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Table of Contents
Vol. 25, No. 3, 2007
Issue release date: September 2007
Dig Dis 2007;25:237–240
(DOI:10.1159/000103892)

Small Intestinal Bacterial Overgrowth: Diagnosis and Treatment

Gasbarrini A. · Lauritano E.C. · Gabrielli M. · Scarpellini E. · Lupascu A. · Ojetti V. · Gasbarrini G.
Internal Medicine Department, Gemelli Hospital, Catholic University of Sacred Heart, Rome, Italy
email Corresponding Author

Abstract

Small intestinal bacterial overgrowth (SIBO) is a clinical condition characterized by a malabsorption syndrome due to an increase in microorganisms within the small intestine. The main mechanisms restricting bacterial colonization in the upper gut are the gastric acid barrier, mucosal and systemic immunity and intestinal clearance. When these mechanisms fail, bacterial overgrowth develops. Diarrhea, steatorrhea, chronic abdominal pain, bloating and flatulence are common symptoms and are similar to those observed in irritable bowel syndrome. Breath tests (glucose and/or lactulose breath tests) have been proposed as a sensitive and simple tool for the diagnosis of bacterial overgrowth, being non-invasive and inexpensive compared to the gold standard represented by the culture of intestinal aspirates. Antibiotic therapy is the cornerstone of SIBO treatment. Current SIBO treatment is based on empirical courses of broad-spectrum antibiotics since few controlled studies concerning the choice and duration of antibiotic therapy are available at present.


 goto top of outline Key Words

  • Small intestinal bacterial overgrowth
  • Antibiotics
  • Breath tests
  • Irritable bowel syndrome

 goto top of outline Abstract

Small intestinal bacterial overgrowth (SIBO) is a clinical condition characterized by a malabsorption syndrome due to an increase in microorganisms within the small intestine. The main mechanisms restricting bacterial colonization in the upper gut are the gastric acid barrier, mucosal and systemic immunity and intestinal clearance. When these mechanisms fail, bacterial overgrowth develops. Diarrhea, steatorrhea, chronic abdominal pain, bloating and flatulence are common symptoms and are similar to those observed in irritable bowel syndrome. Breath tests (glucose and/or lactulose breath tests) have been proposed as a sensitive and simple tool for the diagnosis of bacterial overgrowth, being non-invasive and inexpensive compared to the gold standard represented by the culture of intestinal aspirates. Antibiotic therapy is the cornerstone of SIBO treatment. Current SIBO treatment is based on empirical courses of broad-spectrum antibiotics since few controlled studies concerning the choice and duration of antibiotic therapy are available at present.

