Eradication Of Small Intestinal Bacterial Overgrowth Research Articles

Effect of Trimebutine and Rifaximin on Breath Hydrogen and Methane by Glucose Breath Test in Patients With Functional Bloating: A Randomized Double-blind Clinical Trial.

Drugs that stabilize intestinal motility may improve the efficacy of nonabsorbable antibiotics, such as rifaximin, against small intestinal bacterial overgrowth (SIBO). We compared the efficacy of rifaximin alone with that of its combination with trimebutine maleate against SIBO. We performed a randomized double-blind placebo-controlled trial (https://cris.nih.go.kr, no. KCT0004836) that included patients with functional bloating, no constipation, and SIBO using the hydrogen (H2)-methane (CH4) glucose breath test (GBT). Patients were randomized into 2 groups in a 1:1 ratio, namely rifaximin (1200 mg/day) + trimebutine maleate (600 mg/day) group and rifaximin + placebo group, for 2 weeks. Patients completed a symptom questionnaire and underwent a GBT at baseline and at 1 month after treatment withdrawal. The primary outcome was SIBO eradication. The secondary outcomes included changes in the concentrations of exhaled gases, symptoms, and presence of adverse events. The complete eradication rate of SIBO was 35.9% (14/39) in the rifaximin group, and 34.1% (14/41) in the combined group with no significant differences. In both groups, no significant differences were observed in GBT profiles before and after the treatment, respectively. However total breath H2 and CH4 concentration were conspicuously decreased in the combined group after treatment. The combined group exhibited substantial relief of bloating. The adverse events were similar in the 2 groups. While the combination therapy was not superior over rifaximin alone for SIBO eradication, it improves the symptom of bloating with numerically reducing the concentration of breath H2/CH4.

Efficacy and Safety of a Probiotic Containing Saccharomyces boulardii CNCM I-745 in the Treatment of Small Intestinal Bacterial Overgrowth in Decompensated Cirrhosis: Randomized, Placebo-Controlled Study

(1) Background: The aim was to evaluate the effectiveness of the probiotic containing Saccharomyces boulardii in the treatment of small intestinal bacterial overgrowth (SIBO) in patients with decompensated cirrhosis. (2) Methods: This was a blinded, randomized, placebo-controlled study. (3) Results: After 3 months of treatment, SIBO was absent in 80.0% of patients in the probiotic group and in 23.1% of patients in the placebo group (p = 0.002). The patients with eliminated SIBO had decreased frequency of ascites and hepatic encephalopathy, the increased platelets and albumin levels, the decreased blood levels of total bilirubin, biomarkers of bacterial translocation (lipopolysaccharide [LPS]) and systemic inflammation (C-reactive protein), and positive changes in markers of hyperdynamic circulation compared with the state at inclusion. There were no significant changes in the claudin 3 level (the intestinal barrier biomarker) in these patients. No significant changes were observed in the group of patients with persistent SIBO. The serum level of nitrate (endothelial dysfunction biomarker) was lower in patients with eradicated SIBO than in patients with persistent SIBO. One (5.3%) patient with eradicated SIBO and six (42.9%) patients with persistent SIBO died within the first year of follow-up (p = 0.007). (4) Conclusions: SIBO eradication was an independent predictor of a favorable prognosis during the first year of follow-up.

Efficacy and safety of rifaximin in patients with chronic intestinal pseudo-obstruction: a randomized, double-blind, placebo-controlled, phase II-a exploratory trial.

Chronic intestinal pseudo-obstruction (CIPO) is a rare intractable disease with limited treatment options. Small intestinal bacterial overgrowth (SIBO) often co-occurs with several diseases, including CIPO. While rifaximin (RFX) is effective in treating SIBO, its efficacy for CIPO remains unclear. Here, we aimed to investigate the efficacy and safety of RFX in adult patients with CIPO. Twelve patients were randomly assigned to receive RFX (400 mg three times daily, n=8) or a placebo (PBO, n=4) for 4 weeks. The global symptom score for abdominal bloating (GSS-bloating) and an original whole gastrointestinal symptoms score (O-WGSS) were collected, and a glucose hydrogen breath test (GHBT) and abdominal computed tomography (CT) were performed. No significant differences were observed in the primary endpoint. GSS-bloating improved by 75% and 25% in the PBO and RFX groups, respectively, and O-WGSS improved by 25% in both groups. No significant differences were observed in secondary and other endpoints, including the SIBO eradication rate in the GHBT and small intestinal volume on CT. In a post hoc analysis of SIBO-positive patients with CIPO (4/4 and 4/8 in the PBO and RFX groups), SIBO was eradicated in 25% and 75% of the patients (PBO and RFX groups, respectively) at the end of treatment, indicating a high eradication rate in the RFX group. Furthermore, the small intestinal gas volume decreased in the RFX group, and no severe adverse events occurred. Although no significant improvements were observed in subjective indicators, RFX may be beneficial in alleviating SIBO and reducing the small intestinal gas volume in SIBO-positive patients with CIPO.

