Prevalence of Small Bowel Bacterial Overgrowth (SIBO) in Decompensated Cirrhosis with Portal Hypertension: A Clinical Pilot Study

Abstract

Purpose: Decompensated cirrhosis is associated with portal hypertension and its complications, like spontaneous bacterial peritonitis (SBP), hepato renal syndrome, and minimal and overt encephalopathy (HE), which accelerate mortality and affect quality of life (QOL). Portal hypertension causes transmural edema and dysbiosis, due to altered splanchnic hemodynamics promoting translocation of microbes across the bowel wall, causing SBP and precipitating HE (with substantially reduced survival rates). This study evaluates the prevalence of SIBO in decompensated cirrhotics (without overt HE) and the recurrence of SBP, both leading to a challenging clinical course. Methods: Total of 120 patients were recruited. Group A: (n=30) healthy controls, group B: (n=45) chronic liver disease {(ALD 12/45 (27%), NASH 5/45 (11%), HCV 18/45 (40%)}, group C: (n=45) decompensated cirrhosis with mean MELD of 16. Laboratories studies included: Stool H. pylori antigen, ova and parasites, initial lactoferrin, calprotectin, serum ammonia, anti-sacromyces cervecesiae antibody IgA and IgG, tissue transglutaminase antibody IgA and IgG, endomysial antibody IgA and IgG, de aminated gliadine peptide IgG, and breath resting for SIBO lactose at base-line and after three months. Group C underwent abdominal sonogram-guided baseline paracentesis, which was repeated in 3 months to evaluate the recurrence of SBP in SIBO. Exclusion: Diabetes mellitus, renal failure, IBS, celiac, IBD, parkinsonism, idiopathic dysmotility disorders, hepatic encephalopathy, TIPS, drugs-gut specific antibiotics, anti-cholinergics, tricyclics, methadone, narcotics, and PPis. Results: Group A 2/30 (6%) were positive for SIBO on breath testing, and 1/30 (3%) ASCA IgA-positive. Group B 5/45 (11%) were positive on breath testing, and 4/45 (8%) were ASCA IgA-positive. Group C: 33/45 (73%) were positive on breath testing, and 38/45 (84%) were ASCA IgA-positive. Recurrence of SBP was 28/33 (85%). Conclusion: This observational clinical trial reveals SIBO to be associated with decompensated cirrhosis. SBP with SIBO has independent morbidity with recurrence. Prophylactic antibiotics should be considered to avoid recurrent SBP and encephalopathy in cirrhotics with SIBO. A larger study needs to validate the role of SIBO in decompensated cirrhotics with portal hypertension.