0% found this document useful (0 votes)
26 views

Rumen Ecosystem

In this article, you will explore the fascinating world of the rumen microbial ecosystem and its pivotal role in the ruminant digestive process.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
0% found this document useful (0 votes)
26 views

Rumen Ecosystem

In this article, you will explore the fascinating world of the rumen microbial ecosystem and its pivotal role in the ruminant digestive process.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 8

Vigyan Varta an International E-Magazine for Science Enthusiasts E-ISSN: 2582-9467

Popular Article
www.vigyanvarta.com Vol. 5, Issue 8 Khobragade et al. (2024)
www.vigyanvarta.in

Rumen Ecosystem
Dr. Tathagat P. Khobragade1, Dr. Abhiruchi Damor1,
Dr. Mihirkumar Pandya1, Dr. Darshan Ramana1, Dr. Ankita Majeli1 and
Dr. Mikato Yeptho2
1
M.V.Sc. Scholar, Department of Animal Nutrition, College of Veterinary Science and Animal
Husbandry, Junagadh – 362001, Kamdhenu University, Gujarat
2
M.V.Sc. Scholar, Department of Livestock Production Management, College of Veterinary Science
and Animal Husbandry, Junagadh – 362001, Kamdhenu University, Gujarat

Corresponding Author
Dr. Tathagat P. Khobragade
Email: [email protected]

OPEN ACCESS

Keywords

Rumen, Bacteria, Methanogens, Fungi, Protozoa, Bacteriophage

How to cite this article:

Khobragade, T. P., Damor, A., Pandya, M., Ramana, D., Majeli, A. and Yeptho, M. 2024. Rumen
Ecosystem. Vigyan Varta 5(8): 46-53.

ABSTRACT
Rumen is the first and largest of the four chambers of ruminant foregut. The microbial
ecosystem of the rumen comprises complex interactions between its anaerobic inhabitants,
viz., bacteria, protozoa, fungi, archaea, and also the bacteriophage. In the rumen, the
environment favours the microorganisms to provide the enzymes necessary to digest the
nutrients. Temperature, pH, buffering capacity, osmotic pressure, and redox potential are
the primary factors affecting the growth and activity of these microbes. Bacteria are pre-
dominant (up to 1011 viable cells per gram comprising up to 1000 phylotypes) but a variety of
ciliate protozoa occur widely (104–106 g-1 distributed over 25 genera). The anaerobic fungi
are also widely distributed (zoospore population densities of 103–105 g-1 distributed over six
genera). The occurrence of bacteriophage is well documented (107–109 particles per gram).
The interaction between these microorganisms and the host animal results in a symbiotic
relationship that enables ruminants to digest fibre-rich and low-protein diets. These
microbes play a crucial role in synthesizing essential nutrients such as B vitamins and certain
amino acids, which are vital for the health and growth of the animal. The rumen ecosystem
exhibits high dynamism and can adapt to changes in diet, environmental conditions, and
other factors. Maintaining a healthy rumen ecosystem is paramount for the overall health

August 2024 46 | P a g e
Vigyan Varta an International E-Magazine for Science Enthusiasts E-ISSN: 2582-9467
Popular Article
www.vigyanvarta.com Vol. 5, Issue 8 Khobragade et al. (2024)
www.vigyanvarta.in

and productivity of ruminant animals. Imbalances or disruptions in the rumen microbiota


can lead to digestive disorders and reduced nutrient utilization. Thus, comprehending the
dynamics of the rumen ecosystem is essential for optimizing ruminant nutrition and
productivity.

