.1159/000198932 306. Salzman NH, Hung K, Haribhai D, Chu H, Karlsson-Sjöberg J, Amir E, et al.
287. Abraham C, Cho JH. Mechanisms of inflammatory Bowel disease. N Engl J Enteric defensins are essential regulators of intestinal microbial ecology. Nat
Med. (2009) 361:2066–78. doi: 10.1056/NEJMra0804647 Immunol. (2010) 11:76–83. doi: 10.1038/ni.1825
288. Miner-Williams WM, Moughan PJ. Intestinal barrier dysfunction: 307. Peyrin-Biroulet L, Beisner J, Wang G, Nuding S, Oommen ST, Kelly D, et al.
implications for chronic inflammatory conditions of the bowel. Nutr Peroxisome proliferator-activated receptor gamma activation is required for
Res Rev. (2016) 29:40–59. doi: 10.1017/S0954422416000019 maintenance of innate antimicrobial immunity in the colon. Proc Natl Acad
289. Khan MW, Kale AA, Bere P, Vajjala S, Gounaris E, Pakanati KC. Microbes, Sci USA. (2010) 107:8772–7. doi: 10.1073/PNAS.0905745107
intestinal inflammation and probiotics. Expert Rev Gastroenterol Hepatol. 308. Wehkamp J, Harder J, Weichenthal M, Mueller O, Herrlinger KR,
(2012) 6:81–94. doi: 10.1586/egh.11.94 Fellermann K, et al. Inducible and constitutive beta-defensins are
290. Ingersoll SA, Ayyadurai S, Charania MA, Laroui H, Yan Y, Merlin differentially expressed in Crohn’s disease and ulcerative colitis. Inflamm
D. The role and pathophysiological relevance of membrane Bowel Dis. (2003) 9:215–23. doi: 10.1097/00054725-200307000-00001
transporter pept1 in intestinal inflammation and inflammatory 309. Martini E, Krug SM, Siegmund B, Neurath MF, Becker C. Mend
bowel disease. Am J Physiol Gastrointest Liver Physiol. (2012) your fences: the epithelial barrier and its relationship with
302:G484–92. doi: 10.1152/ajpgi.00477.2011 mucosal immunity in inflammatory bowel disease. Cmgh. (2017)
291. Dalmasso G, Nguyen HTT, Charrier-Hisamuddin L, Yan Y, Laroui 4:33–46. doi: 10.1016/j.jcmgh.2017.03.007
H, Demoulin B, et al., Merlin D. PepT1 mediates transport of the 310. Courth LF, Ostaff MJ, Mailänder-Sánchez D, Malek NP, Stange EF, Wehkamp
proinflammatory bacterial tripeptide L-Ala-γ-D-Glu-meso-DAP in J. Crohn’s disease-derived monocytes fail to induce Paneth cell defensins.
intestinal epithelial cells. Am J Physiol Gastrointest Liver Physiol. (2010) Proc Natl Acad Sci USA. (2015) 112:14000–5. doi: 10.1073/pnas.15100
299:687–96. doi: 10.1152/ajpgi.00527.2009 84112
292. Jappar D, Hu Y, Smith DE. Effect of dose escalation on the in 311. Wehkamp J, Koslowski M, Wang G, Stange EF. Barrier dysfunction due to
vivo oral absorption and disposition of glycylsarcosine in wild- distinct defensin deficiencies in small intestinal and colonic Crohn’s disease.
type and Pept1 knockout mice. Drug Metab Dispos. (2011) Mucosal Immunol. (2008) 1:67–74. doi: 10.1038/mi.2008.48
39:2250–7. doi: 10.1124/dmd.111.041087 312. Paone P, Cani PD. Mucus barrier, mucins and gut microbiota: the expected
293. De Medina FS, Daddaoua A, Requena P, Capitán-Cañadas F, Zarzuelo A, slimy partners? Gut. (2020) 69:2232–43. doi: 10.1136/gutjnl-2020-322260
Dolores Suárez M, et al. New insights into the immunological effects of food 313. Van Der Post S, Jabbar KS, Birchenough G, Arike L, Akhtar N,
bioactive peptides in animal models of intestinal inflammation. Proc Nutr Sjovall H, et al. Structural weakening of the colonic mucus barrier is
Soc. (2010) 69:454–62. doi: 10.1017/S0029665110001783 an early event in ulcerative colitis pathogenesis. Gut. (2019) 68:2142–
294. Nässl AM, Rubio-Aliaga I, Sailer M, Daniel H. The intestinal 51. doi: 10.1136/gutjnl-2018-317571
peptide transporter pept1 is involved in food intake 314. Johansson ME, Ambort D, Pelaseyed T, Schütte A, Gustafsson JK, Ermund
regulation in mice fed a high-protein diet. PLoS ONE. (2011) A, et al. Composition and functional role of the mucus layers in the intestine.
6:e0026407. doi: 10.1371/journal.pone.0026407 Cell Mol Life Sci. (2011) 68:3635–41. doi: 10.1007/S00018-011-0822-3