Prevalence and predictors of small intestinal bacterial overgrowth in systemic sclerosis: a systematic review and meta-analysis.

The reported prevalence of small intestinal bacterial overgrowth (SIBO) among patients with systemic sclerosis (SSc) is highly variable. We conducted this systematic review and meta-analysis to estimate the prevalence and identify predictors of SIBO in SSc by summarizing all of the available data. A comprehensive literature search of the PubMed, Cochrane Library, and EMBASE databases from inception to July 2020 was conducted for studies correlating SIBO with SSc. Studies were screened, and relevant data were extracted and analyzed. The pooled prevalence of SIBO among SSc patients and the odds ratio (OR) of SIBO among SSc patients compared with healthy controls were calculated. Furthermore, predictors of SIBO in SSc were evaluated. Fourteen studies containing 700 SSc patients and 217 healthy controls met the inclusion criteria. The pooled prevalence of SIBO in SSc was 34% (95% CI 27-42%). The OR of SIBO in SSc patients was 12.51 (95% CI 6.51-24.03) compared with the healthy controls. Subgroup analyses showed that the prevalence of SIBO in SSc was higher in studies using the lactulose hydrogen breath test (LHBT) for diagnosis (56%, 95% CI 46-67%) compared with those that used the glucose hydrogen breath test (GHBT) (27%, 95%CI 20-35%) and a jejunal aspirated culture (JAC) (35%, 95%CI 25-51%). The prevalence of SIBO in SSc was higher in studies conducted in Western countries (38%, 95% CI 31-47%) than those conducted in Asian countries (15%, 95%CI 10-23%), and the prevalence of SIBO in the SSc population defined by ACR-EULAR 2013 (50%, 95% CI 0.21-0.79) was higher than the prevalence defined by ACR 1980 (30%, 95% CI 0.17-0.42) or other criteria (32%, 95% CI 0.16-0.48) Moreover, the risk of diarrhea was higher in SSc patients with SIBO than those without SIBO (OR 8.82, 95% CI 4.09-19, P < 0.00001); gender, SSc subset, digital ulcer, and pulmonary fibrosis do not seem to be associated with SIBO in SSc. Antibiotic therapy seems to be effective with SIBO in SSc patients. Approximately one-third of SSc patients tested positive for SIBO with a significantly increased risk over the controls. The prevalence of SIBO in SSc varied according to the SIBO diagnostic test performed, geographic area, and SSc diagnostic criteria. The presence of diarrhea may be a predictor of SIBO in SSc. Antibiotic treatment can lead to eradication of SIBO and gastrointestinal symptomatic improvement in SSc patients. Key Points • The pooled prevalence of SIBO in SSc patients was 34%, which varied according to the SIBO diagnostic test performed, geographic area and SSc diagnostic criteria. • The risk of SIBO in SSc was increased by nearly thirteenfold compared to the healthy controls. • Diarrhoea, but not gender, SSc subset, digital ulcer and pulmonary fibrosis, was associated with SIBO in SSc patients. • For SSc patients with SIBO, antibiotic treatment can lead to eradication of SIBO and gastrointestinal symptomatic improvement.

Short-course Rifaximin therapy efficacy and lactulose hydrogen breath test in Chinese patients with diarrhea-predominant irritable bowel syndrome

BackgroundGut microbiota alterations including small intestinal bacterial overgrowth (SIBO) might play a role in pathogenesis of irritable bowel syndrome (IBS). Rifaximin could effectively and safely improve IBS symptoms. The aim of this study was to investigate the effect of rifaximin on Gastrointestinal (GI) symptoms, quality of life (QOL) and SIBO eradication in Chinese IBS-D patients.MethodsThis study included 78 IBS-D patients defined by the Rome IV criteria. Patients received 400 mg rifaximin twice daily for 2 weeks and 10-week follow-up. GI symptoms were assessed at week 0, 2, 4, 8 and 12. QOL and lactulose hydrogen breath test (LHBT) results were estimated at week 0 and 4.ResultsAll participants showed significant improvements in GI symptom subdomains after rifaximin treatment (all P < 0.05), which could maintain at least 10 weeks of follow-up. Additionally, QOL scores were increased with concomitant improvement of clinical symptoms (all P < 0.05). The 45 rifaximin-responsive patients (57.7%) achieved significantly greater GI-symptom improvement than non-responders (all P < 0.05). No GI symptoms were associated with SIBO (all P > 0.05). SIBO normalization after rifaximin treatment measured by LHBT was found in 44.4% (20/45) of patients with SIBO before treatment.ConclusionA short course (2 weeks) of rifaximin improved GI symptoms and QOL in Chinese IBS-D patients whether they had SIBO or not. However, the efficacy of rifaximin could not be explained by the successful eradication of SIBO. Further studies on the therapeutic mechanisms of rifaximin in IBS are urgently needed.

