small intestinal bacterial overgrowth (sibo) · testing for small intestinal bacterial overgrowth...
TRANSCRIPT
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© 2018 Sharon Erdrich
Testing for Small
Intestinal Bacterial
Overgrowth (SIBO)
1
Sharon ErdrichMHSc (Hons), DipNat, DipHerbMed, DipAroma, NZRN.
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TOPICS
1. Intro to SiBO Clinical Presentation of SiBO
2. Options for Diagnosis
3. SiBO Treatment Guideline
4. Case Examples
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SIBO – definition
• SiBO = Small Intestinal Bacterial Overgrowth• “an increase in the number and/or alteration in the type
of bacteria in the upper gastrointestinal tract”
3
World J Gastroenterol 2010; 16(24): 2978-2990JAMA. 2004;292(7):852-858Am J Gastroenterol. 2000; 95:3503-3506.
• Link between IBS & SIBO• High prevalence of bloating in IBS (~92%)• Gut-produced gases are a leading cause of bloating, pain and altered
gut transit
• 84% of IBS patients have abnormal lactulose breath test → 75% improvement of IBS symptoms after eradication of SIBO
• antibiotic-sensitive pathophysiology of IBS
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JAMA. 2004;292(7):852-858
Recent proposal that IBS be renamed “Irritable Bowel Symptoms”, as most cases of IBS have an underlying (and mostly treatable) cause.
Brown, Ben (ND) 2018 ICNM London
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Clinical Presentations Suggestive of SiBO
• Irritable Bowel symptoms• Abdo pain• Constipation and/or diarrhoea• Urgency
• Burping, Reflux
• Food intolerances /acquired food “allergies”• Includes suspected malabsorption syndromes
• Histadelia
• Intolerance to fermented foods
• Worse for probiotics, prebiotics or fibre supplementation
• Nutrient deficiencies - in spite of adequate intake (esp. iron, B12)
• Weight loss, weight gain – in spite of appropriate intake
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© 2018 Sharon Erdrich
SiBO May be a Factor in:
DIET HISTORY
• Better on Paleo diet/worse on Vegan
• Carbohydrate-rich diet
• Dairy intolerant
• “Food confusion”
• Fructose intolerant
• Gluten/grain intolerant
• Multiple Food intolerances
• Worse for fibre
OTHER
Brain fog
Headache
Joint pain, incl. arthritis
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DIGESTIVE DYSFUNCTION
Leaky gut
GIT dysmotility (ANY)
Burping/reflux
Ileo-caecal reflux
Crohn’s disease/Colitis
Coeliac disease
Malabsorption syndromes
Worse for prebiotics
Worse for probiotics
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DISEASES/CONDITIONS
Cirrhosis, Fatty Liver
Distal bowel problems
Diabetes
Fibromyalgia
Immunodeficiency states
Mood/psychiatric disorders
MS, Alzheimers, Parkinson’s
Pancreatitis
Pelvic inflammation (BV, UTI etc)
Renal failure
Rosacea, Psoriasis
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SiBO can occur due to loss of function of Natural Defences
• Normal GI Secretions• Gastric acid, Bile, Pancreatic enzymes
• Serotonin, Motilin & Others – Affect motility
• Alteration in one or more of:• Anatomy• Normal motility • Normal flora balance• +/- Combination of any of a number of risk factors
• Immune function• Normal flora• Intestinal immunoglobulins
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World J Gastroenterol. 2010;16(24):2978-2990. Gastroenterol Hepatol (N Y). 2007 Feb; 3(2): 112–122.
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© 2018 Sharon Erdrich
Risk Factors for the Development of SIBOANATOMIC
Small intestine diverticula
Small intestine strictures (radiation, medications, Crohn's disease)
Surgically created blind loops
Resection of ileocecal valve
Fistulas between proximal and distal bowel
Gastric resection
Mal-rotated bowel
IRRITABLE BOWEL SYNDROME
Multiple factors (eg Post-infectious, which can cause motility disorder)
ORGAN SYSTEM DYSFUNCTION
Cirrhosis, Fatty Liver
Crohn's disease
Coeliac disease
Gastric resection
Immunodeficiency states
Malnutrition
Pancreatitis
Distal bowel problems
MEDICATIONS
Anticholinergics
Gastric acid suppressants
Opiates
Recurrent antibiotics
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MOTILITY DISORDERS
Gastroparesis
Small bowel dysmotility
Chronic intestinal pseudo-obstruction
Ileo-caecal reflux
Trauma – eg: abdominal or head injury
MEDICATIONS
Recurrent antibiotics
Gastric acid suppression
OTHER DISORDERS
Diabetes
Hypochlorhydria
Recurrent vomiting (egBulimia)
ELDERLYGastroenterol Hepatol (N Y). 2007 Feb; 3(2): 112–122.
