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- 1. Kurdistan Board GEH/GIT Surgery Weekly J Club Supervised by Prof Dr.Mohamed Alshekhani. MBChB-CABM-FRCP-EBGH.
- 3. Background: GI symptoms are commonly seen in PC, 15.9 million visits /year. One of these syndromes, (SIBO), is a diagnosis often entertained in pc& gastroenterology settings. A dysbiosis syndrome is most often referred to as SIBO ,less as blind loop or stagnant loop syndrome. The syndrome first described by Faber in 1897 when he described a case of “blind loop syndrome” in a patient with underlying intestinal strictures. Prevalence stimates from 0-15.6% in healthy individuals, with increasing prevalence with age & medical comorbidities.4 It is often considered in the DD owing to its nonspecific presentation.
- 4. Background: SIBO can be broadly defined as excessive bacteria in the SI,an increase in the number of bacteria in the small bowel to >105 CFU/mL, some 103 CFU/mL. The clinical implications& even the diagnostic criteria themselves, have been debated recently.
- 5. Etiology: There does not seem to be a single unifying underlying etiology. Abnormalities in anatomy, motility, pH,immunity are all contributors allowing for local proliferation of coliform bacteria or penetration of oral-type bacteria. This dysbiosis is characterized by colonic-type bacteria that ferment carbohydrates, leading to gas production. Anato risks can be intrinsic, traumatic, or iatrogenic. Intrinsic anatomical risk factors of SI include obstruction, diverticula fi stulas. Individuals with H/O abdominal surgical intervention can be at increased risk due to either intentional alteration in existing anatomy (ie, Roux-en-Y) or postop complications, including strictures adhesions, lead to dysmotility&independently increase the risk.
- 6. Etiology: Primary dysmotility can be seen, but secondary dysmotility is much more common. Secondary dysmotility can be a consequence of systemic disease, irradiation, or medication use. systemic diseases known to alter motility & associated with SIBO include Parkinson disease, systemic sclerosis, hypothyroidism,diabetes mellitus. The increasing incidence of SIBO with age is also likely secondary to changes in intestinal motility, alchlorhydria &polypharmacy. Medications: Narcotics by effects on GI motility,PPI; effect on gastric pH barrier. Outside classic RFs; cirrhosis, celiac, morbid obesity, pancreatitis, ?IBS.
- 7. Clinical features: Often, SIBO is entertained in the DD due to the variety of people at risk &its non-specific presentation. The classic presentation: steatorrhea, abdominal bloating&weight loss, but this is an infrequent. More commonly, report bloating, flatulence, abd pain& diarrhea. In more severe cases, patients can experience malabsorption leading to weight loss&malnutrition. Patients with severe symptoms are at risk for a variety of defi ciencies, mostly vits A, D, E, B12& iron, leading to either macrocytic or microcytic anemia, polyneuropathy&metabolic bone disease. Vitamin K is usually unaffected because it is a by- product of bacterial metabolism.
- 8. Diagnosis: Because of NS symptoma & broad DD ,effective clinical tests are essential to the diagnosis of SIBO. Several testing options have been extensively studied, including therapeutic trials of antibiotics, SB aspiration / culture& breath testing, all of which have strengths & weaknesses.
- 9. Diagnosis:antibiotics A method often used is a therapeutic trial of antibiotics due to the potential for both diagnostic&therapeutic benefits,but if patients do not respond, the diagnosis has not been ruled out. Risks: Antibacterial stewardship, unwanted adverse effects, antibiotic resistance&C difficile colitis. No criteria to define a response to therapy, especially in patients who have other comorbidities as IBS & patients may have improvement,due to the effect on colonic rather than small-bowel fermentation. This approach can be used after discussing these issues with the patient.
- 10. Diagnosis:Breath testing The most widely available, least expensive. They detect the presence of methane/hydrogen, the human body is unable to produce. Lactulose/glucose solutions are used as carbohydrate substrates. Before testing, patients must be off antibiotics for 2 weeks, avoid high-fiber foods (ie, vegetables /coarse breads) the day before&fast 12 hours before. Results can be variable owing to a variety of host factors, such as the types and proportions of colonizing bacteria, residual carbohydrates,the absorptive capacity of the gut, age & sex. The sensitivities/specificities; 31-77% &44-100%, respectively, leading to high false-positive rates. Glucose breath testing endorsed but more data needed
- 11. Diagnosis:SB Culture The most widely accepted test of choice Most aspirates are obtained from the duodenum during upper endoscopy. Quantification of bacterial growth from SB aspirate is currently the most widely accepted. even this test has limitations: Invasiveness of the upper endoscopy, time consumption, need for sedation,cost. Most accept a threshold of bacterial growth >105 CFU/mL, but some 103 CFU/mL. Technical limitations, including esop/ oral bacterial contamination, leading to false-positives, the inability of the scope to reach the distal small bowel, leading to false-negatives.