Gut microbiome in systemic sclerosis: a potential therapeutic target.

IntroductionSystemic sclerosis (SSc) is a chronic, connective tissue disease characterized by inflammation, fibrosis and microcirculation disturbances. Gastrointestinal involvement and impaired gut motility observed in SSc promotes the small intestinal bacterial overgrowth (SIBO) defined as the increase in the number of bacteria to over 105 CFU/ml or as the presence of atypical flora.AimTo investigate the prevalence and characteristics of SIBO and to assess the efficacy of rifaximin in SIBO treatment in SSc patients.Material and methods40 SSc patients and 39 healthy individuals were enrolled in the study. All subjects completed UCLA SCTC GIT 2.0 questionnaire and query for gastrointestinal symptoms. The presence of SIBO was assessed by the lactulose hydrogen breath test (LHBT). Patients with SIBO received 1200 mg rifaximin daily for 10 days. The same diagnostic procedure was performed after completed treatment in order to evaluate SIBO eradication.ResultsThe prevalence of SIBO was higher in SSc patients compared with the control group (47.5% vs. 12.8%; p = 0.0008). SIBO eradication after rifaximin treatment was successful in 73.3% of SSc patients.ConclusionsThese data suggest that SIBO occurs more frequently in SSc patients than in controls. Eradication therapy with rifaximin is associated with satisfactory results and a high safety profile.

Mechanism of action and therapeutic benefit of rifaximin in patients with irritable bowel syndrome: a narrative review.

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder with a multifactorial pathophysiology. The gut microbiota differs between patients with IBS and healthy individuals. After a bout of acute gastroenteritis, postinfection IBS may result in up to approximately 10% of those affected. Small intestinal bacterial overgrowth (SIBO) is more common in patients with IBS than in healthy individuals, and eradication of SIBO with systemic antibiotics has decreased symptoms of IBS in some patients with IBS and SIBO. The nonsystemic (i.e. low oral bioavailability) antibiotic rifaximin is indicated in the United States and Canada for the treatment of adults with IBS with diarrhea (IBS-D). The efficacy and safety of 2-week single and repeat courses of rifaximin have been demonstrated in randomized, placebo-controlled studies of adults with IBS. Rifaximin is widely thought to exert its beneficial clinical effects in IBS-D through manipulation of the gut microbiota. However, current studies indicate that rifaximin induces only modest effects on the gut microbiota of patients with IBS-D, suggesting that the efficacy of rifaximin may involve other mechanisms. Indeed, preclinical data reveal a potential role for rifaximin in the modulation of inflammatory cytokines and intestinal permeability, but these two findings have not yet been examined in the context of clinical studies. The mechanism of action of rifaximin in IBS is likely multifactorial, and further study is needed.

Treatment of small intestinal bacterial overgrowth in systemic sclerosis: a systematic review.

Almost all patients with SSc have gastrointestinal manifestations. Small intestinal bacterial overgrowth (SIBO) occurs in 30-60% of patients and leads to malnutrition and impaired quality of life. Recent systematic reviews have reported efficacy of treatments for SIBO, but these are not specific to patients with SSc. We conducted a systematic review of the evidence for all possible SIBO treatments in the SSc population. The following databases were searched: MEDLINE, EMBASE and the Cochrane Library, from database inception to 1 January 2017. All evidence for all possible SIBO treatments including antibiotics, prokinetics, probiotics and alternative treatments was included. Treatment outcomes included symptomatic relief or demonstrated SIBO eradication. Of 5295 articles, five non-randomized studies were reviewed with a total of 78 SSc patients with SIBO. One trial assessed octreotide while the remaining four trials investigated the effectiveness of ciprofloxacin, rifaximin, norfloxacin and metronidazole, and the combination of amoxicillin, ciprofloxacin and metronidazole. Studies were generally of low quality and most were un-controlled. Data indicate that, for some SSc patients, antibiotics can eradicate SIBO. There is a paucity of data reporting the effectiveness of either prokinetics or probiotics in SSc.