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HISTORY
Past abdominal surgery
Multiple abx in history
Worse for antibiotics
Better for antibiotics
Onset following gastro/travel bug
Small intestine diverticula
Radiotherapy (to abdomen or pelvis)
Use of opiates
Use of gastric acid suppression
Endometriosis
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Stasis
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MMC Dysfunction
• PHx of Clostridium, Giardia, Lyme disease
• Scleroderma
• Diabetes
• Hypothyroid conditions
• “Pseudo-obstruction”• Abdominal surgery• Chronic endometriosis• Abdominal trauma
• Head injury
• Medications• Opiates, Antibiotics, Anticholinergics
• Stress
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Am. J. Gastroenterol.2016. 111, 93–104
http://library.med.utah.edu/WebPath/GIHTML/GI030.htm
Adhesions between loops of small intestine
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Flora Distribution in SiBO
11JAMA. 2004;292(7):852-858.
DISTRIBUTION OF INTESTINAL BACTERIAL FLORA IN NORMAL GUT
AND IN SMALL INTESTINAL BACTERIAL OVERGROWTH
26cm 2.5m 3.5m
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THE SIBO CYCLE
SIBO
Host eats carbohydrates
Carbohydrates exposed to Bacteria
prematurely
Fermentation
Food = Survival & Proliferation
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START HERE
Predisposing
Factors
GI SYMPTOMS
+/- extra-gastrointestinal manifestations
• Gut inflammation
• ↑LPS
• Brush border damage
• Intestinal permeability
• Bile deconjugation
GAS
SIBO
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Clinical Presentation• Postprandial bloating
• Abdominal distension
• Altered gut motility – or normal
• Visceral hypersensitivity
• Abnormal brain-gut interaction (memory issues, brain fog, sleep problems etc)
• Autonomic dysfunction, and
• Immune activation
13
JAMA. 2004;292(7):852-858. doi:10.1001/jama.292.7.852.
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Clinical Presentation• Multiple food intolerances
• Commonly: apples, dairy, onion, cabbage, grains, legumes• And/or confusion about what does/doesn’t aggravate
• Carbohydrates &/or fats• food not my friend
• Leaky gut - Changes in barrier function• implications for nutrient absorption• systemic manifestations associated with increased absorption of
luminal endotoxins→Calorie-deficit
• Alterations in body composition
14World J Gastroenterol. 2010 Mar 7; 16(9): 1057–1062
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Hyperpermeability is Caused by SiBO
• Damage to the intestinal mucosa
• Bacteria, their biofilms and toxic by-products can all damage the lining of the small intestine
• Impairs nutrient absorption
• Increases intestinal hyperpermeability.
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Clinical Presentation
• Weight loss• Weight gain• Inflammation• Brush border damage
• Malabsorption• Hyper-permeability
• Nutrient deficiencies• Bile deconjugation
• Fat malabsorption
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Bile Salt Malabsorption (BSM)
• Functional diarrhoea / IBS-D assoc w/ BSM (~25% to 50%)
• Bacterial overgrowth in jejunum
→Fat malabsorption→Fat soluble vitamin deficiencies
→Urgency, early morning diarrhoea
→Burning on defaecation
17
J Lip Res. 2006, 47; 241-259.Gut and Liver. 2015, 9;3.
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• Confirm presumptive diagnosis• Determine the gas – guides treatment protocol• Determine the gas pattern – indicates area of dysfunction
(so “collateral damage” can be mitigated – eg proximal more likely to be histadelic, simple carb intolerant)
• Enhances client understanding• Increases compliance with treatment
• Can evaluate changes• Measure of colonic flora activity
Why test for SiBO?
