This document discusses small intestinal bacterial overgrowth (SIBO). It provides background on SIBO, including definitions, prevalence, clinical presentation, and diagnostic testing methods. The main diagnostic tests discussed are breath testing, antibiotic treatment trials, and small bowel aspiration/culture. Treatment options outlined include antibiotic therapy, prokinetic agents, probiotics, and nutritional support. Management of SIBO aims to address underlying causes, eradicate bacterial overgrowth, and provide nutritional support.
Small Intestinal Bacterial Overgrowth Update 2015Adam Rinde, ND
Dr. Adam Rinde updates Integrative Medicine Providers on Small Intestinal Bacterial Overgrowth (SIBO) which is explored as a potential contributing factor in Irritable Bowel Syndrome as well as a com-morbidity of motility disorders and diseases with disrupted motility (ie. Parkinsons Disease, and Diabetes). Dr. Rinde is a Bastyr University trained Naturopathic Physician in General Practice in Kirkland, Washington. He has a special interesting in mind-gut-immune-endocrine underpinnings of health.
SIBO Webinar 2015 - Advances in the Treatment and Management of SIBO by Dr N...Nirala Jacobi
This in-depth webinar, free for all health professionals, examines some of the latest advances in the treatment and management of small intestine bacterial overgrowth, or SIBO. SIBO is now understood as a prime cause of leaky gut, IBS and many autoimmune diseases.
Presented by Dr Nirala Jacobi ND, CMO, SIBOTest following the SIBO Symposium at the SIBO Center in Portland, Oregon, June 2015.
Key Learning Objectives:
Updated SIBO assessment and treatment
New information on the autoimmune link to SIBO
Key herbal and conventional strategies
Adhesions and restrictions; often a key element in the development of SIBO..
Many people who try an Ancestral Diet don’t get adequate relief for their digestive complaints. A key reason why may be the presence of SIBO. This presentation will discuss symptoms, causes, pathophysiology, diagnosis and treatment of SIBO. A simple breath test can diagnose SIBO and treatments include diet, antibiotics, herbal antibiotics, elemental diet, and probiotics. Central in all treatment of SIBO is a low- carbohydrate, grain-free diet (Specific Carbohydrate Diet, Gut and Psychology Diet, modified Low Fodmaps Diet). Discussion will include why an ancestral diet can benefit digestion and how the SIBO diets differ from standard Paleo/Primal diets.
A new theory suggests that acid reflux is caused by carbohydrate malabsorption, small intestinal bacterial overgrowth (SIBO) and microbe-induced gas pressure. The pressure drives acid reflux much like dropping a Mentos in a bottle of coke. Difficult-to-digest Carbohydrates lactose, fructose, resistant starch, fiber and sugar alcohols are most likely to cause malabsorption and symptoms of SIBO-related conditions such as GERD and IBS. A novel calculation called fermentation potential (FP) can measure the gut symptom potential of any food. The low FP approach was successfully tested in a small clinical study in the Boston area.
Small Intestinal Bacterial Overgrowth Update 2015Adam Rinde, ND
Dr. Adam Rinde updates Integrative Medicine Providers on Small Intestinal Bacterial Overgrowth (SIBO) which is explored as a potential contributing factor in Irritable Bowel Syndrome as well as a com-morbidity of motility disorders and diseases with disrupted motility (ie. Parkinsons Disease, and Diabetes). Dr. Rinde is a Bastyr University trained Naturopathic Physician in General Practice in Kirkland, Washington. He has a special interesting in mind-gut-immune-endocrine underpinnings of health.
SIBO Webinar 2015 - Advances in the Treatment and Management of SIBO by Dr N...Nirala Jacobi
This in-depth webinar, free for all health professionals, examines some of the latest advances in the treatment and management of small intestine bacterial overgrowth, or SIBO. SIBO is now understood as a prime cause of leaky gut, IBS and many autoimmune diseases.
Presented by Dr Nirala Jacobi ND, CMO, SIBOTest following the SIBO Symposium at the SIBO Center in Portland, Oregon, June 2015.
Key Learning Objectives:
Updated SIBO assessment and treatment
New information on the autoimmune link to SIBO
Key herbal and conventional strategies
Adhesions and restrictions; often a key element in the development of SIBO..
Many people who try an Ancestral Diet don’t get adequate relief for their digestive complaints. A key reason why may be the presence of SIBO. This presentation will discuss symptoms, causes, pathophysiology, diagnosis and treatment of SIBO. A simple breath test can diagnose SIBO and treatments include diet, antibiotics, herbal antibiotics, elemental diet, and probiotics. Central in all treatment of SIBO is a low- carbohydrate, grain-free diet (Specific Carbohydrate Diet, Gut and Psychology Diet, modified Low Fodmaps Diet). Discussion will include why an ancestral diet can benefit digestion and how the SIBO diets differ from standard Paleo/Primal diets.
