Diagnosis Of Small Intestinal Bacterial Overgrowth Research Articles

Small Intestinal Bacterial Overgrowth in Various Specialties of Medical Practice (Literature Review and Expert Council Resolution)

Aim: to discuss current views on the clinical significance, diagnostic opportunities, and therapeutic approaches in the treatment of small intestinal bacterial overgrowth (SIBO) as an important component in the gut microbiota function assessment, to assess the awareness of physicians and the opportunities in the diagnosis and treatment of this disease in patients in the Federal districts of the Russian Federation, as well as to present the proceedings of the Expert Council held on December 16, 2023 in Moscow.Key points. SIBO is a common syndrome often associated with irritable bowel syndrome, liver cirrhosis, asthma, and congestive heart failure, being also a predictor of early death in the elderly. Today, in many regions of the Russian Federation, there are limitations for instrumental diagnosis of this disease — lack of awareness among doctors, unavailability of gas analyzers for diagnosing SIBO, lack of information about the need to diagnose SIBO in the standards of compulsory health insurance. Rifaximin is the first-line treatment due to the highest therapeutic efficacy. One of the ways to increase the efficacy of SIBO treatment is to include strain-specific probiotics in the treatment regimen. Saccharomyces boulardii CNCM I-745 is thought to be the most studied, promising probiotic. The review also presents statistical data on the issues in the diagnosis and treatment of SIBO in the regions of the Russian Federation.Conclusion. Optimization of approaches to the diagnosis and treatment of SIBO, the development of domestic gas analyzers, increasing the awareness of physicians in all regions of the Russian Federation, as well as the development and optimization of clinical recommendations appear to be necessary measures to increase the effectiveness of medical care, the duration and quality of life of the Russian population. These goals can be achieved within the framework of Federal programs under the supervision of specialized reference centers of the Ministry of Health of the Russian Federation.

The Prevalence of Small Intestinal Bacterial Overgrowth After Roux-en-Y Gastric Bypass (RYGB): a Systematic Review and Meta-analysis.

We reviewed the literature on the prevalence of small intestinal bacterial overgrowth (SIBO) after Roux-en-Y gastric bypass (RYGB). Eight studies examining 893 patients were included. The mean age of the patients was 48.11 ± 4.89years. The mean BMI before surgery and at the time of SIBO diagnosis was 44.57 ± 2.89kg/m2 and 31.53 ± 2.29kg/m2, respectively. Moreover, the results showed a 29% and 53% prevalence of SIBO at < 3-year and > 3-year follow-up after RYGB, respectively. Symptoms included abdominal pain, diarrhea, bloating, nausea, vomiting, constipation, soft stool, frequent defecation, flatulence, rumpling, dumping syndrome, and irritable bowel syndrome. SIBO is prevalent after RYGB; digestive symptoms should prompt the consideration of SIBO as a potential etiology. Antibiotic therapy has proven to be therapeutic.

Comparison of jejunal aspirate culture and methane and hydrogen breath test in the diagnosis of small intestinal bacterial overgrowth.

Small intestinal bacterial overgrowth (SIBO) is still difficult to diagnose. Quantitative culture of small intestine aspirate is recommended to be the gold standard. The methane and hydrogen breath tests are easily repeatable, sufficiently sensitive and highly specific for SIBO diagnosis. Our goal is to contrast the diagnostic value of the breath tests with jejunal aspiration cultures. 40 adult outpatients (age < 60) were enrolled in our study. Randomly, within 2days, both the methane and the hydrogen breath test and jejunal aspiration culture were performed on each patient and the results of both tests were evaluated and contrasted. The jejunal culture was positive (105CFU / mL) in 14/40(35%) subjects, the lactulose breath test (LBT) was positive in 18/40 (45%) subjects, and the glucose breath test (GBT) was positive in 12/40 (30%). The GBT showed good agreement (κ = 0.659) and LBT showed poor agreement (κ = 0.588) with the jejunal aspirate culture. The sensitivity, specificity, positive and negative predictive values of LBT/GBT were 85.7/71.4%,76.9/92.3%, 66.6/83.3% and 90.9/85.7%, respectively. 35% of patients with suspected SIBO are identified using jejunal aspirate cultures. For the identification of SIBO, GBT is more specific than LBT, but has a lower sensitivity. In individuals with suspected SIBO, the breath test should be initially due to its good agreement with the jejunal aspirate culture.