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How to diagnose SIBO
1. Jejunal aspirate and culture
2. Hydrogen-Methane Breath testing• Humans can not make Hydrogen or Methane
• ONLY produced by bacteria• Any gases produced following ingestion of a
sugar MUST be coming from bacterial fermentation, so testing at intervals can track this.
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Indications for Breath testing
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Am J Gastroenterol 2017; 112:775–784
Performance of breath tests6. We suggest that the presence of bacterial overgrowth should be ruled out before performing lactose or fructose breath testing. (100% agreement)
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Why is the Gas Important?• Hydrogen
• Associated with diarrhoea• Visceral sensitiser• 100% correlation to fibromyalgia
• Methane• Normally produced by colonic flora• Associated with constipation
• Hydrogen sulphide• To date not measurable• Olfaction is best diagnostic tool
• Can have any combination of the above.
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J Neurogastroenterol Motil, 2010, 16; 2
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Choosing the Substrate
GLUCOSE
• 98% specific for SIBO but just 27% sensitivity • was compared to jejunal aspirate• ie – only correlates to proximal SIBO
• Hence the low sensitivity – will give false negative if SiBO occurs after first few feet of SI.
• RECOMMENDATION:• Glucose is best for those with significant reflux, eructation within 30-60 mins
of eating• Never in diabetics• MUST use if dairy ALLERGIC (not intolerant)
• Dose: 1g / kg up to 100g max dose.
22Eur J Gastroenterol Hepatol. 2014 Jul;26(7):753-60
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Choosing the SubstrateLACTULOSE• a synthetic sugar
• Humans lack ability to digest (no enzyme)• Dose: 10g (15mL) in 250-300mL water
• False positive is common – depends on transit time of individual
• Enables observation of flora activity from mouth to colon
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Testing for Malabsorption• Breath tests are also used to diagnose:
• Lactose intolerance• Fructose malabsorption• Sucrose malabsorption• Must rule out SIBO first
• These sugars normally absorbed in duodenum and proximal jejunum
• Testing protocol is similar – ask!
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Preparation for Breath Testing
25Am J Gastroenterol 2017; 112:775–784
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Preparation for Breath Testing
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• Stop antibiotics 4 weeks before
• Stop herbal antimicrobials minimum 2 weeks before
• Stop pro & prebiotics minimum 1 week before• Diet prep 24 hours – non-fermentable, no residue
• Overnight fast 12 hours – water only
• Test period 4 hours (3 hours of sample collection)1. Arise one hour prior to testing
• No smoking or vigorous exercise
2. Baseline breath sample3. Consume test substrate4. Repeat breath collections at 20 min intervals (15 mins for glucose challenge)
• RECORD SYMPTOMS including gas/bowel movements during testing
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ONE DAY• ALLOWED: eggs, fish, chicken/meat, white rice, white rice
noodles, white bread (milk-free: a good quality sourdough is best), clear meat broth (NOT bone broth). Salt, pepper, oil/butter for cooking. Small amount of hard cheese for flavour. Black tea, coffee, herb tea (not liquorice)
• STOP all non-essential medication• NO: fruit, veges, wholegrains, legumes, nuts, seeds, milk,
processed meat,
Prep Diet Guidelines
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What’s in the Test Kit:
Pre-paid bag (CourierPost) to send samples to
the lab.
Diet instructions & Client forms – to
send in with sample.
Laxative Herbal Tea (Alpine tea)ONLY for those with constipation, who did not have a bowel
motion the day before the prep diet.
Lactulose (15ml)
Breath collection device
10 test-tubesBubble bags to pack test tubes
in for sending to the lab.
Cardboard box to protect samples
10 labels
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The Collection DeviceBREATHE into this end –
lips sealed around outside
1
1.BREATHE until this bag is full….2
Test tube in “ready” position.
Continue breathing OUT. Push test tube fully onto the needle.
Count to 3. Remove. Label.