A new theory suggests that acid reflux is caused by carbohydrate malabsorption, small intestinal bacterial overgrowth (SIBO) and microbe-induced gas pressure. The pressure drives acid reflux much like dropping a Mentos in a bottle of coke. Difficult-to-digest Carbohydrates lactose, fructose, resistant starch, fiber and sugar alcohols are most likely to cause malabsorption and symptoms of SIBO-related conditions such as GERD and IBS. A novel calculation called fermentation potential (FP) can measure the gut symptom potential of any food. The low FP approach was successfully tested in a small clinical study in the Boston area.
As a newly emphasized modality to treat infectious complications and also to folloew non-antibiotic regimens against infection, Probiotics has recieved more and more attention now a days.
gutCARE IBS Talk on 20/5/2020.
In this talk, we update Singapore local epidemiology about increasing trend of IBS locally since 1998. There is also challenges in diagnosing IBS confidently in primary care due to patient presentation and symptoms.
We also update audience about latest diagnostic criteria for IBS.
New treatment for IBS, relationship between Small intestine bacterial overgrowth and IBS and the role of hydrogen breath testing in managing IBS.
We hope you enjoy the slides.
Irritable Bowel Syndrome: An Update in Pathophysiology and Management Monkez M Yousif
Irritable bowel syndrome is the commonest health problem in hospital outpatient clinics and in private health care facilities and represents a big challenge for patients and physicians. This presentation discusses a different aspect of the disease from pathophysiology, clinical presentation and management
Diet microbiota interactions: the mediterranean diet as a key to a healthy mi...Fabio Piccini
Lecture for: The Mediterranean Diet from an Italian Perspective
“Let food be thy medicine and medicine be thy food”
A knowledge and application-based continuing education activity for US pharmacists and dietitians
Florence, Italy - November 6-9, 2018
GASBARRINI A. Nutrizione Clinica e Gastroenterologia. ASMaD 2017Gianfranco Tammaro
PROF. ANTONIO GASBARRINI - Convegno "Il Presente ed il Futuro della Nutrizione Clinica" - 24/03/2017 - Sala Rita Levi Montalcini - Ospedale S.Eugenio - ROMA
Sito ASMaD: http://www.asmad.net
Canale Youtube: https://youtu.be/FYlsQzE8xfk
As a newly emphasized modality to treat infectious complications and also to folloew non-antibiotic regimens against infection, Probiotics has recieved more and more attention now a days.
gutCARE IBS Talk on 20/5/2020.
In this talk, we update Singapore local epidemiology about increasing trend of IBS locally since 1998. There is also challenges in diagnosing IBS confidently in primary care due to patient presentation and symptoms.
We also update audience about latest diagnostic criteria for IBS.
New treatment for IBS, relationship between Small intestine bacterial overgrowth and IBS and the role of hydrogen breath testing in managing IBS.
We hope you enjoy the slides.
Irritable Bowel Syndrome: An Update in Pathophysiology and Management Monkez M Yousif
Irritable bowel syndrome is the commonest health problem in hospital outpatient clinics and in private health care facilities and represents a big challenge for patients and physicians. This presentation discusses a different aspect of the disease from pathophysiology, clinical presentation and management
Diet microbiota interactions: the mediterranean diet as a key to a healthy mi...Fabio Piccini
Lecture for: The Mediterranean Diet from an Italian Perspective
“Let food be thy medicine and medicine be thy food”
A knowledge and application-based continuing education activity for US pharmacists and dietitians
Florence, Italy - November 6-9, 2018
GASBARRINI A. Nutrizione Clinica e Gastroenterologia. ASMaD 2017Gianfranco Tammaro
PROF. ANTONIO GASBARRINI - Convegno "Il Presente ed il Futuro della Nutrizione Clinica" - 24/03/2017 - Sala Rita Levi Montalcini - Ospedale S.Eugenio - ROMA
Sito ASMaD: http://www.asmad.net
Canale Youtube: https://youtu.be/FYlsQzE8xfk
Diarrhea and vomiting in children
Vomiting (throwing up) and diarrhea (frequent, watery bowel movements) can be caused by viruses, bacteria, parasites, foods that are hard to digest (such as too many sweets) and other things.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
1. Kurdistan Board GEH/GIT Surgery Weekly J Club
Supervised by Prof Dr.Mohamed Alshekhani.
MBChB-CABM-FRCP-EBGH.
2.
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.
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
20.
21.
22.
23.
24.
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!