IBS SIBO/SIFO Flashcards
Describe the clinical features of SIBO
small intestinal inflammation maldigestion malabsorption Gas-bloat • Flatulence • Abdominal discomfort • Diarrhea • Steatorrhea • Weight loss • Symptoms from micronutrient deficiencies
dominant types of SIBO
Hydrogen-dominant SIBO – associated with diarrhea • Methane-dominant SIBO – associated with constipation (methane delays intestinal transit, possibly acting as a neuromuscular transmitter) Hydrogen and Methane Recurrent-returns after 4 weeks of Rx Hydrogen Sulfide Refractory-fails multiple rounds of therapy
IBS and CFIDS
Fibromyalgia and CFIDS
• 78% and 77% of subjects, respectively, have SIBO
Nutrient deficiencies associated with SIBO
Vitamins B12, A, D, E, K, iron, thiamine, niacin
laboratory testing for the diagnosis of SIBO
Direct Tests Quantitative culture of luminal contents
Indirect Tests Breath tests: 14C d-xylose, hydrogen
Other diagnostic tests Urinary tests, serum test
SIBO definition
Abnormally large numbers of bacteria (at least 10,000 or 10 4 bacteria per ml of duodenal aspirate) are present in the small intestine - AND - • Decreased Biodiversity
How does breath testing work?
Hydrogen breath testing (HBT) after ingestion of lactulose or glucose is the most commonly used method, based on the principle that exhaled hydrogen and methane are solely produced by bacterial fermentation of carbohydrates.
What gets malabsorbed in SIBO?
carbs - from damage to villi and mucosa
fat - from psedomembrane blocking and also bacteria deconj bile acids
Malnutrition in SIBO
Unabsorbed fatty acids may form insoluble soaps with minerals such as Ca and Mg, leading to:
• Osteomalacia, night blindness, hypocalcemic tetany, and possibly metabolic bone disease
Vitamin B12 deficiency
• Bacteria utilize B12 and detach B12 from intrinsic factor
• Serum folate usually normal or elevated
Hypoproteinemia
• Protein-losing enteropathy or protein malabsorption
Bacterial metabolism of proteins to ammonia and fatty acids
Iron deficiency anemia (rare)
Pathophysiologic Mechanisms of SIBO
Stomach-Small Bowel Etiologies • Atrophic gastritis • PPIs • Advanced age • Vagotomy • Gastrectomy • Gastric Bypass • Myopathies • CTD, Amyloid Chagas, RT • Medications (i.e., opioids)
IBS and SIBO
More than 1/3 of IBS patients tested positive for SIBO, and
the odds of SIBO in IBS were increased by nearly fivefold
IBS
• 78% of patients tested positive
• 48% of successfully treated patients no longer met Rome criteria for IBS
type of SIBO associated with diarrhea
H2
type of SIBO associated with constipation
methane
SIFO frequency in pts with GI Sx
About a quarter of patients with unexplained GI symptoms likely have SIFO.