Diagnosis by Microbial Culture, Breath Tests and Urinary Excretion Tests, and Treatments of Small Intestinal Bacterial Overgrowth.

Small intestinal bacterial overgrowth (SIBO) is characterized as the increase in the number and/or alteration in the type of bacteria in the upper gastrointestinal tract and accompanies various bowel symptoms such as abdominal pain, bloating, gases, diarrhea, and so on. Clinically, SIBO is diagnosed by microbial culture in duodenum/jejunum fluid aspirates and/or the breath tests (BT) of hydrogen/methane gases after ingestion of carbohydrates such as glucose. The cultural analysis of aspirates is regarded as the golden standard for the diagnosis of SIBO; however, this is invasive and is not without risk to the patients. BT is an inexpensive and safe diagnostic test but lacks diagnostic sensitivity and specificity depending on the disease states of patients. Additionally, the urinary excretion tests are used for the SIBO diagnosis using chemically synthesized bile acid conjugates such as cholic acid (CA) conjugated with para-aminobenzoic acid (PABA-CA), ursodeoxycholic acid (UDCA) conjugated with PABA (PABA-UDCA) or conjugated with 5-aminosalicylic acid (5-ASA-UDCA). These conjugates are split by bacterial bile acid (cholylglycine) hydrolase. In the tests, the time courses of the urinary excretion rates of PABA or 5-ASA, including their metabolites, are determined as the measure of hydrolytic activity of intestinal bacteria. Although the number of clinical trials with this urinary excretion tests is small, results demonstrated the usefulness of bile acid conjugates as SIBO diagnostic substrates. PABA-UDCA disulfate, a single-pass type unabsorbable compound without the hydrolysis of conjugates, was likely to offer a simple and rapid method for the evaluation of SIBO without the use of radioisotopes or expensive special apparatus. Treatments of SIBO with antibiotics, probiotics, therapeutic diets, herbal medicines, and/or fecal microbiota transplantation are also reviewed.

Prevalence of small intestinal bacterial overgrowth in patients with gastroparesis: a systematic review and meta-analysis.

We performed a systematic review and meta-analysis to identify the prevalence of small intestinal bacterial overgrowth (SIBO) in patients with gastroparesis. Several studies have suggested an association between SIBO and gastroparesis, which is characterized by delayed gastric emptying in the absence of mechanical obstruction. A comprehensive search was performed using MEDLINE, EMBASE, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) through January, 2022 for randomized controlled trials and observational studies reporting the prevalence of SIBO in gastroparesis. Pooled prevalence was estimated using a random effects model. Heterogeneity was assessed by using the inconsistency index (I2). Among the 976 articles identified, 43 studies were selected for full text review. Six studies, with 385 patients, were deemed eligible for inclusion, with a perfect agreement between investigators (kappa=1.0). Overall, 379 patients were diagnosed with gastroparesis by gastric emptying scintigraphy and six were diagnosed with a wireless motility capsule. The pooled prevalence of SIBO was 41% (95% confidence interval 0.23-0.58). SIBO was diagnosed using jejunal aspirate cultures (N=15, 8.4%), lactulose breath test (N=80, 44.7%), glucose breath test (N=30, 16.8%), D-xylose breath test (N=52, 29.1%), and hydrogen breath test (N=2, 1.1%). Heterogeneity was significant and noted to be high at 91%. Only one study reported SIBO diagnosis in controls, therefore no pooled odds ratio was calculated. SIBO was present in almost half of the patients with gastroparesis. Future studies should examine and identify the association between SIBO and gastroparesis.

S540 Change in Severity of Abdominal Pain and Flatulence During Lactulose Breath Testing Associated With Positive Small Intestinal Bacterial Overgrowth Diagnosis

S540 Change in Severity of Abdominal Pain and Flatulence During Lactulose Breath Testing Associated With Positive Small Intestinal Bacterial Overgrowth Diagnosis

S1554 Rectal Evacuation Disorder Associated With a Higher Rate of Small Intestinal Bacterial Overgrowth Diagnosis Compared to Slow Transit Constipation

S1554 Rectal Evacuation Disorder Associated With a Higher Rate of Small Intestinal Bacterial Overgrowth Diagnosis Compared to Slow Transit Constipation

Current and Future Approaches for Diagnosing Small Intestinal Dysbiosis in Patients With Symptoms of Functional Dyspepsia.