- 12. Management: Antibiotics are the hallmark therapy. Antibioticsshown to be superior to placebo in resolution of SIBO measured by normalization of BTs. the most common; ciprofloxacin, metronidazole, neomycin, rifaximin,tracycline. The overall rate of breath test normalization with antibiotics was 50% vs 10% for placebo. Rfaximin, had similar efficacy compared with ciprofloxacin&metronidazole. Rifaximin may be preferable due to its intrinsic lack of systemic bioavailability, but the cost of can be limiting. Commonly used regimens include ciprofloxacin 250 mg orally twice daily for 7 days, metronidazole 250 mg orally twice daily for 7 days&rifaximin 550 mg orally twice daily for 7 days.
- 13. Management: In patients who have contraindications to antibiotics or who prefer to avoid antibiotics. Use of elemental diet, which includes only nutrients absorbed in the proximal small bowel, shown to lead to breath test normalization & improvement in symptoms in a large proportion of patients. Widespread use of elemental diets is unlikely given the amount of restriction required. The evidence for probiotics is inconclusive at best Herbal &homeopathic regimens; there is a lack of evidence to support a specific regimen.
- 14. Management: SIBO is often a relapsing condition given it is a secondary process. A variety of predisposing factors lead to the development of SIBO. Alteration of these factors is preferable (ie, removal of intra-abdominal adhesions), but most often is not possible. Recurrent infections can be treated with a repeated antibiotic course or with alternating antibiotic regimens. Prokinetics promising to prevent recurrence, but more data are needed.
- 15. Small Bowel Bacterial Overgrowth (SBBO or SIBO) Bacteria and the gut Definition Symptoms Causes and conditions
- 16. Hydrogen Breath Testing QuinTron: www.quintron-usa.com Measures both hydrogen and methane Mail-in kit option MicroDirect: www.breathh2.com Measures hydrogen only Web site offers info on billing, coding, reimbursement GI Pathology: offers mail-in kit
- 17. Testing Instructions No antibiotics for at least 7 days NPO for 12 hours before test NPO during test except for substrate in 6-8 ounces of water Avoid eating slowly digesting foods the day before No smoking 30 min. before or during test No sleeping 30 min. before or during test
- 18. Testing Instructions Baseline breath sample Substrate (lactulose 10 grams) mixed in 6-8 ounces of water. Additional breath samples taken at 20 minute intervals for at least 5 additional samples.
- 19. Interpreting Results Look for bi-phasic peaks in true positives Early increase of at least 12 ppm Investigate interferences to accurate results: Smoking, laxative use, last meal, antibiotic use, previous surgeries, COPD
- 25. Treatment Options The goal is to treat the underlying cause(s), eradicate the bacterial overgrowth, and nutritional support Antibiotic therapy Prokinetic agents Probiotics Nutritional support
Editor's Notes
- Ask: How many are familiar with? How many know if your physicians are testing for?
- Symptoms Abdominal pain or discomfort Bloating/abdominal distention Constipation Diarrhea Extra-bowel symptoms – fatigue, headache, backache, muscle pain, sleep disturbance Causes: Genetic – runs in families (inflammatory process or serotonin related) Inflammatory – activation of immune system – on-going low-grade inflammatory process – affects GI motor and sensory function Neurological – brain/gut connection, psychological factors Infectious – 10 - 20% of patients can link to a gut infection that precipitated IBS – food poisoning, traveler’s diarrhea Treatment: Whole patient assessment (education, goals/expectations, stress, other illnesses, support, psychological) Fiber, dietary interventions, tegaserod (Zelnorm off market), or Amitiza (lubiprostone) for constipation, Imodium (loperamide) or Lotronex (alosetron) for diarrhea, pain treatment - antispasmodic (anticholinergic) medication
- Symptoms Abdominal pain or discomfort Bloating/abdominal distention Constipation Diarrhea Extra-bowel symptoms – fatigue, headache, backache, muscle pain, sleep disturbance Causes: Genetic – runs in families (inflammatory process or serotonin related) Inflammatory – activation of immune system – on-going low-grade inflammatory process – affects GI motor and sensory function Neurological – brain/gut connection, psychological factors Infectious – 10 - 20% of patients can link to a gut infection that precipitated IBS – food poisoning, traveler’s diarrhea Treatment: Whole patient assessment (education, goals/expectations, stress, other illnesses, support, psychological) Fiber, dietary interventions, tegaserod (Zelnorm off market), or Amitiza (lubiprostone) for constipation, Imodium (loperamide) or Lotronex (alosetron) for diarrhea, pain treatment - antispasmodic (anticholinergic) medication
- Perform blood tests to check for anemia and erythrocyte sedimentation rate (ESR) to check for inflammation Elevated thyroid – diarrhea Low Thyroid – constipation Warning Signs: Blood in stool Constant diarrhea Fever Diarrhea at night Weight loss Age over 50 years – consider colonoscopy Vomiting