INTRODUCTION

T
he ruminant animal has a complex o Ruminal Redox Potential The normal
stomach that is divided into four ruminal redox potential remains in the
chambers i.e., rumen, reticulum, range of -350 to -400 mV.
omasum and abomasum. Ex. Cow, Buffalo,
Goat. The rumen (also called as "paunch") is o Osmolarity: The ruminal fluid osmolarity
the largest compartment of the ruminal is approximately 250 mOsm/kg. After
stomach and is the first chamber in the eating it can reach up to 350 to 400
alimentary canal of ruminant animals. The mOsm/kg.
rumen in the adult cow comprises
approximately 80% of the abdominal cavity, o Gas phase % : CO2 65% ; CH4 27% ; N2
with a capacity of around 80 L (roughly 16% 7% ; O2 0.6% ; H2 0.2 % (Mackie RI et
of body weight). Some sources report al. 1999)
capacities varying from 102-148 L for mature
cattle (Niehaus Andrew 2009). The foods of Establishment of rumen microbial
ruminants-forages and fibrous roughages ecosystem: In young calves less than 3 weeks
consist mainly of polysaccharides such as old, the bacteria are mostly of the lactate
cellulose, which mammalian digestive fermenting type, aerobes and coliforms. By 3
enzymes cannot break down. Ruminants have months of age rumen bacteria characteristic of
therefore evolved a special system of digestion the adult animal, which are anaerobic get
that involves microbial fermentation of food themselves established. (D.V. Reddy, 2016).
before its exposure to their digestive enzymes. Rumen protozoa get established in young
Microscopic organisms called rumen microbes calves when they are about 3 to 4 months old.
break down (or digest) the ingested feed by a They are of two types: ciliates and flagellates
fermentation process. Rumen microorganisms Microorganisms are continuously removed
(primarily bacteria) digest cellulose from plant from the reticulo-rumen by the onward flow of
cell walls, digest complex starch, synthesize digesta to the omasum. To maintain a stable
protein from nonprotein nitrogen, and population in the reticulo-rumen, the microbes
synthesize B vitamins and vitamin K. that are removed must be replaced. To become
established, each type of microorganism must
❖ Physiochemical properties of the have a retention time in the reticulo-rumen
rumen: exceeding its lifespan, Microbes possessing a
lifespan greater than 8-16 h must thus attach to
o Temperature of Rumen: The Normal the rumen wall or fibre-containing material
Rumen Temperature is 39 to 39.5 °C (D.V. Reddy, 2016). The ruminal ecosystem
consists of a wide diversity of microorganisms
o pH of Rumen: The pH of the Rumen that are in a symbiotic relationship in a strict
usually remains in the range of 5.5 to 6.7 anaerobic environment. (Woese et al. 1990).
The anaerobiosis inside the rumen is one of the
major constraints in the rumen ecosystem,

August 2024 47 | P a g e
Vigyan Varta an International E-Magazine for Science Enthusiasts E-ISSN: 2582-9467
Popular Article
www.vigyanvarta.com Vol. 5, Issue 8 Khobragade et al. (2024)
www.vigyanvarta.in

which helps in conserving the energy break β-glycosidic bonds (1-4) of the
ultimately to be used by the host animal. biopolymer provides sugars for use by
Anaerobic ciliate protozoa anaerobic bacteria microorganisms. In addition, the presence of
and anaerobic fungi are the major microbes in ionized calcium (Ca+2) favours the
the rumen (Woese et al. 1990). The adhesion establishment of cellulose-degrading bacteria,
of microbes to solid substances is an important except for F. succinogenes. The establishment
factor in successful competition and survival of this bacterial group can be affected by the
in the rumen, as well as in the digestion of presence of certain types of lipids in the diet.
solid feed (Minato et al. 1966). The main For example, medium-chain fatty acids are
advantage of rumen microbes is their ability to often toxic to cellulolytic bacteria, reducing
use plant polysaccharides and non-protein the digestibility of the fibre. (Castillo-
nitrogen in a diet, which the host cannot digest gonzález et al , 2013)
and utilise. In ruminants, microorganisms
break down the higher carbohydrates, Fibrobacter succinogenes, Butyrivibrio
cellulose, pentosans and starch (protein as fibrisolvens, Ruminococcus albus, and
well) into monosaccharides and then ferment Clostridium lochheadii are important
to VFA and methane. Microbial mass cellulose-degrading bacteria. (Paswan et al,
synthesized in the rumen provides about 20% 2022)
of the nutrients absorbed by the host animal.
Microbial fermentation of carbohydrates and AMYLOLYTIC BACTERIA
protein yields volatile and short-chain fatty
The action of amylolytic and saccharolytic
acids which provide 60-80% of total
bacteria in the rumen is also important as high
metabolizable energy.
milk-yielding cattle are fed on concentrates
RUMINAL BACTERIA containing large proportions of grains. Starch
and sugars are the readily fermentable source
The rumen contains a variety of bacterial of energy for ruminants, and the major bacteria
genera, which constitute the majority of the that thrive on them are Streptococcus bovis,
microorganisms that live in anaerobic Bacteroides ruminicola, Ruminobacter
environments. The competition between amylophilus, Selenomonas ruminantium, and
bacteria in the rumen is determined by several Succinomonas amylolytica. These
factors, among which are the preference for microorganisms ferment starch and sugars into
certain substrates, energy requirements for VFAs such as acetate, propionate, butyrate,
maintenance, and resistance to certain formate, and succinate. (Cotta 1992).
metabolism products that can be toxic.
(Castillo-gonzález et al , 2013 ) LACTATE-DEGRADING BACTERIA

