Small intestinal bacterial overgrowth syndrome

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Mazia Fatima, MBBS [2]

Small intestinal bacterial overgrowth syndrome
ICD-10 K63
ICD-9 579.9
DiseasesDB 29209
MedlinePlus 000222
eMedicine med/198 

Synonyms and Keywords: SIBO; small bowel bacterial overgrowth.

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Overview

Small intestinal bacterial overgrowth (SIBO) was first discovered by Barber and Hummel in 1939. There is no established system for the classification of small intestinal bacterial overgrowth (SIBO).The pathogenesis of small intestinal bacterial overgrowth (SIBO) is characterized by an increased microbial load in the small intestine. Disruption of protective homeostatic mechanisms can increase the risk of SIBO. Bacterial colonization causes an inflammatory response in the intestinal mucosa. Damage to the intestinal mucosa leads to malabsorption of bile acids, carbohydrates, proteins and vitamins resulting in symptoms of diarrhea and weight loss. On gross pathology, mucosal edema, loss of normal vascular pattern, patchy erythema, friability and ulceration of the small intestinal wall is associated with small intestinal bacterial overgrowth (SIBO). On microscopic histopathological analysis small intestine and colon are normal in most patients with SIBO. Findings include blunting of the intestinal villi, thinning of the mucosa and crypts, increased intraepithelial lymphocytes. Small intestinal bacterial overgrowth (SIBO) must be differentiated from other diseases that cause chronic diarrhea. Small intestinal bacterial overgrowth is more commonly observed among elderly patients. Small intestinal bacterial overgrowth (SIBO) affects men and women equally.There is no racial predilection for small intestinal bacterial overgrowth (SIBO). Early clinical features include bloating, flatulence, abdominal pain. If left untreated, patients with small intestinal bacterial overgrowth (SIBO) may progress to develop diarrhea, dyspepsia and weight loss. Prognosis is generally good and associated with frequent relapses and symptom-free periods. The diagnosis of small intestinal bacterial overgrowth (SIBO) is made when at least one of the following diagnostic criteria are met: a positive carbohydrate breath test or bacterial concentration of >103 units/mL in a jejunal aspirate culture. Physical examination may be remarkable for distended abdomen with positive succussion splash as a result of distended bowel loops and peripheral edema due to malabsorption. Small intestinal bacterial obstruction(SIBO) may also be diagnosed using breath tests. The mainstay of therapy for small intestinal bacterial overgrowth (SIBO) is antibiotic therapy. Surgical approach can only be performed for patients with strictures, fistulae, and diverticula or any other structural abnormality resulting in obstruction and resultant bacterial overgrowth. Effective measures for the prevention of small bowel bacterial overgrowth syndrome include avoiding medications like narcotics and benzodiazepines that decrease intestinal motility and avoid achlorhydria in high-risk patients. Consider antibiotic prophylaxis for patients with four or more episodes of recurrent small bowel bacterial overgrowth syndrome within one year.

Historical Perspective

Classification

  • There is no established system for the classification of small intestinal bacterial overgrowth (SIBO).

Pathophysiology

Causes

Differentiating Small Intestinal Bacterial Overgrowth from other Diseases

  • Small intestinal bacterial overgrowth (SIBO) must be differentiated from other diseases that cause chronic diarrhea. For differential diagnosis of chronic diarrhoea, click here.

Epidemiology and Demographics

Epidemiology and demographics of small intestinal bacterial overgrowth is as follows: [7]

Age

  • Small intestinal bacterial overgrowth is more commonly observed among elderly patients.

Gender

  • Small intestinal bacterial overgrowth (SIBO) affects men and women equally.

Race

  • There is no racial predilection for small intestinal bacterial overgrowth (SIBO).

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

Symptoms

  • Symptoms of small intestinal bacterial overdose (SIBO) may include the following:[8]

Physical Examination

Laboratory Findings

Imaging Findings

  • The CT abdomen or MRI may demonstrate associated strictures, malrotation, fistulae.[1]
  • Small intestinal bacterial overgrowth can result in small bowel obstruction that presents as small bowel feces sign on abdominal CT.
  • Small bowel feces sign is the presence of particulate feculent material mingled with gas bubbles in the lumen of the small intestine, it is believed to be the result of delayed intestinal transit.
Small bowel faeces signCase courtesy of Dr Ian Bickle, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/29769">rID: 29769</a>