The development and application of next generation sequencing technologies for clinical gastroenterology research has provided evidence that microbial dysbiosis is of relevance for the pathogenesis of gastrointestinal and extra-intestinal diseases. Microbial dysbiosis is characterized as alterations of diversity, function, and density of the intestinal microbes. Emerging evidence suggests that alterations of the gastrointestinal microbiome are important for the pathophysiology of a variety of functional gastrointestinal conditions, e.g., irritable bowel syndrome (IBS) and functional dyspepsia (FD), also known as disorders of brain-gut axis interaction. Clinicians have for many years recognized that small intestinal bacterial overgrowth (SIBO) is typified by a microbial dysbiosis that is underpinned by abnormal bacterial loads in these sites. SIBO presents with symptoms which overlap with symptoms of FD and IBS, point toward the possibility that SIBO is either the cause or the consequence of functional gastrointestinal disorders (FGIDs). More recently, new terms including “intestinal methanogen overgrowth” and “small intestinal fungal overgrowth” have been introduced to emphasize the contribution of methane production by archea and fungi in small intestinal dysbiosis. There is emerging data that targeted antimicrobial treatment of SIBO in patients with FD who simultaneously may or may not have IBS, results in symptom improvement and normalization of positive breath tests. However, the association between SIBO and FGIDs remains controversial, since widely accepted diagnostic tests for SIBO are lacking. Culture of jejunal fluid aspirate has been proposed as the “traditional gold standard” for establishing the diagnosis of SIBO. Utilizing jejunal fluid culture, the results can potentially be affected by cross contamination from oropharyngeal and luminal microbes, and there is controversy regarding the best cut off values for SIBO diagnosis. Thus, it is rarely used in routine clinical settings. These limitations have led to the development of breath tests, which when compared with the “traditional gold standard,” have sub-optimal sensitivity and specificity for SIBO diagnosis. With newer diagnostic approaches–based upon applications of the molecular techniques there is an opportunity to characterize the duodenal and colonic mucosa associated microbiome and associated gut microbiota dysbiosis in patients with various gastrointestinal and extraintestinal diseases. Furthermore, the role of confounders like psychological co-morbidities, medications, dietary practices, and environmental factors on the gastrointestinal microbiome in health and disease also needs to be explored.

S1370 Small Intestinal Bacterial Overgrowth Prevalence in Patients With Systemic Sclerosis

Introduction: Currently, there is a paucity of information regarding the prevalence of small intestinal bacterial overgrowth (SIBO) in patients with systemic sclerosis (SSc). SIBO occurs when the small bowel becomes colonized with the bacteria normally found in the colon and can cause a variety of gastrointestinal (GI) symptoms including bloating, nausea, abdominal pain, flatulence, and diarrhea. Several risk factors for developing SIBO have been identified including intestinal dysmotility, anatomic disorders, and gastric hypochlorhydria, among others. We hypothesized that patients with SSc would have a higher incidence of SIBO than patients who have similar symptoms without underlying SSc. Methods: We performed a retrospective review of patients with and without SSc who underwent testing for SIBO between 2007-2017 (n = 2545). SIBO was diagnosed either via carbohydrate breath testing or small bowel aspiration during esophagogastroduodenoscopy (EGD). Breath testing was considered positive for SIBO if the concentration of exhaled hydrogen demonstrated a rise to at least 20 parts per million. Small bowel aspirates obtained during EGD were sent for quantitative cultures. A positive culture was defined as bacterial growth of >105 cfu/mL. Comparison was made between patients with SSc who tested positive for SIBO and patients without SSc who tested positive for SIBO. Other variables were also collected including demographic data, narcotic use, proton pump inhibitor use, and diagnosis of gastroparesis Results: A total of 2545 patients were reviewed (Table 1). Forty-eight of 126 patients with SSc tested positive for SIBO and 342 of 2419 patients without SSc tested positive for SIBO (38.1% vs 14.1%, P = 0.0001). Patients with SSc also had a higher incidence of gastroparesis, proton-pump inhibitor use, and abdominal surgeries compared with patients without SSc (Table 1). Conclusion: This is one of the largest studies so far investigating SIBO in patients with SSc. We found that patients with SSc had a higher incidence of SIBO compared with patients who had similar GI symptoms without underlying SSc. This is likely related to the fact that patients with SSc often have multiple risk factors for SIBO compared with their non-SSc counterparts. Because a large majority of patients with SSc also have GI symptoms, clinicians should consider the diagnosis of SIBO and initiate testing early.Table 1.: Patients with SIBO with and without systemic sclerosis

A Promising Approach: Artificial Intelligence Applied to Small Intestinal Bacterial Overgrowth (SIBO) Diagnosis Using Cluster Analysis.