315. Cornick S, Tawiah A, Chadee K. Roles and regulation 336. Hugot JP, Chamaillard M, Zouali H, Lesage S, Cézard JP, Belaiche J, et al.
of the mucus barrier in the gut. Tissue Barriers. (2015) Association of NOD2 leucine-rich repeat variants with susceptibility to
3:e982426. doi: 10.4161/21688370.2014.982426 Crohn’s disease. Nature. (2001) 411:599–603. doi: 10.1038/35079107
316. Vivinus-Nébot M, Frin-Mathy G, Bzioueche H, Dainese R, Bernard G, 337. Kosovac K, Brenmoehl J, Holler E, Falk W, Schoelmerich J, Hausmann M,
Anty R, et al. Functional bowel symptoms in quiescent inflammatory bowel et al. Association of the NOD2 genotype with bacterial translocation via
diseases: role of epithelial barrier disruption and low-grade inflammation. altered cell-cell contacts in Crohn’s disease patients. Inflamm Bowel Dis.
Gut. (2014) 63:744–52. doi: 10.1136/gutjnl-2012-304066 (2010) 16:1311–21. doi: 10.1002/ibd.21223
317. Hollander D, Vadheim CM, Brettholz E, Peterson GM, Delahunty T, Rotter 338. Rosenstiel P, Sebreiber S. NOD-like receptors-pivotal guardians of the
J. Increased intestinal permeability in patients with Crohn’s disease and their immunological integrity of barrier organs. Adv Exp Med Biol. (2009) 653:35–
relatives. Ann Intern Med. (1986) 105:883–5. 47. doi: 10.1007/978-1-4419-0901-5_3
318. Arnott IDR, Kingstone K, Ghosh S. Abnormal intestinal permeability 339. Girardin SE, Boneca IG, Viala J, Chamaillard M, Labigne A,
predicts relapse in inactive Crohn disease. Scand J Gastroenterol. (2000) Thomas G, et al. Nod2 is a general sensor of peptidoglycan
35:1163–9. doi: 10.1080/003655200750056637 through muramyl dipeptide (MDP) detection. J Biol Chem. (2003)
319. Wyatt J, Vogelsang H, Hübl W, Waldhoer T, Lochs H. Intestinal permeability 278:8869–72. doi: 10.1074/jbc.C200651200
and the prediction of relapse in Crohn’s disease. Lancet. (1993) 341:1437– 340. Inohara N, Ogura Y, Fontalba A, Gutierrez O, Pons F, Crespo J,
9. doi: 10.1016/0140-6736(93)90882-H et al. Host recognition of bacterial muramyl dipeptide mediated through
320. Arrieta MC, Bistritz L, Meddings JB. Alterations in intestinal permeability. NOD2: implications for Crohn’s disease. J Biol Chem. (2003) 278:5509–
Gut. (2006) 55:1512–20. doi: 10.1136/gut.2005.085373 12. doi: 10.1074/jbc.C200673200
321. Madsen KL, Malfair D, Gray D, Doyle JS, Jewell LD, Fedorak RN. Interleukin- 341. Rosenstiel P, Fantini M, Bräutigam K, Kühbacher T, Waetzig GH, Seegert
10 gene-deficient mice develop a primary intestinal permeability defect D, et al. TNF-α and IFN-γ regulate the expression of the NOD2 (CARD15)
in response to enteric microflora. Inflamm Bowel Dis. (1999) 5:262– gene in human intestinal epithelial cells. Gastroenterology. (2003) 124:1001–
70. doi: 10.1097/00054725-199911000-00004 9. doi: 10.1053/gast.2003.50157