THE EFFICACY OF ERADICATION OF SMALL INTESTINAL BACTERIAL OVERGROWTH IN PATIENTS WITH NON-ALCOHOLIC FATTY LIVER DISEASE

Background. Emerging evidence suggests a strong interaction between the gut, gut microbiota and liver. Derangement of gut flora, particularly small intestinal bacterial overgrowth (SIBO), occurs in a large percentage of patients with non-alcoholic fatty liver disease (NAFLD) and plays an important role in its pathogenesis. Aim. Study of the frequency of SIBO in various forms of non-alcoholic fatty liver disease, as well as the possibilities of its pathomorphosis as a result of eradication of SIBO as a result of the use of rifaximin or multicomponent probiotic. Material and methods. There were investigated 125 patients with non-alcoholic fatty liver disease (70 men, 55 women aged 18 to 65 years, mean age 37±6.7 years) developed at obesity or type 2 diabetes mellitus, including 85 patients with liver steatosis (group1) and 40 patients with non-alcoholic steatohepatitis (group 2). Patients with concomitant SIBO (70 patients) was treated with rifaximin or multicomponent probiotic. As the main endpoints of the study, the frequency of achieving eradication of SIBO was evaluated (estimated from the results of a repeated H2-lactulose hydrogen test after treatment), as well as a decrease in the severity of liver steatosis by steatometry and a decrease / normalization of transaminase levels 3 months after the start of the treatment. Secondary endpoints included the change in BMI and the HOMA-IR index 3 months after the start of the treatment. Results. SIBO in patients with non-alcoholic fatty liver disease was significantly more frequent than in control (p &lt;0.005), and in patients with non-alcoholic steatohepatitis – significantly more often than in patients with liver steatosis (80 % vs 47.1 %, P &lt;0.01). Eradication of SIBO after use of rifaximin was recorded in 30 of 36 patients with non-alcoholic fatty liver disease (83.3 %), including 16 of 20 patients with steatosis (80 %) and 14 of 16 (87.5 %) patients with non-alcoholic steatohepatitis. In the group of patients taking multicomponent probiotics after treatment, eradication of SIBO was noted in 12 of 36 patients (33.3 %), including 7 patients with steatosis (35 %) and 5 patients (31.3 %) with non-alcoholic steatohepatitis Conclusion. The investigation shows that the eradication of small intestinal bacterial overgrowth has the positive influence on the natural course of NAFLD and use of rifaximine should be discussed as a perspective therapeutic strategy at this pathology

Rifaximin: The Revolutionary Antibiotic Approach for Irritable Bowel Syndrome.

A large number of clinical studies using breath testing and a smaller number of studies using quantitative cultures of the upper small intestine established a link between irritable bowel syndrome (IBS) and small intestinal bacterial overgrowth (SIBO). A series of 12 studies both prospective and retrospective in design in a population of patients with SIBO without IBS showed that the non-absorbable antibiotic rifaximin can eradicate SIBO as proved through decrease of the exhaled hydrogen and methane in breath tests. The efficacy of rifaximin was superior over the comparator treatment in most of these studies. Based on these findings, short course rifaximin was tested in various concentrations in eight open-label trials in patients with IBS and proven SIBO by breath test. Similar efficacy of rifaximin was shown in SIBO eradication; this was accompanied by improvement of the global score for IBS symptoms. Finally, five double-blind randomized clinical trials were conducted in patients with IBS; four were placebo-controlled. The larger trials were TARGET 1 and TARGET 2 studies testing rifaximin at a regimen of 550 mg tid for 14 days. All trials showed a significant superiority of rifaximin over comparator for the improvement of global symptoms of IBS and bloating. Although the aforementioned results render rifaximin a revolutionary therapeutic approach for IBS, several concerns on induction of antimicrobial resistant flora remain.

Helicobacter pylori infection but not small intestinal bacterial overgrowth may play a pathogenic role in rosacea.

Recent studies suggest a potential relationship between rosacea and Helicobacter pylori (H. pylori) infection or small intestinal bacterial overgrowth (SIBO), but there is no firm evidence of an association between rosacea and H. pylori infection or SIBO. We performed a prospective study to assess the prevalence of H. pylori infection and/or SIBO in patients with rosacea and evaluated the effect of H. pylori or SIBO eradication on rosacea. We enrolled 90 patients with rosacea from January 2012 to January 2013 and a control group consisting of 90 patients referred to us because of mapping of nevi during the same period. We used the (13)C Urea Breath Test and H. pylori stool antigen (HpSA) test to assess H. pylori infection and the glucose breath test to assess SIBO. Patients infected by H. pylori were treated with clarithromycin-containing sequential therapy. Patients positive for SIBO were treated with rifaximin. We found that 44/90 (48.9%) patients with rosacea and 24/90 (26.7%) control subjects were infected with H. pylori (p = 0.003). Moreover, 9/90 (10%) patients with rosacea and 7/90 (7.8%) subjects in the control group had SIBO (p = 0.6). Within 10 weeks from the end of antibiotic therapy, the skin lesions of rosacea disappeared or decreased markedly in 35/36 (97.2%) patients after eradication of H. pylori and in 3/8 (37.5%) patients who did not eradicate the infection (p < 0.0001). Rosacea skin lesions decreased markedly in 6/7 (85.7%) after eradication of SIBO whereas of the two patients who did not eradicate SIBO, one (50%) showed an improvement in rosacea (p = 0.284). Prevalence of H. pylori infection was significantly higher in patients with rosacea than control group, whereas SIBO prevalence was comparable between the two groups. Eradication of H. pylori infection led to a significant improvement of skin symptoms in rosacea patients.