Small intestinal bacterial overgrowth (SIBO) is characterized by abnormal and excessive amounts of bacteria in the small intestine. Since symptoms and lab tests are non-specific, the diagnosis of SIBO is highly dependent on breath testing. There is a lack of a universally accepted cut-off point for breath testing to diagnose SIBO, and the dilemma of defining “SIBO patients” has made it more difficult to explore the gold standard for SIBO diagnosis. How to validate the gold standard for breath testing without defining “SIBO patients” has become an imperious demand in clinic. Breath-testing datasets from 1071 patients were collected from Xiangya Hospital in the past 3 years and analyzed with an artificial intelligence method using cluster analysis. K-means and DBSCAN algorithms were applied to the dataset after the clustering tendency was confirmed with Hopkins Statistic. Satisfying the clustering effect was evaluated with a Silhouette score, and patterns of each group were described. Advantages of artificial intelligence application in adaptive breath-testing diagnosis criteria with SIBO were discussed from the aspects of high dimensional analysis, and data-driven and regional specific dietary influence. This research work implied a promising application of artificial intelligence for SIBO diagnosis, which would benefit clinical practice and scientific research.

The diagnostic value of hydrogen sulfide breath test for small intestinal bacterial overgrowth

Objective: To evaluate the diagnostic value of hydrogen sulfide breath test(SBT) for small intestinal bacterial overgrowth (SIBO). Methods: College students were enrolled to complete gastrointestinal symptom scale, food frequency questionnaire, lactulose hydrogen- methane breath test (LHMBT) and SBT. Based on the correlation between hydrogen sulfide(H2S) and hydrogen or methane gas,the receiver operating characteristic (ROC) curve of H2S was drawn and diagnostic criteria of SBT was defined. Results: A total of 300 subjects including 84 males and 216 females with age 17-32 (21.6±2.4) years were enrolled from April 2019 to December 2019 and divided into two groups.Two hundred and three patients reported SIBO discomforts with 99 (48.8%) LHMBT positive, while 38 (39.2%) were LHMBT positive in 97 health controls. Rise of H2S at 90 min was positively related with that of hydrogen (r=0.516, P<0.01), and H2S levels at 90 min were positively correlated with methane (r=0.632, P<0.01). A rise in H2S of ≥25.0 ppb or H2S levels ≥62.5 ppb at 90 min during lactulose breath test was considered positive for SIBO, that sensitivity, specificity and accuracy were 66.4%,79.1% and 73.3% respectively. H2S levels were significantly related to the amount of Vitamin B12 intake (P=0.011). H2S-positive subjects exhibited a constipation-predominant pattern. Conclusion: SBT is consistent with LHMBT, especially in constipation-predominant patients, which may provide a reference to the diagnosis of SIBO.

Assessment of small intestinal bacterial overgrowth in chronic pancreatitis patients using jejunal aspirate culture and glucose hydrogen breath test

Background A subset of chronic pancreatitis patients respond poorly to pancreatic enzyme replacement therapy. Small intestinal bacterial overgrowth (SIBO) is considered to be one of the major reasons for this poor response. Previous studies have reported a wide range of prevalence of SIBO in patients with chronic pancreatitis. We aimed to assess the prevalence of SIBO in chronic pancreatitis using quantitative jejunal aspirate culture and glucose hydrogen breath test (GHBT). The sensitivity and specificity of GHBT for the diagnosis of SIBO in chronic pancreatitis were also estimated. Methods Newly diagnosed chronic pancreatitis patients were recruited into the study. A detailed history and relevant laboratory tests were done. All patients underwent an endoscopy and jejunal fluid aspiration for bacterial cultures and GHBT to detect SIBO. The results of GHBT were compared with jejunal fluid aspirate culture. Results The jejunal aspirate culture was positive in 18/48 (37.5%) patients while the GHBT showed that 14/48 (29%) patients had SIBO. The sensitivity, specificity, positive and negative predictive value of GHBT in our study was 44.4, 80, 57.14 and 70.59%, respectively. Conclusions SIBO is not uncommon in chronic pancreatitis patients. One-third of our study population had SIBO. GHBT has low sensitivity but had high specificity in the diagnosis of SIBO in chronic pancreatitis.