322. Reuter BK, Pizarro TT. Mechanisms of tight junction dysregulation in the 342. Buhner S, Buning C, Genschel J, Kling K, Herrmann D, Dignass A,
SAMP1YitFc model of Crohn’s disease-like ileitis. Ann N Y Acad Sci. (2009) et al. Genetic basis for increased intestinal permeability in families with
1165:301–7. doi: 10.1111/j.1749-6632.2009.04035.x Crohn’s disease: role of CARD15 3020insC mutation? Gut. (2006) 55:342–
323. Su L, Shen L, Clayburgh DR, Nalle SC, Sullivan EA, Jon B, et al. Activation 7. doi: 10.1136/gut.2005.065557
and contributes to development of experimental colitis. Gastroenterology. 343. Matsuoka K, Kanai T. The gut microbiota and inflammatory bowel disease.
(2010) 136:551–63. doi: 10.1053/j.gastro.2008.10.081 Semin Immunopathol. (2015) 37:47–55. doi: 10.1007/s00281-014-0454-4
324. Blair SA, Kane S V., Clayburgh DR, Turner JR. Epithelial myosin light 344. Fukata M, Arditi M. The role of pattern recognition receptors in intestinal
chain kinase expression and activity are upregulated in inflammatory inflammation. Mucosal Immunol. (2013) 6:451–63. doi: 10.1038/mi.2013.13
bowel disease. Lab Investig. (2006) 86:191–201. doi: 10.1038/labinvest.37 345. Zeuthen LH, Fink LN, Frokiaer H. Epithelial cells prime the
00373 immune response to an array of gut-derived commensals towards
325. Swidsinski A, Ladhoff A, Pernthaler A, Swidsinski S, Loening Baucke a tolerogenic phenotype through distinct actions of thymic stromal
V, Ortner M, et al. Mucosal flora in inflammatory bowel disease. lymphopoietin and transforming growth factor-β. Immunology. (2008)
Gastroenterology. (2002) 122:44–54. doi: 10.1053/gast.2002.30294 123:197–208. doi: 10.1111/j.1365-2567.2007.02687.x
326. Prasad S, Mingrino R, Kaukinen K, Hayes KL, Powell RM, MacDonald 346. Rimoldi M, Chieppa M, Salucci V, Avogadri F, Sonzogni A, Sampietro
TT, et al. Inflammatory processes have differential effects on claudins GM, et al. Intestinal immune homeostasis is regulated by the crosstalk
2, 3 and 4 in colonic epithelial cells. Lab Investig. (2005) 85:1139– between epithelial cells and dendritic cells. Nat Immunol. (2005) 6:507–
62. doi: 10.1038/labinvest.3700316 14. doi: 10.1038/ni1192
327. Ménard S, Cerf-Bensussan N, Heyman M. Multiple facets of intestinal 347. Travis S, Menzies I. Intestinal permeability: functional assessment and
permeability and epithelial handling of dietary antigens. Mucosal Immunol. significance. Clin Sci. (1992) 82:471–88. doi: 10.1042/cs0820471
(2010) 3:247–59. doi: 10.1038/mi.2010.5 348. Bjarnason I, Macpherson A, Hollander D. Intestinal
328. Oshima T, Laroux FS, Coe LL, Morise Z, Kawachi S, Bauer P, permeability: an overview. Gastroenterology. (1995) 108:1566–
et al. Interferon-γ and interleukin-10 reciprocally regulate endothelial 81. doi: 10.1016/0016-5085(95)90708-4