CELLULOSE-DEGRADING BACTERIA They have a very important role in the rumen,


mainly in those ruminants that are fed with
The ruminant diet is based on plant-based feed high grains in the diet. These bacteria
consumption. Because cellulose is the main metabolize lactic acid and control its
component of the cell wall of these plants, accumulation, which helps to keep the pH in
cellulolytic ruminal microorganisms play an the proper range. This type of bacteria
important role in animal nourishment. A increases when the diet consists of
temperature of 39 °C affects the adhesion approximately 70% concentrate. Megasphaera
ability of bacteria to feed particles, while the elsdenii is the main lactate degrader and helps
presence of extracellular cellulase enzymes to prevent ruminal acidosis when high-grain diets

August 2024 48 | P a g e
Vigyan Varta an International E-Magazine for Science Enthusiasts E-ISSN: 2582-9467
Popular Article
www.vigyanvarta.com Vol. 5, Issue 8 Khobragade et al. (2024)
www.vigyanvarta.in

are introduced gradually over an extended LIPOLYTIC BACTERIA


duration for adaptation to such diets. (Paswan
et al, 2022) Lipolytic microorganisms such as
Anaerovibrio lipolytic cause lipolysis, and
PECTIN-DEGRADING BACTERIA Butyrivibrio fibrisolvens cause saturation of
unsaturated fatty acids by hydrogenation. The
They are important because the pectin acidic and highly reductive environment of the
represents 10-20% of total carbohydrates in rumen, with a surplus of Hydrogen coupled
forages used in ruminant nutrition. Pectin is with the actions of microbial lipases and
fermented by both bacteria and protozoa and hydrogenase from this microorganism, favours
the main bacteria that perform this function are saturation of polyunsaturated fatty acids
Butyrivibrio fibrisolvens, Prevotella (Paswan et al, 2022). Dietary lipids
ruminicola, Bacteroides ruminicola and (triglycerides, galactolipids and phospholipids)
Lachnospira multiparus. These ruminal are rapidly hydrolysed in the rumen to
bacteria produce and release pectinolytic glycerol, free fatty acids and galactose.
enzymes into the ruminal environment; pectin Butyrivibrio fibrisolvens and Anaerovibrio
lyases are the primary enzymes that hydrolyze lipolytica are actively lipolytic whereas the
the pectin in oligogalacturonoides ( Duskova long-chain FAs are isomerised and
and Marounek 2001) hydrogenated by a range of bacteria (B.
fibrisolvens, Treponema bryantii, Eubacterium
PROTEOLYTIC BACTERIA sp. and Ruminococcus albus). ( Mackie et al
2013).
In the rumen, the forage proteins and
structural polysaccharides are degraded by 50- RUMINAL ARCHAEA OR
70% by the action of microorganisms. METHANOGENS
Ruminal proteolysis is carried out by
enzymatic production of ruminal The domain Archaea is represented in the
microorganisms by protein hydrolysis rumen by methanogens, which are unified and
processes, degradation of peptides, and amino defined as a group by methanogenesis but are
acid deamination (Cotta et al 1986). The main otherwise extremely diverse. The methanogens
bacterial species with proteolytic activity are are perhaps the strictest anaerobes known,
Bacteroides amylophilus, Bacteroides requiring special techniques for their
rutminicola, and Butyrivibrio fibrisolvens. The cultivation and study. Methanobrevibacter
degradation of proteins and NPN substances ruminantium is dominant in the cattle rumen.
such as polypeptides, oligopeptides, amino Methanobacterium formicicum and
acids, and urea causes the production of Methanomicrobium mobile have also been
ammonia, VFAs, and H2S. Microorganisms isolated. An acetoclastic methanogen,
utilize these and cause de novo synthesis of Methanosarcina barkeri (also Methanosarcina
microbial protein. About 60% of protein mazei), has also been isolated from the rumen.
needed by the host ruminant comes from the Anaerobic ciliate protozoa produce hydrogen
subsequent digestion of ruminal and have methanogens attached to the cell
microorganisms in the omasum and small surface in an episymbiotic mutualistic
intestine. (Paswan et al, 2022) association. The importance of gut
methanogens in greenhouse gas emissions has
stimulated the study of biodiversity in ruminal