Liquid melevodopa versus standard levodopa in patients with Parkinson disease and small intestinal bacterial overgrowth.

Patients with Parkinson disease exhibit a highly increased prevalence of small intestinal bacterial overgrowth (SIBO), which has been also associated with the severity of motor fluctuations. Aim of this study was to test the efficacy of liquid levodopa with higher bioavailability in patients with SIBO. Thirty-three patients with Parkinson disease underwent both lactulose and glucose breath tests to assess the presence of SIBO. A urea breath test was performed to assess the presence of a concomitant Helicobacter pylori infection. Patients were challenged with 250 mg of levodopa and 314 mg of levodopa methylester. Drug challenges were performed on different days and at baseline and 1 month after SIBO eradication. During the tests, the motor condition and the plasma levodopa concentrations were evaluated. At baseline, the onset of motor benefit was significantly shorter after melevodopa than after standard levodopa, as confirmed by the latency to motor on condition and t max (time to the on condition, 28.8±11.5 vs 55.5±40.2 minutes; P=0.0004; and t max, 28.2±9.7 vs 50.0±11.0 minutes; P=0.002). The duration of the on time or area under the curve was not significantly different. The underlying gastrointestinal condition did not influence these results. The reduction of the latency to the on condition in the absence of a reduction of the on duration is a promising feature of melevodopa because this effect would increase the total daily on duration. Future studies that evaluate the usefulness of melevodopa beyond the acute challenge (eg, using motor diaries) in patients with gastrointestinal infections are warranted.

Why Should Gastroenterologists Know About Fibromyalgia? Common Pathogenesis and Clinical Implications