Repeat every 20 mins
3
Rubber-covered needle
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The SiBO Breath Test
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1. Test sugar consumed after collecting baseline sample
2. If present, SI bacteria ferment the sugar, producing
hydrogen and/or methane gas
3. Gases are absorbed into the blood stream and transported to
the lungs
4. Hydrogen, methane & carbon dioxide are
measured in the breath
• Medication restrictions/washout periods after antibiotics, unusual diarrhoea
• Prep period 24-48 hours• Restricted diet
• low residue = low fermentable
• Overnight fast (water only)
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How Samples are Analysed
• 8-day window for sample analysis
• Samples extracted by the Alveolac
• Quintron Breath Tracker • Uses gas chromatography
• Gold standard in breath testing
• Evaluates• Methane
• Hydrogen
• Carbon dioxide
• Corrects automatically based on CO2 content
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Interpreting Results• First principle
• ONLY bacteria produce these gases
• Second principle• Elevated baselines considered abnormal
• As long as prep diet was adhered to
• Third principle• Increases after 100 minutes most likely indicate
colonic fermentation
• Fourth principle• The rise in gas or gases must be significant
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Interpreting Results
33Am J Gastroenterol 2017; 112:775–784
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Interpreting Results• Various criteria in the literature
• Currently – Diagnosis based on what happens in the first 90 minutes • Hydrogen
• Rise of 20 ppm (c.f. lowest preceding value)
• Methane• Any methane at or above 10 • A rise of 12ppm (c.f. lowest preceding value)
• Combined• Rise of 15 ppm in methane + hydrogen
EXPECT: Double peak (but not required) – aids understanding of localityEXPECT: A rise after 100-120mins (colonic fermentation)
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An (almost) Normal
Breath Test
• Slightly elevated baselines
• No significant change until after 100mins
• Good colonic increase• NB symptoms:
• ? Lactose intolerance
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Looks normal but is missing a significant colonic rise
• Reasonable baselines
• Flatline until 3 hour mark
• Moderate increase only
• “The expected colonic rise is late and less than expected”
• Abnormal test.
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DISTAL SIBO• Low baselines
• Flatline for 40mins = duodenum and proximal jejunum are intact
• Large increase +57ppm H2 & + 13ppm CH4 at 60 mins
• Sustained rise
• FALLS in the colon
• DISTAL SIBO
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Elevated baseline,
invalid sample
?FLATLINE
38
Missing data – not enough CO2 in test tube
IMP: Gases produced in colon were passed (sample #1)• Absent colonic rise. • ? Hydrogen-sulphide (evaluate food sensitivities/stool/gas odour), OR• Inadequate colonic flora
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POSITIVE SIBO• Elevated baseline – esp
CH4
• Significant increase CH4 + H2 at 40 mins (+39ppm)
• Increases continue to peak at 100mins
• Significant symptoms during testing
• Abnormal test – Mixed gas SIBO
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Invalid Sample
“Not enough CO2 in the test tube”
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© 2018 Sharon Erdrich
Methane-Positive SIBO• NB: consensus document did not specify methane
increase for bacterial overgrowth (just that 10ppm or more was abnormal)
• Note:
• immediate increase +45ppm CH4 within 20 mins of consumption of lactulose.
• + 45ppm CH4 from 20 – 40 mins
• Decrease, then +24ppm CH4 between samples 3 & 4
• Flat-line hydrogen (H2 used by methanogenic bacteria)
C + H2 + H2 = CH4
• THIS CASE: Proximal SiBO & Distal SiBO
41
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Glucose challenge note the decrease in gases as the substrate is absorbed
42
• Testing at 15-minute intervals
• Extremely elevated baselines
• Big drop after swallowing (?oral flora)
• Calculate from LOWEST value (@15mins)
• Combined gases = 46
• 60 mins total H2 + CH4 = 63
• Increase = +17ppm
• POSITIVE
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Hydrogen-positive, Distal SIBO43
• BO 3 x day
• BSC #6-7
• Note the presumed transit at sample #7
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Successful Treatment
• Same client – positive SIBO at 20 mins (severe histadelia)
• Very high methane
• Note the resizing of the graph
• Successful treatment of proximal SiBO & reduction of methane levels
• Absent colonic rise
Read the data, not the graph
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For an more in-depth understanding of SiBO, visit the education portal –you can download the full seminar. Join our closed facebook group for practitioners only “NZ Clinicians for
Gut Health”