August 2024 49 | P a g e
Vigyan Varta an International E-Magazine for Science Enthusiasts E-ISSN: 2582-9467
Popular Article
www.vigyanvarta.com Vol. 5, Issue 8 Khobragade et al. (2024)
www.vigyanvarta.in

methanogens and resulted in the isolation of decrease the risk of acidosis after consuming
fresh strains. ( Mackie et al 2013). foods with high concentrations of easily
digestible sugars (van Zwieten et al. 2008).
Although ruminal archaea constitute a minor
proportion of the ruminal microbial The rumen ciliates are of two types, which
population, by capturing Hydrogen and have been studied inside the rumen:-
converting it to CH4, they create a ruminal
environment conducive to efficient ❑ Holotrichs (cilia present on all over the
fermentation of the key nutrients by the other body)
ruminal microbial population. The main
fermentation end products of fibre, starch, Holotrichs use – soluble carbohydrates
sugars, and proteins from ruminant diets are (Isotricha intestinalis, Dasytricha
VFAs, NH3, CO2, and H2. While, VFAs and ruminantium, Charon eguii,
NH3 are utilized as energy sources and Blepharoprosthium pierum) (Shreya Patel et al
synthesis of microbial proteins, H2 and CO2 2018).
are taken up by these methanogens for
❑ Oligotrichs (Entodiniomorphs – cilia
conversion into methane. Although in
present on one side of body)
ruminants methane production is the main sink
of H+, it is a wasteful process in which 2–12% Entodiniomorphs - use particulate material like
of gross energy is wasted through methane starch (Entodinium busa, Diplodinium
emission. (van Zijderveld et al. 2011). cristagalli, Diploplastron affine,
Ostracodinium gracile, Epidinium caudate,
RUMEN PROTOZOA
Ophryoscolex purkynei, Eudiplodinium
Protozoa are a group of single-celled maggaii, Metadinium medium) ( Shreya Patel
eukaryotes, either free-living parasitic, that et al 2018 ).
feed on organic matter such as other
Besides having the ability to digest cellulose,
microorganisms or organic debris. Rumen
Diploplastron affine has amylolytic activity;
Protozoal population is up to 106 per ml. All
due to its ability to produce amylolytic
the protozoa are strictly anaerobic. Flagellates
enzymes, including two isoforms of α-amylase
are less; ciliates are predominating. Rumen
and maltase, it produces maltose, maltotriose,
protozoa are responsible for 30-40% of total
and glucose.
rumen microbial fibre digestion.
Morphological studies have identified more Proteolytic protozoa: In the ruminal
than 250 species of ciliates living in the environment, soluble proteins are mostly
various ruminants. ( Mackie et al. 1999 ). degraded by bacteria and protozoa. The
proteolytic activity of ruminal bacteria is 6 to
Protozoa constitute 40-80% of the biomass,
10 times greater than that of protozoa ( Akin et
the most abundant of which are the orders
al 1982 ). Rumen protozoa are proteolytic and
Entodiniomorphida and Holotricha. The flow
actively ingest bacteria as a protein source.
of ruminal protozoa to the ruminant abomasum
This predatory relationship results in inverse
is less than that of bacteria since they are
relative numbers of ciliate protozoa and
retained in the feed particles. The digestion of
anaerobic bacteria. In defaunated animals,
cellulose by the larger entodiniomorphid
bacterial numbers are higher, as are NH3 and
protozoa. Holotrichs can assimilate soluble
total VFA concentrations as well as the
sugars and keep some of them in reserve
numbers of fungal zoospores. Rumen protozoa
polysaccharides; thus, these protozoa can