- Perform blood tests to check for anemia and erythrocyte sedimentation rate (ESR) to check for inflammation Elevated thyroid – diarrhea Low Thyroid – constipation Warning Signs: Blood in stool Constant diarrhea Fever Diarrhea at night Weight loss Age over 50 years – consider colonoscopy Vomiting
- Perform blood tests to check for anemia and erythrocyte sedimentation rate (ESR) to check for inflammation Elevated thyroid – diarrhea Low Thyroid – constipation Warning Signs: Blood in stool Constant diarrhea Fever Diarrhea at night Weight loss Age over 50 years – consider colonoscopy Vomiting
- Perform blood tests to check for anemia and erythrocyte sedimentation rate (ESR) to check for inflammation Elevated thyroid – diarrhea Low Thyroid – constipation Warning Signs: Blood in stool Constant diarrhea Fever Diarrhea at night Weight loss Age over 50 years – consider colonoscopy Vomiting
- Perform blood tests to check for anemia and erythrocyte sedimentation rate (ESR) to check for inflammation Elevated thyroid – diarrhea Low Thyroid – constipation Warning Signs: Blood in stool Constant diarrhea Fever Diarrhea at night Weight loss Age over 50 years – consider colonoscopy Vomiting
- Perform blood tests to check for anemia and erythrocyte sedimentation rate (ESR) to check for inflammation Elevated thyroid – diarrhea Low Thyroid – constipation Warning Signs: Blood in stool Constant diarrhea Fever Diarrhea at night Weight loss Age over 50 years – consider colonoscopy Vomiting
- Perform blood tests to check for anemia and erythrocyte sedimentation rate (ESR) to check for inflammation Elevated thyroid – diarrhea Low Thyroid – constipation Warning Signs: Blood in stool Constant diarrhea Fever Diarrhea at night Weight loss Age over 50 years – consider colonoscopy Vomiting
- Perform blood tests to check for anemia and erythrocyte sedimentation rate (ESR) to check for inflammation Elevated thyroid – diarrhea Low Thyroid – constipation Warning Signs: Blood in stool Constant diarrhea Fever Diarrhea at night Weight loss Age over 50 years – consider colonoscopy Vomiting
- Perform blood tests to check for anemia and erythrocyte sedimentation rate (ESR) to check for inflammation Elevated thyroid – diarrhea Low Thyroid – constipation Warning Signs: Blood in stool Constant diarrhea Fever Diarrhea at night Weight loss Age over 50 years – consider colonoscopy Vomiting
- Perform blood tests to check for anemia and erythrocyte sedimentation rate (ESR) to check for inflammation Elevated thyroid – diarrhea Low Thyroid – constipation Warning Signs: Blood in stool Constant diarrhea Fever Diarrhea at night Weight loss Age over 50 years – consider colonoscopy Vomiting
- Normal Gut: Acid in the stomach kills most of the bacteria we ingest. Bacteria is normally only found in the colon, the proximal small intestine (duodenum and jejunum) has few to no bacteria. When bacteria metabolize carbs (fermentation), acids, water and gases are produced. The major gases are carbon dioxide and hydrogen. Only bacteria can produce hydrogen and methane. Definition: SIBO is a syndrome that involves excessive numbers of bacteria growing in the small intestine. The large numbers of bacteria compete for nutrients with the person who has the condition. As a result, the person with the condition may not absorb enough nutrients. Mark Pimentel, MD, “guru” of SIBO. Author of book “A New IBS Solution” – states as many as 84% of IBS suffers have an abnormal lactulose breath test. Symptoms: In addition to IBS symptoms - malabsorptive symptoms: anemia, weight loss, fatty/floating stool (steattorrhea) Causes & Conditions: Previous intestinal infection (food poisoning, traveler’s diarrhea) Achlorhdria or hypochlorhydria caused by surgical interventions or prolonged use of PPI’s Short bowel syndrome Intestinal obstruction Diverticulosis (duodenal or jejunal) Dysmotility from various causes Crohn’s disease Chronic pancreatitis Cirrhosis Immunodeficiency syndromes - lupus, scleroderma
- CPT Code: 91065 (hydrogen breath test). It is a laboratory test, usually done in office setting (or OBE) CLIA waived Reimbursement varies $50 - $90. Costs involved: Machine (one time) or kit (each test), substrate (lactulose), staff cost, cardboard tube
- Second peak usually larger than 1st – 12-20 ppm increase May need to extend test up to 3 hours to obtain 2nd peak If no 2nd peak, can be due to antibiotic use, increased acid in colon Peaks may merge.
- Antibiotics: Rifaximin, neomycin, erythromycin, flagyl, Augmentin Prokinetic Agents: Erythromycin, Zelnorm, Amitiza Probiotics: Align, FloraQ Nutritional Support Don’ts (Avoid) Foods in which bacteria thrive – hard-to-digest sugars High amounts of carbohydrates Sugar substitutes – i.e. sorbitol - Splenda – humans are unable to digest, so not absorbed, so bacteria feed on it and replicate Avoid sugar-free gum Fructose found in fruits (corn syrup) High fiber diets Frequent meals High residue meals Do’s: Moderate amounts of fiber found in fruits and vegetables Easily digestible foods (don’t leave much behind) – low residue Three meals a day – avoid snacking (allows “cleansing waves”) Adequate fluid intake Low carb diet that limits lactose (FYI – hydrogen breath testing also tests for lactose intolerance when lactose is the substrate) Potatoes, pasta, rice, bread and cereals are OK because they are absorbed high up in the small intestine – white bread is better!