junction integrity and barrier function. Microvasc Res. (2001) 61:130– 349. Wehkamp J, Stange EF. Paneth’s disease. J Crohn’s Colitis. (2010) 4:523–
43. doi: 10.1006/mvre.2000.2288 31. doi: 10.1016/j.crohns.2010.05.010
329. Albert-Bayo M, Paracuellos I, González-Castro AM, Rodríguez-Urrutia A, 350. Khoshbin K, Camilleri M. Effects of dietary components on intestinal
Rodríguez-Lagunas MJ, Alonso-Cotoner C, et al. Intestinal mucosal mast permeability in health and disease. Am J Physiol Gastrointest
cells: key modulators of barrier function and homeostasis. Cells. (2019) Liver Physiol. (2020) 319:G589–608. doi: 10.1152/AJPGI.0024
8:135. doi: 10.3390/cells8020135 5.2020
330. Al-Sadi R, Ye D, Boivin M, Guo S, Hashimi M, Ereifej L, et al. 351. Camilleri M. Human intestinal barrier: effects of stressors, diet,
Interleukin-6 modulation of intestinal epithelial tight junction prebiotics, and probiotics. Clin Transl Gastroenterol. (2021)
permeability is mediated by JNK pathway. PLoS ONE. (2014) 12:e00308. doi: 10.14309/ctg.0000000000000308
9:e0085345. doi: 10.1371/journal.pone.0085345 352. Klimberg VS, Souba WW. The importance of intestinal glutamine
331. Gassler N, Rohr C, Schneider A, Kartenbeck J, Bach A, Obermüller metabolism in maintaining a healthy gastrointestinal tract and
N, et al. Inflammatory bowel disease is associated with changes of supporting the body’s response to injury and illness. Surg Annu. (1990)
enterocytic junctions. Am J Physiol Gastrointest Liver Physiol. (2001) 22:61–76.
281:216–28. doi: 10.1152/ajpgi.2001.281.1.g216 353. Zhou YP, Jiang ZM, Sun YH, Wang XR, Ma EL, Wilmore D. The effect
332. Shih DQ, Michelsen KS, Barrett RJ, Biener-Ramanujan E, Gonsky R, Zhang of supplemental enteral glutamine on plasma levels, gut function, and
X, et al. Insights into TL1A and IBD pathogenesis. Adv Exp Med Biol. (2011) outcome in severe burns: a randomized, double-blind, controlled clinical
691:279–88. doi: 10.1007/978-1-4419-6612-4_29 trial. J Parenter Enter Nutr. (2003) 27:241–5. doi: 10.1177/01486071030270
333. Cooney R, Jewell D. The genetic basis of inflammatory bowel disease. Dig 04241
Dis. (2009) 27:428–42. doi: 10.1159/000234909 354. Peng X, Yan H, You Z, Wang P, Wang S. Effects of enteral supplementation
334. Ishihara S, Aziz MM, Yuki T, Kazumori H, Kinoshita Y. Inflammatory with glutamine granules on intestinal mucosal barrier function in
bowel disease: review from the aspect of genetics. J Gastroenterol. (2009) severe burned patients. Burns. (2004) 30:135–9. doi: 10.1016/j.burns.200
44:1097–108. doi: 10.1007/s00535-009-0141-8 3.09.032
335. Mayer L. Evolving paradigms in the pathogenesis of IBD. J Gastroenterol. 355. Zhou QQ, Verne ML, Fields JZ, Lefante JJ, Basra S, Salameh H,
(2010) 45:9–16. doi: 10.1007/s00535-009-0138-3 et al. Randomised placebo-controlled trial of dietary glutamine