Copyright © 2007 S. Karger AG, Basel


 goto top of outline References
  1. Luckey TD: Introduction to intestinal microecology. Am J Clin Nutr 1972;25:1292–1294.
  2. Hooper LV, Midtvedt T, Gordon JI: How host-microbial interactions shape the nutrient environment of the mammalian intestine. Annu Rev Nutr 2002;22:283–307.
  3. Donaldson RM Jr: Normal bacterial population of the intestine and their relation to intestinal function. N Engl J Med 1964;270:938–945.
  4. Nucera G, Gabrielli M, Lupascu A, Lauritano EC, Santoliquido A, Cremonini F, Cammarota G, Tondi P, Pola P, Gasbarrini G, Gasbarrini A: Abnormal breath tests to lactose, fructose and sorbitol in irritable bowel syndrome may be explained by small intestinal bacterial overgrowth. Aliment Pharmacol Ther 2005;21:1391–1395.
  5. Varcoe R, Haliday D, Tavill AS: Utilization of urea nitrogen for albumin synthesis in the stagnant loop syndrome: Gut 1974;15:898–902.
  6. Wanitschke R, Ammon HV: Effects of dihydroxy bile acids and hydroxy fatty acids on the absorption of oleic acid in the human jejunum. J Clin Invest 1978;61:178–186.
  7. Saltzman JR, Kowdley KV, Pedrosa MC, Sepe T, Golner B, Perrone G, Russell RM: Bacterial overgrowth without clinical malabsorption in elderly hypochlorhydric subjects. Gastroenterology 1994;106:615–623.
  8. Lin EC: Small intestinal bacterial overgrowth, a framework for understanding irritable bowel syndrome. JAMA 2004;292:852–858.
  9. Lupascu A, Gabrielli M, Lauritano EC, Scarpellini E, Santoliquido A, Cammarota G, Flore R, Tondi P, Pola P, Gasbarrini G, Gasbarrini A: Hydrogen glucose breath test to detect small intestinal bacterial overgrowth: prevalence case-control study in irritable bowel syndrome. Aliment Pharmacol Ther 2005;22:1157–1160.
  10. Corazza GR, Menozzi MG, Strocchi A, Rasciti L, Vaira D, Lecchini R, Avanzini P, Chezzi C, Gasbarrini G: The diagnosis of small bowel bacterial overgrowth. Gastroenterology 1990;98:302–309.
  11. Romagnuolo J, Schiller D, Bailey RJ: Using breath tests wisely in a gastroenterology practice: an evidence-based review of indications and pitfalls in interpretation. Am J Gastroenterol 2002;97:1113–1126.
  12. Di Stefano M, Malservisi S, Veneto G, Ferrieri A, Corazza GR: Rifaximin versus chlortetracycline in the short-term treatment of small intestinal bacterial overgrowth. Aliment Pharmacol Ther 2000;14:551–556.
  13. Di Stefano M, Miceli E, Missanelli A, Mazzochi S, Corazza GR: Absorbable vs. non-absorbable antibiotics in the treatment of small intestine bacterial overgrowth in patients with blind-loop syndrome. Aliment Pharmacol Ther 2005;21:985–992.
  14. Attar A, Flourie B, Rambaud JC, Franchisseur C, Ruszniewski P, Bouhnik Y: Antibiotic efficacy in small intestinal bacterial overgrowth related chronic diarrhea: a crossover, randomized trial. Gastroenterology 1999;117:794–797.
  15. Castiglione F, Rispo A, Di Girolamo E, Cozzolino A, Manguso F, Grassia R, Mazzacca G: Antibiotic treatment of small bowel bacterial overgrowth in patients with Crohn’s disease. Aliment Pharmacol Ther 2003;18:1107–1112.
  16. Scarpignato C, Pelosini I: Experimental and clinical pharmacology of rifaximin, a gastrointestinal selective antibiotic. Digestion 2006;73(suppl 1):13–27.
  17. Lauritano EC, Gabrielli M, Lupascu A, Santoliquido A, Nucera G, Scarpellini E, Vincenti F, Cammarota G, Flore R, Pola P, Gasbarrini G, Gasbarrini A: Rifaximin dose-finding study for the treatment of small intestinal bacterial overgrowth. Aliment Pharmacol Ther 2005;22:31–35.
  18. Cuoco L, Salvagnini M: Small intestine bacterial overgrowth in irritable bowel syndrome: a retrospective study with rifaximin. Minerva Gastroenterol Dietol 2006;52:89–95.
  19. Pimentel M, Chow EJ, Lin HC: Normalization of lactulose breath testing correlates with symptom improvement in irritable bowel syndrome: a double-blind, randomized, placebo-controlled study. Am J Gastroenterol 2003;98:412–419.

 goto top of outline Author Contacts

Prof. Antonio Gasbarrini
Internal Medicine Department, Catholic University of Sacred Heart
Gemelli Hospital, Largo A. Gemelli, 8
IT–00168 Rome (Italy)
Tel. +39 06 3015 4294, Fax +39 06 3550 2775, E-Mail angiologia@rm.unicatt.it


 goto top of outline Article Information

Number of Print Pages : 4
Number of Figures : 0, Number of Tables : 0, Number of References : 19


 goto top of outline Publication Details

Digestive Diseases (Clinical Reviews)

Vol. 25, No. 3, Year 2007 (Cover Date: September 2007)

Journal Editor: Malfertheiner, P. (Magdeburg)
ISSN: 0257–2753 (print), 1421–9875 (Online)

For additional information: http://www.karger.com/DDI


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Small intestinal bacterial overgrowth (SIBO) is a clinical condition characterized by a malabsorption syndrome due to an increase in microorganisms within the small intestine. The main mechanisms restricting bacterial colonization in the upper gut are the gastric acid barrier, mucosal and systemic immunity and intestinal clearance. When these mechanisms fail, bacterial overgrowth develops. Diarrhea, steatorrhea, chronic abdominal pain, bloating and flatulence are common symptoms and are similar to those observed in irritable bowel syndrome. Breath tests (glucose and/or lactulose breath tests) have been proposed as a sensitive and simple tool for the diagnosis of bacterial overgrowth, being non-invasive and inexpensive compared to the gold standard represented by the culture of intestinal aspirates. Antibiotic therapy is the cornerstone of SIBO treatment. Current SIBO treatment is based on empirical courses of broad-spectrum antibiotics since few controlled studies concerning the choice and duration of antibiotic therapy are available at present.



 goto top of outline Author Contacts

Prof. Antonio Gasbarrini
Internal Medicine Department, Catholic University of Sacred Heart
Gemelli Hospital, Largo A. Gemelli, 8
IT–00168 Rome (Italy)
Tel. +39 06 3015 4294, Fax +39 06 3550 2775, E-Mail angiologia@rm.unicatt.it


 goto top of outline Article Information

Number of Print Pages : 4
Number of Figures : 0, Number of Tables : 0, Number of References : 19


 goto top of outline Publication Details

Digestive Diseases (Clinical Reviews)

Vol. 25, No. 3, Year 2007 (Cover Date: September 2007)