August 2024 50 | P a g e
Vigyan Varta an International E-Magazine for Science Enthusiasts E-ISSN: 2582-9467
Popular Article
www.vigyanvarta.com Vol. 5, Issue 8 Khobragade et al. (2024)
www.vigyanvarta.in

sequester particulate matter through organisms/ml of rumen fluid. These are


chemotaxis and exit the rumen at a slower rate specific for different bacteria present in the
than the bacteria ( Mackie et al. 1999 ). rumen. These are also considered to be
obligate pathogens for the bacteria, as
RUMINAL FUNGI bacteriophages are capable of lysing/engulfing
the bacteria. These phages help in bacterial
The rumen fungi are anaerobic, zoospore- mass turnover in the rumen, which may be
forming and very sensitive to oxygen. The considered not so useful for the animals on
fungi are established within the first 2 weeks different feeding schedules but by lysing the
of age. Dominant role in the degradation of bacterial cells, bacterial protein is easily made
lignocellulosic components of the feed available to the animals as a source of amino
particles. The organisms are important for the acids ( Karma, 2005).
initiation and continuation of rumen
fermentation. Rumen fungi have amylolytic The specificity of the bacteriophages for a
and proteolytic activities. Anaerobic fungi are particular rumen bacterium may be exploited
among the most active organisms in fibre for removal or killing by lysis of unwanted
digestion. ( Akin et al,1990 ) . Anaerobic rumen bacteria from the ecosystem like
rumen fungi have been classified into six Streptococcus bovis and Methanogens. These
genera, viz., Neocallimastix, Piromyces viruses belonged to 3 distinct families of tailed
(Piromonas), and Caecomyces phages; the Myoviridae, Siphoviridae, and
(Sphaeromonas)—all with monocentric Podoviridae, which are the predators of
sporangia—and Orpinomyces, Anaeromyces ruminal bacteria of the genera Bacteroides,
(Ruminomyces), and Cyllamyces, with Ruminococcus, and Streptococcus. (Ritchie et
polycentric sporangia. These fungi represent a al. 1970)
small proportion of the ruminal microbes but
perform important functions in fibre Siphoviridae such as Methanobacterium phage
degradation through their cellulolytic and Ψ M1, Methanobacterium phage Ψ M10,
hemicellulolytic enzymatic profiles and Methanobacterium phage Ψ M100,
breaking lignocellulosic bonds. (Paswan et al, Methanobacterium phage Ψ M2 infect
2022) Methanogens like Methanobrevibacter
ruminantium, Methanomicrobium mobile. (
Table: Cellulolytic fungi and their McAllister et al., 2008 )
fermentation product
Genus Species Fermentation CONCLUSION
Products
Neocallimastix N. Lactate, The rumen is the largest compartment of a
frontalis formate, acetate,
succinate, ruminant’s stomach, housing a diverse
ethanol microbial community. Bacteria, protozoa,
Piromyces P. Cellobiose, fungi, and archaea coexist in the rumen.
communis oligosaccharides Bacteria are the most abundant and play a key
Orpinomyces O. joyonii Glucose
role in fibre degradation. Protozoa contribute
(Castillo-gonzález et al , 2013)
to protein metabolism and microbial predation.
RUMEN BACTERIOPHAGE Archaea are involved in methane production.
The rumen ecosystem recycles nutrients by
Bacteriophages are one of the most important fermenting ingested feed. Microbes in the
components of the rumen microbial rumen break down complex carbohydrates
community and are present typically at 108-109 (cellulose, hemicellulose) into simpler

August 2024 51 | P a g e
Vigyan Varta an International E-Magazine for Science Enthusiasts E-ISSN: 2582-9467
Popular Article
www.vigyanvarta.com Vol. 5, Issue 8 Khobragade et al. (2024)
www.vigyanvarta.in