Other Diagnostic Studies

Breath Tests

Preparation for breath testing

Indications for the patient

  • Fasting period prior to test should be 8-12 h
  • Antibiotics should be avoided 4 weeks prior to test
  • Prokinetic agents (e.g. cisapride, domperidone, erythromycin) and laxatives should be stopped 1 week prior to test–if tolerated by the patient
  • Complex carbohydrates (e.g. bread, pasta, rice, legumes, etc.) should be avoided 24 hours prior to test
  • Physical activity should be avoided during the test
  • Smoking should be avoided on the day of the test
  • It is not necessary to stop proton pump inhibitors for the test

Indications for the physician

  • Lactulose dose: 10 g followed by one cup of water
  • Glucose dose: 75 g mixed with or followed by one cup of water
  • Lactose: 25 g mixed with one cup of water
  • Fructose: 25 g mixed with or followed by one cup of water

Treatment

Treatment options available for small intestinal bacterial overgrowth syndrome are as follows: [12][7]

Medical Therapy

Surgery

Prevention

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Hao WL, Lee YK (2004). "Microflora of the gastrointestinal tract: a review". Methods Mol. Biol. 268: 491–502. doi:10.1385/1-59259-766-1:491. PMID 15156063.
  2. Sachdev AH, Pimentel M (2013). "Gastrointestinal bacterial overgrowth: pathogenesis and clinical significance". Ther Adv Chronic Dis. 4 (5): 223–31. doi:10.1177/2040622313496126. PMC 3752184. PMID 23997926.
  3. Mathias JR, Clench MH (1985). "Review: pathophysiology of diarrhea caused by bacterial overgrowth of the small intestine". Am. J. Med. Sci. 289 (6): 243–8. PMID 3890541.
  4. 4.0 4.1 4.2 Bures J, Cyrany J, Kohoutova D, Förstl M, Rejchrt S, Kvetina J, Vorisek V, Kopacova M (2010). "Small intestinal bacterial overgrowth syndrome". World J. Gastroenterol. 16 (24): 2978–90. PMC 2890937. PMID 20572300.
  5. Deng L, Liu Y, Zhang D, Li Y, Xu L (2016). "Prevalence and treatment of small intestinal bacterial overgrowth in postoperative patients with colorectal cancer". Mol Clin Oncol. 4 (5): 883–887. doi:10.3892/mco.2016.807. PMC 4840787. PMID 27123301.
  6. 6.0 6.1 McEvoy A, Dutton J, James OF (1983). "Bacterial contamination of the small intestine is an important cause of occult malabsorption in the elderly". Br Med J (Clin Res Ed). 287 (6395): 789–93. PMC 1549133. PMID 6412829.
  7. 7.0 7.1 7.2 7.3 7.4 7.5 King CE, Toskes PP (1979). "Small intestine bacterial overgrowth". Gastroenterology. 76 (5 Pt 1): 1035–55. PMID 437407.
  8. 8.0 8.1 8.2 Saltzman JR, Russell RM (1994). "Nutritional consequences of intestinal bacterial overgrowth". Compr Ther. 20 (9): 523–30. PMID 7805370.
  9. 9.0 9.1 Donald IP, Kitchingmam G, Donald F, Kupfer RM (1992). "The diagnosis of small bowel bacterial overgrowth in elderly patients". J Am Geriatr Soc. 40 (7): 692–6. PMID 1607585.
  10. Stotzer PO, Kilander AF (2000). "Comparison of the 1-gram (14)C-D-xylose breath test and the 50-gram hydrogen glucose breath test for diagnosis of small intestinal bacterial overgrowth". Digestion. 61 (3): 165–71. doi:10.1159/000007753. PMID 10773721.
  11. Saad RJ, Chey WD (2014). "Breath testing for small intestinal bacterial overgrowth: maximizing test accuracy". Clin. Gastroenterol. Hepatol. 12 (12): 1964–72, quiz e119–20. doi:10.1016/j.cgh.2013.09.055. PMID 24095975.
  12. Pimentel M (2009). "Review of rifaximin as treatment for SIBO and IBS". Expert Opin Investig Drugs. 18 (3): 349–58. doi:10.1517/13543780902780175. PMID 19243285.
  13. Peralta S, Cottone C, Doveri T, Almasio PL, Craxi A (2009). "Small intestine bacterial overgrowth and irritable bowel syndrome-related symptoms: experience with Rifaximin". World J. Gastroenterol. 15 (21): 2628–31. PMC 2691494. PMID 19496193.

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