Patients with irritable bowel syndrome (IBS) frequently present non-gastrointestinal (GI) somatic disorders about twice as much as a control population.1 Fibromyalgia (FM), chronic fatigue syndrome, temporomandibular joint disorder and chronic pelvic pain are the best documented non-GI somatic comorbidities.1 The presence of comorbidities in patients with IBS can lead to decrease quality of life, increase health care seeking and increase medical cost.2 FM, the most frequently investigated comorbidity of IBS, is a soft tissue disorder characterized by diffuse musculoskeletal pain and specific tender points on examination.3 Its prevalence is estimated around 2% in the general population and up to 20% among rheumatology outpatients.1,4 However, the prevalence of FM in patients with IBS is approximately 32.5% (26%-65%) and the prevalence of IBS in patients with FM is approximately 48% (32%-77%).1-3 The high prevalence of non-GI comobidites in IBS suggests that there might be common pathophysiologic mechanisms in IBS and comorbidities such as abnormal pain sensitivity and descending pain inhibition, autonomic nervous system dysregulation, brain-gut axis dysfunction, immune dysfunction and abnormalities in the levels of serotonin or its receptor.1,2,5 In addition, psychosocial factors including psychological stress, emotional stress and emotional, physical or sexual abuse are trigger factors in both IBS and FM.5 However, these possible common underlying pathophysiologic mechanisms have not been proven yet.2 Although IBS and FM are widely overlapped, gastroenterologists usually do not pay attention to FM or other non-GI co-morbidities when they diagnose or manage patients with IBS. And the researchers of IBS clinical trials also have not considered this problem when they set the study population or analyze the therapeutic effects of certain drugs. In contrast, physicians who deal with FM (eg, neurologist, primary care physician, pain specialist and rheumatologist etc) considered IBS and pain/cramp in abdomen as one of 10 most relevant to a diagnosis of FM.6 Especially, it is difficult to diagnose or assess FM in the GI clinic because it requires a trained rheumatologist to perform physical examination according to American College of Rheumatology criteria. In this issue of the Journal, Sperber et al demonstrated new symptom-based FM criteria that can be used in IBS patients without physical examination. This study should be welcomed because there are several points that gastroenterologists should consider about FM in diagnosis and management of IBS. First, IBS patients with co-morbid FM might be a new separate IBS subgroup. Riedl et al2 suggest that patients with IBS could be categorized according to existence of co-morbidity and hypothesized that psychological factors play a common etiological role in IBS and co-morbidities. Patients with a high degree of somatic co-morbidity also present higher levels of anxiety and depression, as well as a more pronounced decrease in quality of life and higher intensity of abdominal pain/discomfort.7 Because usual conventional management for IBS symptoms could not improve global symptoms in this patients group, it is necessary to identify the IBS patient with co-morbid FM and to establish a new treatment strategy with optimal consultation. Second, FM may contribute the female predominance of IBS. Sperber et al recruited only female patients in this study and it was based on the fact that the IBS or FM is a predominantly female disorder. It was one of the major limitations of this study. Then, what about the sex difference according to co-morbid FM in patients with IBS? Akkus et al8 performed a comparative study addressing the effects of female predominance of FM on the female-to-male ratios of IBS. There was a significant female predominance in patients with IBS + FM (F:M = 5:1), but the proportion of male is higher than that of female in patients with IBS only (F:M= 2:3). They postulated that coexisting FM increases the female proportion of IBS patients. Although it needs to be confirmed in a large study, we should keep FM in mind when we see female patients with IBS. Third, co-morbid FM could be a confounding factor in clinical trials of therapeutic drug for IBS. Because common pathogenesis is present in IBS and FM, treatment for IBS could affect not only abdominal pain/discomfort but also symptoms of FM in IBS patient with co-morbid FM. Low serum level of serotonin and tryptophan, low cerebrospinal fluid level of serotonin metabolite and increased density of serotonin receptors on circulating platelets have been found in patients with FM.5,9 Therefore we can postulate that serotonergic drug used in treatment of IBS could have an effect on symptoms of FM, however many clinical trials of serotonergic drugs usually ignored this possibility. Although studied with a small number, 5-HT4 agonist, tegaserod, improved not only constipation predominant IBS status but also FM impact questionnaire score.9 However, the correlation between changes in constipation predominant IBS status and FM impact questionnaire score was relatively low and insignificant. The 5-HT3 antagonist, ondansetron and tropistron, also improved pain intensity in studies with patients with FM.10,11 Another interesting finding is the presence of small intestinal bacterial overgrowth (SIBO) in patient with FM. Pimentel et al12 reported that an abnormal breath test was higher in FM (100%) than control (20%) or even IBS (84%). Furthermore, significantly greater hydrogen production was noted in FM than IBS and peak hydrogen level correlated with the degree of somatic pain. Although there have been no direct evidence that eradication of SIBO can improve symptoms of FM, in a study with IBS patients with co-morbid restless legs syndrome that frequently occurs in FM, restless legs syndrome was significantly improved after rifaximin and tegaserod therapy or rifaximin monotherapy.13 Interestingly, despite of author's worry about the propensity for reporting pain in IBS patients, IBS patients exhibited relatively low sensitivity of new symptom-based criteria. This unexpected result might be related to low number of IBS group, therefore it needs to be investigated in a large number of IBS patients. In summary, the very significant study by Sperber et al validated new symptom-based FM criteria in a population including IBS and FM patients for the first time. Although further validation studies with a large number of patients with IBS in different races and cultures are still needed, this study gave us a useful tool to approach FM more easily in the GI clinic. In the future, gastroenterologists could identify a new IBS subgroup, establish a new therapeutic strategy and modify the methodical design in clinical trials by using new symptom-based FM criteria.

280 Efficacy of Rifaximin for Sibo Treatment in Ibs Children

Background: Our previous study suggested a significant epidemiologic association between SIBO (Small Intestinal Bacterial Overgrowth) and IBS (Irritable Bowel Syndrome) in childhood. Rifaximin has already been successfully used in adults with SIBO and IBS. Aim: To assess the SIBO prevalence and symptoms improvement in IBS children after treatment with Rifaximin. Study design: 43 (mean age 9,5 ys) consecutive children affected by IBS according to Rome II criteria were enrolled. The control population (n = 28, mean age 10 ys) consisted of healthy subjects without IBS symptoms. All subjects underwent lactulose/methane breath test (LBT) to assess SIBO before and one month after the treatment with Rifaximin 600 mg daily. All IBS pts filled out a Visual Analogic Scale (VAS) score to evaluate symptoms (abdominal pain, constipation, diarrhoea, bloating, flatulence) at time zero and 1 month after the treatment. Results: The prevalence of abnormal LBT result was significantly higher in patients with IBS than controls (65%, 28/43 vs 7%, 2/28, p< 0.05). One month after the treatment 18 pts had a negative LBT while 10 stayed positive (64%, 18/28 vs 36%, 10/28, p< 0.05). In IBS pts VAS score was significantly higher in SIBO positive than SIBO negative children. One month after treatment VAS score was significantly lower in eradicated than non-eradicated pts. Conclusions: Rifaximin is safe and seems to be effective in SIBO eradication and symptoms improvement of IBS pts. Other placebo-controlled interventional studies to treat bacterial overgrowth are warranted to verify the real impact of SIBO on IBS symptoms.