compounds (volatile fatty acids, gases, and utilization of maltooligosaccharides


microbial biomass). These microbial products from starch. Appl Environ Microbiol
serve as an energy source for the host animal. 58, 48-54.
Nitrogen metabolism is critical, microbes
convert ammonia (from protein breakdown) D.E. Akin, W.S. Borneman (1990), Role of
into microbial protein. This microbial protein Rumen Fungi in Fiber Degradation,
is then digested by the host animal. Diet Journal of Dairy Science Volume 73,
composition (fibre content, protein levels) Issue 10, October 1990, Pages 3023-
affects microbial populations. Proper feeding 3032 https://doi.org/10.3168/jds.
and watering techniques maintain a healthy S0022-0302(90)78989-8
rumen environment. Remember, the rumen’s
microbial ecosystem adapts to diet changes, D.V. Reddy: Applied Nutrition (3rd ed.), CBS
making it a dynamic and essential part of Publishers & Distributors Pvt Ltd.,
ruminant nutrition. New Delhi 2016. Pages 101-112.

Abbreviations Duskova D, M Marounek. 2001. Fermentation


of pectin and glucose, and activity of
VFA: Volatile Fatty Acids pectin-degrading enzymes in the
rumen bacterium Lachnospira
NPN: Non-protein Nitrogen multiparus. Lett Appl Microbiol 33,
159-163.
REFERENCES
Kamra, D. N. (2005). Rumen microbial
Brock FM, CW Forsberg, JG Buchanan-Smith. ecosystem. Current Science, 89(1),
1982. Proteolytic activity of rumen 124–135. http://www.jstor.org/stable/
microorganisms and effects of 24110438
proteinase inhibitors. Appl Environ
Microbiol 44, 561-569. Mackie RI, McSweeney CS, Aminov RI
(1999) Rumen. In: Encyclopedia of life
Castillo, Alexas & Burrola-Barraza, sciences. Nature Publishing Company,
M.Eduviges & Viveros, Joel & London
Chavez-Martinez, America. (2013).
Rumen microorganisms and Mackie, Roderick & Mcsweeney, Christopher
fermentation. Archivos de medicina & Aminov, Rustam. (2013). Rumen.
veterinaria. 46. 349-361. 10.1002/9780470015902.a0000404.pu
10.4067/S0301-732X2014000300003. b2.

Choudhury Prasanta & A.Z.M., Salem, & McAllister TA, Newbold CJ (2008)
Jena, Rajashree & Kumar, Sanjeev & Redirecting rumen fermentation to
Singh, Rameshwar & Puniya, Anil. reduce methanogenesis. Aust J Exp
(2015). Rumen Microbiology: An Agric 48:7–13
Overview. Rumen Microbiology: From
Evolution to Revolution. 1. Niehaus Andrew. (2009). Rumenotomy and
10.1007/978-81-322-2401-3_1. Rumenostomy. 10.1016/B978-
141603591-6.10009-0
Cotta MA. 1992. Interaction of ruminal
bacteria in the production and Paswan, V K & Kumar, Kaushalendra &
Shehata, Abdelrazeq. (2022). Rumen

August 2024 52 | P a g e
Vigyan Varta an International E-Magazine for Science Enthusiasts E-ISSN: 2582-9467
Popular Article
www.vigyanvarta.com Vol. 5, Issue 8 Khobragade et al. (2024)
www.vigyanvarta.in

Microbiology and Microbial van Zijderveld SM, Fonken B, Dijkstra J,


Degradation of Feedstuffs. Gerrits WJJ, Perdok HB, Fokkink W,
10.1007/978-3-030-97291-2_4. Newbold JR (2011) Effects of a
combination of feed additives on
Ritchie AE, Robinson IM, Allison MJ (1970) methane production, diet digestibility,
Rumen bacteriophage: survey of and animal performance in lactating
morphological types. In: Societie dairy cows. J Dairy Sci 94:1445–1454
Francaise de Microscopie
Electronique. Grenoble, pp 333–334 Woese CR, Kandler O, Wheelis ML. Towards
a natural system of organisms:
Shreya Patel, Padma Ambalam. Role of Rumen proposal for the domains Archaea,
Protozoa: Metabolic and Fibrolytic. Bacteria, and Eucarya. Proc Natl
Adv Biotech & Micro. 2018; 10(4): Acad Sci U S A. 1990
555793. DOI: 10.19080/ Jun;87(12):4576-9. doi: 10.1073/pnas.
AIBM.2018.10.555793 87.12.4576. PMID: 2112744;
PMCID: PMC54159.

August 2024 53 | P a g e

You might also like