supplements for postinfectious irritable bowel syndrome. Gut. (2019) bacteria from the human gut. Appl Environ Microbiol. (2000)
68:996–1002. doi: 10.1136/gutjnl-2017-315136 66:1654–61. doi: 10.1128/AEM.66.4.1654-1661.2000
356. Norman AW. From vitamin D to hormone D: fundamentals of the vitamin 366. Louis P, Young P, Holtrop G, Flint HJ. Diversity of human colonic
D endocrine system essential for good health. Am J Clin Nutr. (2008) butyrate-producing bacteria revealed by analysis of the butyryl-
88:491–9S. doi: 10.1093/ajcn/88.2.491s CoA:acetate CoA-transferase gene. Environ Microbiol. (2010)
357. Kong J, Zhang Z, Musch MW, Ning G, Sun J, Hart J, et al. Novel role 12:304–14. doi: 10.1111/j.1462-2920.2009.02066.x
of the vitamin D receptor in maintaining the integrity of the intestinal 367. Vital M, Howe AC, Tiedje JM. Revealing the bacterial butyrate
mucosal barrier. Am J Physiol Gastrointest Liver Physiol. (2007) 294:G208– synthesis pathways by analyzing (meta)genomic data. MBio. (2014)
16. doi: 10.1152/ajpgi.00398.2007 5:e00889. doi: 10.1128/mBio.00889-14
358. Hewison M. Vitamin D and innate and adaptive immunity. Vitam Horm. 368. Kannampalli P, Shaker R, Sengupta JN. Colonic butyrate-
(2011) 86:23–62. doi: 10.1016/B978-0-12-386960-9.00002-2 algesic or analgesic? Neurogastroenterol Motil. (2011) 23:975–
359. Froicu M, Cantorna MT. Vitamin D and the vitamin D receptor are critical 9. doi: 10.1111/j.1365-2982.2011.01775.x
for control of the innate immune response to colonic injury. BMC Immunol. 369. Banasiewicz T, Krokowicz, Stojcev Z, Kaczmarek BF, Kaczmarek E, Maik
(2007) 8:5. doi: 10.1186/1471-2172-8-5 J, et al. Microencapsulated sodium butyrate reduces the frequency of
360. Zhao H, Zhang H, Wu H, Li H, Liu L, Guo J, et al. Protective role abdominal pain in patients with irritable bowel syndrome. Color Dis. (2013)
of 1,25(OH)2vitamin D3 in the mucosal injury and epithelial barrier 15:204–9. doi: 10.1111/j.1463-1318.2012.03152.x
disruption in DSS-induced acute colitis in mice. BMC Gastroenterol. (2012)
12:57. doi: 10.1186/1471-230X-12-57 Conflict of Interest: The authors declare that the research was conducted in the
361. Guzman-Prado Y, Samson O, Segal JP, Limdi JK, Hayee B. Vitamin D therapy absence of any commercial or financial relationships that could be construed as a
in adults with inflammatory bowel disease: a systematic review and meta- potential conflict of interest.
analysis. Inflamm Bowel Dis. (2020) 26:1819–30. doi: 10.1093/ibd/izaa087
362. Raftery T, Martineau AR, Greiller CL, Ghosh S, McNamara D, Bennett K, Publisher’s Note: All claims expressed in this article are solely those of the authors
et al. Effects of vitamin D supplementation on intestinal permeability, and do not necessarily represent those of their affiliated organizations, or those of
cathelicidin and disease markers in Crohn’s disease: results from
the publisher, the editors and the reviewers. Any product that may be evaluated in
a randomised double-blind placebo-controlled study. United Eur
this article, or claim that may be made by its manufacturer, is not guaranteed or
Gastroenterol J. (2015) 3:294–302. doi: 10.1177/2050640615572176
363. Corrêa-Oliveira R, Fachi JL, Vieira A, Sato FT, Vinolo MAR. Regulation of endorsed by the publisher.
immune cell function by short-chain fatty acids. Clin Transl Immunol. (2016)
5:e73. doi: 10.1038/cti.2016.17 Copyright © 2021 Barbara, Barbaro, Fuschi, Palombo, Falangone, Cremon, Marasco
364. Ríos-Covián D, Ruas-Madiedo P, Margolles A, Gueimonde M, De and Stanghellini. This is an open-access article distributed under the terms of
los Reyes-Gavilán CG, Salazar N. Intestinal short chain fatty acids the Creative Commons Attribution License (CC BY). The use, distribution or
and their link with diet and human health. Front Microbiol. (2016) reproduction in other forums is permitted, provided the original author(s) and the
7:185. doi: 10.3389/fmicb.2016.00185 copyright owner(s) are credited and that the original publication in this journal
365. Barcenilla A, Pryde SE, Martin JC, Duncan SH, Stewart CS, is cited, in accordance with accepted academic practice. No use, distribution or
Henderson C, et al. Phylogenetic relationships of butyrate-producing reproduction is permitted which does not comply with these terms.

Fnut 08 718356

Uploaded by

Copyright:

Available Formats

Fnut 08 718356

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Fnut 08 718356

Uploaded by

Copyright:

Available Formats

REVIEW

published: 13 September 2021

Received: 31 May 2021

Frontiers in Nutrition | www.frontiersin.org 1 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 2 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 3 September 2021 | Volume 8 | Article 718356

TABLE 1 | Characteristics of claudins and their changes in intestinal diseases.

Tight junction protein Size (kDa) Interactions Role in disease

Frontiers in Nutrition | www.frontiersin.org 4 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 5 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 6 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 7 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 8 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 9 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 10 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 11 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 12 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 13 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 14 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 15 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 16 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 17 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 18 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 19 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 20 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 21 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 22 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 23 September 2021 | Volume 8 | Article 718356

Frontiers in Nutrition | www.frontiersin.org 24 September 2021 | Volume 8 | Article 718356

You might also like