Chronic Abdominal Pain in Children Is Associated with High Prevalence of Abnormal Microbial Fermentation

Chronic abdominal pain (CAP) in children, a condition that accounts for approximately 25% of pediatric gastroenterology office visits, may be a precursor to irritable bowel syndrome in adults. Recently, small intestinal bacterial overgrowth (SIBO) has been reported in 78-84% of IBS patients regardless of their abdominal symptoms, compared to 20% in healthy controls. Aims The aim of this study was, therefore, to assess the prevalence of SIBO in children with CAP. Seventy-five children aged 8-18 years diagnosed with CAP based on the Rome II criteria and 40 healthy controls were enrolled. All subjects underwent a lactulose breath hydrogen test (LBT) to assess for SIBO. Children with CAP also filled out symptom questionnaires. There was a 91% prevalence of an abnormal LBT suggestive of SIBO in the children with CAP and 35% in controls (odds ratio = 16.7, 95% confidence interval 6.0-57.5, P < 0.0001). A comparison of CAP children with a positive LBT to CAP children with a negative LBT revealed the former had significantly more "urgency to have a bowel movement" (P = 0.049) and experienced less "soiling" (P = 0.016) than those with a negative LBT. No significant differences were found between the two groups in terms of the location of their pain or any other associated symptoms. Similar to adults with IBS, there is a significantly higher prevalence of SIBO in children with CAP. Randomized controlled studies are needed to determine if eradication of SIBO will lead to symptom improvement in these patients.

Positive Glucose Breath Testing is More Prevalent in Patients With IBS-like Symptoms Compared With Controls of Similar Age and Gender Distribution

Small intestinal bacterial overgrowth (SIBO) may mimic a functional disorder such as irritable bowel syndrome (IBS) or functional bloating (FB). In this study, we aimed to assess the utility of glucose breath test (GBT) in patients with the above conditions. This study included 200 consecutive patients (130 with IBS and 70 with FB on the basis of Rome III criteria) and 70 controls with similar age and sex distribution. Patients and controls underwent 50 g GBT and a H2 peak of > or = 12 ppm was considered diagnostic of SIBO. Positive patients received rifaximin of 1200mg/day for 10 days and underwent a second GBT 1 month after the end of treatment. A symptom questionnaire was completed before and after therapy. GBT resulted to be altered in 21 out of 130 IBS patients and in 2 out of 70 FB patients with a significant difference of the former group compared with controls (3 out of 70, P=0.0137). Most IBS patients with a positive GBT complained of diarrhea. GBT showed an increased methane excretion in 26% of patients, who were equally distributed among different bowel pattern subgroups. Previous abdominal surgery was more frequently seen in GBT-positive patients (P=0.008). After antibiotic treatment, eradication of SIBO was achieved in 70% of patients, with a significant improvement of symptoms in eradicated patients compared with the not eradicated ones (P<0.001). GBT is useful to identify a subgroup of IBS-like patients, whose symptoms are owing to SIBO. Normalization of GBT after antibiotic therapy is associated with a significant improvement of symptoms. GBT does not offer any advantage in FB patients.

Small intestinal bacterial overgrowth in systemic sclerosis

The aims of this study were to: (i) determine the prevalence of small intestinal bacterial overgrowth (SIBO) in unselected patients with SSc; (ii) assess both clinical presentation and outcome of SIBO; and (iii) make predictions about which SSc patients are at risk for SIBO. Fifty-one consecutive patients with SSc underwent glucose hydrogen and methane (H(2)/CH(4)) breath test. All SSc patients also completed a questionnaire for intestinal symptoms, and a global symptomatic score (GSS) was calculated. SSc patients with SIBO were given rotating courses of antibiotics (norfloxacin/metronidazole) for 3 months; glucose H(2)/CH(4) breath test was performed at 3-month follow-up. The prevalence of SIBO was 43.1% in our SSc patients. After logistic regression, we identified the following risk factors for SIBO: presence of diarrhoea and constipation. Interestingly, we observed a marked correlation between values of GSS of digestive symptoms (> or =5) and the presence of SIBO (P = 10(-6)); indeed, both sensitivity and specificity of GSS > or =5 to predict SIBO were as high as 0.909 and 0.862, respectively. Finally, eradication of SIBO was obtained in 52.4% of the SSc patients with a significant improvement of intestinal symptoms. Our study underscores that SIBO often occurs in SSc patients. We further suggest that GSS may be systematically performed in SSc patients; since we found a correlation between GSS of digestive symptoms > or =5 and SIBO, we suggest that glucose H(2)/CH(4) breath test may be performed in the subgroup of SSc patients exhibiting GSS > or =5.