Small Intestinal Bacterial Overgrowth in Functional Dyspepsia: A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to determine the role of small intestinal bacterial overgrowth (SIBO) in patients with functional dyspepsia (FD). Electronic databases were searched until July 2020 for studies reporting prevalence of SIBO in FD. The prevalence rates, odds ratio, and 95% confidence intervals (CIs) of SIBO in FD and controls were calculated. Seven studies with 263 patients with FD and 84 controls were identified. The odds for SIBO in patients with FD were significantly higher as compared to that in controls (odds ratio = 4.3, 95% CI, 1.1-17.5, 4 studies, 234 participants); however, there was moderate heterogeneity in this analysis. Including high-quality, case-control studies (all using glucose breath tests [GBTs]), the risk of SIBO in patients with FD as compared to controls was 2.8 higher (95% CI 0.8-10.0, 3 studies, 200 participants) with minimal heterogeneity in this analysis. Using the lactulose breath test, SIBO prevalence in FD was significantly higher (53.4%, 95% CI 33.9-71.9, 3 studies, 110 participants) as compared to that with GBT (17.2%, 95% CI 8.6-31.6, 4 studies, 153 participants). Substantial heterogeneity was found in studies using the lactulose breath test but not in studies using GBT. There was no significant difference in SIBO prevalence in patients with FD according to FD subtype. This meta-analysis suggests a link between FD and SIBO. The quality of evidence is low and can be largely attributed to the type of breath test for SIBO diagnosis and clinical heterogeneity. More appropriately designed studies are required to confirm the link between SIBO and FD.

Can concurrent lower gastrointestinal manifestations help the timely diagnosis of small intestinal bacterial overgrowth in CVID patients?.

Introduction and objective. Gastrointestinal complications are considered as one of the most common manifestations in patients with Common Variable Immunodeficiency (CVID). These complications can result from Small Intestinal Bacterial Overgrowth (SIBO). Hydrogen breath test is extensively used to diagnose SIBO. The objective of this study was to evaluate the prevalence of SIBO using the Hydrogen Breath Test (HBT) in patients with CVID. Materials and methods. Twenty-seven patients with CVID entered this cross-sectional study. Demographic and lower gastrointestinal symptoms were recorded in a check list. Hemoglobin level was measured in all patients. The concentration of IgA and IgG was assessed using nephelometry. Moreover, SIBO was detected by means of Glucose hydrogen breath test. Results. The mean (plus-minus SD) age of the patients was 35.25 (plus-minus 11.69) years. Twenty patients (74.1%) manifested at least one lower gastrointestinal symptom. The most frequent lower gastrointestinal manifestations were bloating (66.7%) and chronic diarrhea (40.7%), respectively. IgA level less than 10 mg/dl and IgG level less than 600 mg/dl were determined in 77.8% and 25.9% of patients, respectively. Positive HBT was detected in 40.7% (n = 11) of the patients. In the positive HBT group, bloating, chronic diarrhea and abdominal pain were the most common lower GI manifestations. There was no significant difference in terms of age, BMI, IgA level, and duration of CVID between the positive and negative HBT groups. The significant association of co-occurrence of anemia and abdominal pain with positive HBT (positive predictive value: 100%) might be considered as a clue to SIBO diagnosis. Conclusions. Regarding the high prevalence and non-specific manifestation of SIBO, it is suggested to consider concurrent symptoms in patients with CVID to manage the timely and precise diagnosis of SIBO.

Small-bowel aspiration during upper esophagogastroduodenoscopy: Rao technique.

Small-bowel aspiration during upper esophagogastroduodenoscopy: Rao technique.

PERIPHERAL BLOOD ENDOTOXIN LEVELS ARE NOT ASSOCIATED WITH SMALL INTESTINAL BACTERIAL OVERGROWTH IN NONALCOHOLIC FATTY LIVER DISEASE WITHOUT CIRRHOSIS.