SIBO and SIFO overlap
55% of pts with SIBO also have SIFO
SIBO etiologies
Etiologies: • Achlorhydria • Hypochlorhydria • PPIs, opioids, (possible: levothyroxine) • Stasis: dysmotility • Malnutrition • Collagen vascular disease • Immune deficiency • Surgery (loops, vagotomy) • Advancing Age, Female • Smoking • Celiac disease, Crohn's disease • Pancreatitis (moderate to severe)
SIBO consequences
Consequences: • Carbohydrate/Fiber intolerance • Bloating after meals • Iron, Vitamin D, & B12 deficiencies • Fat malabsorption • Enteropathy • Food allergies • Systemic inflammation • Autonomic dysfunction • Chronic Fatigue, Restless legs syndrome (RLS) • Atherosclerosis • Depression • Rosacea
Type of SIBO that needs antibiotics
methane
best initial diet for SIBO
low FODMAP
Herbs for “weeding” SIBO
berberine
oregano oil
wormwood
Non pharmacologic prokinetics (to use for SIBO)
- Iberogast (adaptogenic herbal formula):
- Ginger root
- Tryptophan:
- Magnesium citrate:
- Ascorbic acid or Sodium Ascorbate
- Vitamin D: Minimum D3 5,000 IU qd
- Swedish bitters:
- D-Limonene: 1000 mg BID
- Triphala
- Chinese Herbs (TJ 43)
- Acupuncture & acupressure
- Deep breathing/stress reduction
- Exercise
Pharmacologic prokinetics
LDN
metoclopramide
low dose erythromycin
Prucalopride
Non-pharm Tx options for SIBO
- Iberogast (adaptogenic herbal formula):
- Ginger root
- Tryptophan:
- Magnesium citrate:
- Ascorbic acid or Sodium Ascorbate
- Vitamin D: Minimum D3 5,000 IU qd
- Swedish bitters:
- D-Limonene: 1000 mg BID
- Triphala
- Chinese Herbs (TJ 43)
- Acupuncture & acupressure
- Deep breathing/stress reduction
- Exercise
low FODMAP - high or low prebiotics?
LOW
Rifaximin dose for SIBO
400 mg bid or tid
Predisposing factors for methane pos
Geographical area Higher in Africa
Lower in USA-Europe
Socioeconomic status High in lower socioeconomic situations
Gender Higher in females than in males
Age Age < 3 yr: undetectable
Age 3-15 yr: increases and reached adults level by adolescence
Family clustering Similar levels between sibling, parents and children but not in
spouses
Neomycin
when adding to rifaximin, better rates for SIBO
dose 500 mg po BID
Botanical formulation for methane-dominant SIBO
Peppermint Leaf
Quebracho extract
Saponins from Horse Chestnut
probiotics and SIBO - effectiveness for prevention/Tx
do not PREVENT but are effective for Tx of SIBO (~50%) more effective (80+%) when paired with antibiotics
Phases of low FODMAP Diet
- Elimination: 4-6 weeks of eliminating all FODMAPs;
symptoms should diminish during this time. - Reintroduction: Continue FODMAP diet. FODMAPs are
reintroduced one sub-group at a time for 6-8 weeks with
close monitoring for symptoms to re-emerge. - Personalized Maintenance: Begin normalizing diet and avoid
only the high FODMAP foods that triggered symptoms
PE findings of SIBO
Abdominal distension, Nonspecific findings: abdominal distension,
small intestinal succession splash [Taylor et al. 1991], scarring
associated with prior surgeries, severe cases may have latent tetany,
polyneuropathy and skin manifestations (rosacea)
Other lab findings in SIBO
Anemia, low vitamin B12, signs of malnutrition (lymphopenia, low serum pre-albumin and transferrin), elevated serum folate and vitaminK levels (bacteria produce these)
How is methane produced in SIBO?
bacteria overgrowth –> produce hydrogen –> archea bacteria produce methane –> 20-50% exhaled
false positive breath testing if
too fast transit
Specific GI d/o associated with SIBO
• SB diverticulosis • Fistula, strictures • Ileo-cecal valve resection • Common Variable Immunodeficiency • Hypogammaglobulinemia • T cell Deficiency • Celiac Disease • Cirrhosis • Chronic pancreatitis
Causes of SIFO
Small intestinal dysmotility and use of PPIs
Tx duration for SIFO
A 2–3 week course of antifungal therapy is recommended and may be effective in improving symptoms, but evidence for
eradication is lacking.
Which type of breath testing is most sensitive
lactulose
Which type of breath testing is most specific
glucose
Adding methane to breath testing
• The measurement of methane in addition to hydrogen may improve the diagnostic yield of breath testing. (20% to 30% of the general population produces methane as the main by-product of carbohydrate fermentation)
best antibiotics for SIBO
neomycin and rifaximin