Journal Editor: Malfertheiner, P. (Magdeburg)
ISSN: 0257–2753 (print), 1421–9875 (Online)

For additional information: http://www.karger.com/DDI


Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Luckey TD: Introduction to intestinal microecology. Am J Clin Nutr 1972;25:1292–1294.
  2. Hooper LV, Midtvedt T, Gordon JI: How host-microbial interactions shape the nutrient environment of the mammalian intestine. Annu Rev Nutr 2002;22:283–307.
  3. Donaldson RM Jr: Normal bacterial population of the intestine and their relation to intestinal function. N Engl J Med 1964;270:938–945.
  4. Nucera G, Gabrielli M, Lupascu A, Lauritano EC, Santoliquido A, Cremonini F, Cammarota G, Tondi P, Pola P, Gasbarrini G, Gasbarrini A: Abnormal breath tests to lactose, fructose and sorbitol in irritable bowel syndrome may be explained by small intestinal bacterial overgrowth. Aliment Pharmacol Ther 2005;21:1391–1395.
  5. Varcoe R, Haliday D, Tavill AS: Utilization of urea nitrogen for albumin synthesis in the stagnant loop syndrome: Gut 1974;15:898–902.
  6. Wanitschke R, Ammon HV: Effects of dihydroxy bile acids and hydroxy fatty acids on the absorption of oleic acid in the human jejunum. J Clin Invest 1978;61:178–186.
  7. Saltzman JR, Kowdley KV, Pedrosa MC, Sepe T, Golner B, Perrone G, Russell RM: Bacterial overgrowth without clinical malabsorption in elderly hypochlorhydric subjects. Gastroenterology 1994;106:615–623.
  8. Lin EC: Small intestinal bacterial overgrowth, a framework for understanding irritable bowel syndrome. JAMA 2004;292:852–858.
  9. Lupascu A, Gabrielli M, Lauritano EC, Scarpellini E, Santoliquido A, Cammarota G, Flore R, Tondi P, Pola P, Gasbarrini G, Gasbarrini A: Hydrogen glucose breath test to detect small intestinal bacterial overgrowth: prevalence case-control study in irritable bowel syndrome. Aliment Pharmacol Ther 2005;22:1157–1160.
  10. Corazza GR, Menozzi MG, Strocchi A, Rasciti L, Vaira D, Lecchini R, Avanzini P, Chezzi C, Gasbarrini G: The diagnosis of small bowel bacterial overgrowth. Gastroenterology 1990;98:302–309.
  11. Romagnuolo J, Schiller D, Bailey RJ: Using breath tests wisely in a gastroenterology practice: an evidence-based review of indications and pitfalls in interpretation. Am J Gastroenterol 2002;97:1113–1126.
  12. Di Stefano M, Malservisi S, Veneto G, Ferrieri A, Corazza GR: Rifaximin versus chlortetracycline in the short-term treatment of small intestinal bacterial overgrowth. Aliment Pharmacol Ther 2000;14:551–556.
  13. Di Stefano M, Miceli E, Missanelli A, Mazzochi S, Corazza GR: Absorbable vs. non-absorbable antibiotics in the treatment of small intestine bacterial overgrowth in patients with blind-loop syndrome. Aliment Pharmacol Ther 2005;21:985–992.
  14. Attar A, Flourie B, Rambaud JC, Franchisseur C, Ruszniewski P, Bouhnik Y: Antibiotic efficacy in small intestinal bacterial overgrowth related chronic diarrhea: a crossover, randomized trial. Gastroenterology 1999;117:794–797.
  15. Castiglione F, Rispo A, Di Girolamo E, Cozzolino A, Manguso F, Grassia R, Mazzacca G: Antibiotic treatment of small bowel bacterial overgrowth in patients with Crohn’s disease. Aliment Pharmacol Ther 2003;18:1107–1112.
  16. Scarpignato C, Pelosini I: Experimental and clinical pharmacology of rifaximin, a gastrointestinal selective antibiotic. Digestion 2006;73(suppl 1):13–27.
  17. Lauritano EC, Gabrielli M, Lupascu A, Santoliquido A, Nucera G, Scarpellini E, Vincenti F, Cammarota G, Flore R, Pola P, Gasbarrini G, Gasbarrini A: Rifaximin dose-finding study for the treatment of small intestinal bacterial overgrowth. Aliment Pharmacol Ther 2005;22:31–35.
  18. Cuoco L, Salvagnini M: Small intestine bacterial overgrowth in irritable bowel syndrome: a retrospective study with rifaximin. Minerva Gastroenterol Dietol 2006;52:89–95.
  19. Pimentel M, Chow EJ, Lin HC: Normalization of lactulose breath testing correlates with symptom improvement in irritable bowel syndrome: a double-blind, randomized, placebo-controlled study. Am J Gastroenterol 2003;98:412–419.