Nonalcoholic fatty liver disease (NAFLD) is one of the most common forms of chronic liver disease worldwide. Approximately 20% of individuals with NAFLD develop nonalcoholic steatohepatitis (NASH), which is associated with increased risk of cirrhosis, portal hypertension, and hepatocellular carcinoma. Intestinal microflora, including small intestinal bacterial overgrowth (SIBO), appear to play an important role in the pathogenesis of the disease, as demonstrated in several clinical and experimental studies, by altering intestinal permeability and allowing bacterial endotoxins to enter the circulation. To determine the relationship between SIBO and endotoxin serum levels with clinical, laboratory, and histopathological aspects of NAFLD and the relationship between SIBO and endotoxin serum levels before and after antibiotic therapy. Adult patients with a histological diagnosis of NAFLD, without cirrhosis were included. A comprehensive biochemistry panel, lactulose breath test (for diagnosis of SIBO), and serum endotoxin measurement (chromogenic LAL assay) were performed. SIBO was treated with metronidazole 250 mg q8h for 10 days and refractory cases were given ciprofloxacin 500 mg q12h for 10 days. Overall, 42 patients with a histopathological diagnosis of NAFLD were examined. The prevalence of SIBO was 26.2%. Comparison of demographic and biochemical parameters between patients with SIBO and those without SIBO revealed no statistically significant differences, except for use of proton pump inhibitors, which was significantly more frequent in patients with positive breath testing. The presence of SIBO was also associated with greater severity of hepatocellular ballooning on liver biopsy. Although the sample, as a whole, have elevated circulating endotoxin levels, we found no significant differences in this parameter between the groups with and without SIBO. Endotoxin values before and after antibiotic treatment did not differ, even on paired analysis, suggesting absence of any relationship between these factors. Serum endotoxin levels were inversely correlated with HDL levels, and directly correlated with triglyceride levels. Serum endotoxin levels did not differ between patients with and without SIBO, nor did these levels change after antibacterial therapy, virtually ruling out the possibility that elevated endotoxinemia in non-cirrhotic patients with NAFLD is associated with SIBO. Presence of SIBO was associated with greater severity of ballooning degeneration on liver biopsy, but not with a significantly higher prevalence of NASH. Additional studies are needed to evaluate the reproducibility and importance of this finding in patients with NAFLD and SIBO.

S0507 SIBO Diagnosis: Clinical Survey of Practice Patterns, Unmet Needs, and Perception of a Novel Ingestible Diagnostic Capsule

INTRODUCTION: Small intestinal bacterial overgrowth (SIBO) has clinical overlap with irritable bowel syndrome (IBS) and is diagnosed either by endoscopic small bowel aspiration (SBA) with quantitative bacterial culture or hydrogen breath testing (BT). SBA is invasive and lacks standardization and BT has questionable accuracy and unreliable performance. METHODS: Qualitative phone interviews with 7 GIs/3 IBS experts explored unmet needs in SIBO diagnosis and gathered feedback on a novel smart capsule bacterial detection system (SCBDS)—an ingestible capsule with an integrated assay for wirelessly determining small intestinal total bacterial count based on an FDA-approved threshold of ≥105 CFU/ml. A quantitative online survey of 28 academic and 62 community GIs assessed practice patterns and preferred clinical characteristics of SCBDS. RESULTS: GIs saw 77 IBS and 22 SIBO patients on average per month. Suspected SIBO patients (36%) were formally diagnosed by BT with academic GIs placing a greater importance on a formal diagnosis rather than empiric antibiotic therapy. 10% of practices performed SBA for SIBO diagnosis (Figure 1). SIBO diagnosis was evaluated by BT in 47% of patients with only a fraction of GIs giving high ratings for BT accuracy. Empiric antibiotic therapy was performed in ∼50% of suspected SIBO patients across both settings, but 91% were at least somewhat concerned with this practice and 60% were unsatisfied with all current diagnostic options (Figure 2). Insufficient accuracy was the most frequently selected diagnostic unmet need, with 58% of GIs selecting it as one of the greatest unmet needs, followed by difficulty in interpreting results (48%) (Figure 3). Over 70% of GIs indicated that SCBDS would be more accurate than BT and would recommend it to almost two-thirds of patients evaluated for SIBO and to one-third for IBS. Two-thirds of GIs also anticipated using SCBDS first over empiric antibiotic therapy alone. In addition, 59% of BT users and 66% performing SBA would replace these methods with SCBDS. CONCLUSION: GIs in both community and academic settings expressed a significant unmet need in SIBO diagnosis driven by BT performance limitations, and only a small minority of GIs were performing SBA to diagnose SIBO. A perceived strength of an FDA-approved SCBDS would be improved accuracy, interpretation and precision as compared to BT, with the majority of GIs suggesting they would replace conventional SIBO diagnostics with such a technology.Figure 1.: Patient workup for suspected of SIBO vs IBS.Figure 2.: Gastroenterologists satisfaction with currently available options to diagnose SIBO.Figure 3.: Gastroenterologists current perception of unmet medical need for diagnosing SIBO.