Small Intestinal Bacterial Overgrowth in Rosacea: Clinical Effectiveness of Its Eradication

To better understand the role of small intestinal bacterial overgrowth (SIBO) in rosacea, we aimed to assess the presence of SIBO in patients with rosacea and the clinical effectiveness of its eradication. We enrolled 113 consecutive rosacea ambulatory patients (31 M/82 F; mean age, 52 +/- 15 years) and 60 healthy controls who were sex- and age-matched. Patients and controls underwent lactulose and glucose breath tests (BTs) to assess the presence of SIBO. Patients positive for SIBO were randomized to receive rifaximin therapy (1200 mg/day for 10 days) or placebo. A group of patients with negative BTs were also treated with rifaximin. Eradication was assessed 1 month after the end of therapy. Two dermatologists, unblinded on therapy, evaluated rosacea patients before and after treatment on the basis of an objective scale. The prevalence of SIBO was higher in patients than controls (52/113 vs 3/60, P < .001). After eradication, cutaneous lesions cleared in 20 of 28 and greatly improved in 6 of 28 patients, whereas patients treated with placebo remained unchanged (18/20) or worsened (2/20) (P < .001). Placebo patients were subsequently switched to rifaximin therapy, and SIBO was eradicated in 17 of 20 cases. Fifteen had a complete resolution of rosacea. After antibiotic therapy, 13 of 16 patients with negative BTs for SIBO remained unchanged, and this result differed from SIBO-positive cases (P < .001). This study demonstrated that rosacea patients have a significantly higher SIBO prevalence than controls. Moreover, eradication of SIBO induced an almost complete regression of their cutaneous lesions and maintained this excellent result for at least 9 months.

Small Intestinal Bacterial Overgrowth in Patients Suffering From Scleroderma: Clinical Effectiveness of Its Eradication

After the skin, the gastrointestinal tract is the second most common target of systemic sclerosis (SSc). Our aims were to investigate orocecal transit time (OCTT) and the presence of small intestinal bacterial overgrowth (SIBO) in SSc as a cause of intestinal symptoms. Fifty-five SSc patients and 60 healthy controls, sex and age matched, entered the study. Enrolled subjects completed a questionnaire for intestinal symptoms and a global symptomatic score (GSS) was calculated. OCTT and the presence of SIBO were assessed by a lactulose breath test (LBT). Patients with SIBO were treated with rifaximin 1,200 mg/day for 10 days. Finally, a second questionnaire and LBT were performed 1 month after the end of therapy. The prevalence of SIBO was higher in SSc patients compared with controls (30/54 vs 4/60, respectively, P < 0.001). OCTT was significantly slower in SSc patients compared with controls (150 min, 25-75th percentile 142.5-165 vs 105 min, 25-75th percentile 90-135, respectively, P < 0.001). In patients with SIBO, the median GSS score was 8 (25-75th percentile 3.25-10.75). Eradication of SIBO was achieved in 73.3% of patients, with a significant reduction of symptoms in 72.7% of them (GSS score 2, 25-75th percentile 1-3, P < 0.05). These data suggest that SIBO occurs more frequently in SSc patients than in controls. Intestinal symptoms in these patients may be related to this syndrome and its eradication seems useful to improve clinical features. OCTT is significantly delayed in SSc patients, suggesting an impairment of intestinal motility, a further risk factor for the development of SIBO.

[Small intestinal bacterial overgrowth in patients with functional gastrointestinal diseases].

Recent studies have described a high percentage of small intestinal bacterial overgrowth (SIBO) in patients with irritable bowel syndrome (IBS). However, the prevalence of SIBO has not been well established in other functional disorders. To evaluate the prevalence of SIBO in patients with different functional gastrointestinal disorders (FGID). Patients with FGID completed a self-administered questionnaire providing information to diagnose functional disorders on the basis of Rome II criteria. SIBO was assessed using a standardized lactulose breath test. A basal value of breath hydrogen (H2) >20 ppm and/or two lectures of HZ values >20 ppm during the first 60 minutes were considered suggestive of SIBO. We studied 367 patients with a mean age of 50 years (87% females). Of these, 225 had IBS (45 constipation predominant, 121 diarrhea predominant and 59 alternating type), 33 had functional constipation, 83 had functional bloating and 26 had functional diarrhea. SIBO was found in 76% of patients with IBS, 73% of those with functional constipation, 69% of those with functional diarrhea and 68% of those with functional bloating. This study confirms a high percentage of SIBO in patients with IBS and other FGID. The eradication of SIBO should be considered as a therapeutic tool in these patients.