Small Intestinal Bacterial Overgrowth (SIBO): Result of Altered Defensive Mechanism in Gastrointestinal – A Review

Small intestinal bacterial overgrowth (SIBO) is a condition that is characterized by an increased number of bacteria in the small intestine or an existence of bacteria type that generally should not be in the small intestine. In SIBO, the number of bacteria found in culture was more than 105 CFU (Colony-Forming unit) per ml. The fundamental problem in which SIBO occurred was the disruption in defensive mechanisms to prevent bacteria from overgrowing, including gastric acid juice, intestine motility, competent immune function, and intact anatomy. Disruption of this defensive mechanism will lead to SIBO, which furthermore will result in not only mild complications, such as abdominal complaints, but also severe complications, such as maldigestion/malabsorption, nutrient deficiency, or even systemic infection and acidosis. The manifestations of SIBO were often unclear so that it is hard to distinguish with other diseases, which much lead to misdiagnosis or underdiagnosis. Diagnosis of SIBO should be conducted very meticulously regarding underlying diseases that resulted in gastrointestinal defensive mechanism disturbance and malassimilation syndrome. Additional examinations for SIBO currently were jejunal aspiration and breath test, but both of them had their limitations in sensitivity and specificity. Therapeutical management consisted of treating the underlying diseases, eradicating bacteria with the antibiotic, particularly rifaximin, and improving nutritional deficiency.

Surgical Management of Small Intestinal Bacterial Overgrowth After Roux-en-Y Gastric Bypass.

Small intestinal bacterial overgrowth (SIBO) is a common adverse effect after laparoscopic Roux-en-Y gastric bypass (LRYGB) and may be responsible for chronic diarrhea, abdominal pain, and discomfort. Although its pathophysiology is still unclear, surgical management may be appropriate in selected cases. In this video, we present a surgical revision of LRYGB, 12years after the initial surgery, for late postoperative chronic diarrhea. The diagnosis of SIBO was finally established and associated with a dilated jejuno-jejunostomy diagnosed through a small bowel follow-through. Revision of the RYGB was performed by resecting the dilated jejunostomy and fashioning a new one with a shorter Roux-en-Y limb. During follow-up, the patient showed fast improvement and complete resolution of symptoms was obtained at 12months. SIBO may be responsible for postoperative chronic diarrhea in RYGB patients, possibly in the long term, and it is often misdiagnosed. Primary treatment is conservative with appropriate dietary measures, antibiotics, and probiotics but surgical management can be very effective in selected patients presenting with failure of prolonged medical treatment and an anatomic abnormality.

Delayed Gastric Emptying Is Not Associated with a Microbiological Diagnosis of Small Intestinal Bacterial Overgrowth.

Clinical symptoms of patients with small intestinal bacterial overgrowth (SIBO) may overlap with symptoms of gastroparesis. Prior studies suggest delayed small intestinal transit is associated with SIBO, but have not shown an association between delayed gastric emptying and SIBO. However, these studies have generally relied on the indirect method of breath testing to diagnose SIBO. The aim of this study was to examine the association between amicrobiological diagnosis of SIBO and delayed gastric emptying by scintigraphy. In a single-center retrospective study of previous research participants who presented for small bowel enteroscopy for diagnostic evaluation of SIBO, we identified 73 participants who underwent gastric emptying study by scintigraphy. A microbiological diagnosis of SIBO was made in patients based on culture results of jejunal aspirates. Clinical symptoms were assessed using the total gastroparesis cardinal symptom index (GCSI) score. We compared delayed gastric emptying, 2- and 4-h gastric retention, and gastroparesis symptoms between patients with and without a microbiological diagnosis of SIBO. Among 29 participants with SIBO and 44 without SIBO, 33 (45%) had evidence of delayed gastric emptying. There was no significant association between a microbiological diagnosis of SIBO and delayed gastric emptying by scintigraphy. Percent retained at 2 and 4h, and total GCSI scores did not differ significantly between those with and without SIBO. Although delayed gastric emptying is common in patients with suspected SIBO, gastric emptying is not associated with a microbiological diagnosis of SIBO.