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Small intestinal bacterial overgrowth
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'''Small intestinal bacterial overgrowth''' (SIBO) is an excessive population of bacteria in the [[small intestine]]. Unlike the large intestine, which is has a very high population of bacteria, the small intestine ordinarily has a very low population of bacteria in healthy people.{{Citation needed| date = July 2022}} There is some limited evidence that SIBO has a high prevalence in ME/CFS patients, and as yet little evidence that treatment may improve symptoms. == Prevalence == The rate of a positive lactulose test is low in healthy adults (0 to 20%).<ref name="Dukowicz2007">{{Cite journal | last1 = Dukowicz | first1 = AC | authorlink1 = Andrew Dukowicz | last2 = Lacy | first2 = BE | authorlink2 = Brian Lacy | last3 = Levine | first3 = GM | authorlink3 = Gary Levine | title = Small Intestinal Bacterial Overgrowth | journal = Gastroenterology & Hepatology | volume = 3 | issue = 2| pages = 112–122 | date = Feb 2007 | pmid = 21960820 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099351/ }}</ref> == Comorbidities == Anecdotal reports suggest a high prevalence of SIBO among CFS patients.{{Citation needed| date = July 2022}} One study of 24 CFS patients found 77% had SIBO, however it found no difference between the blinded treatment arms after treatment with neomycin, an antibiotic. Including patients with both open label and blinded treatment, it did find that those that had eradication improved compared to their baseline scores.<ref name="Pimentel2000">{{Cite journal | last1 = Pimentel | first1 = M | authorlink1 = Mark Pimentel | last2 = Hallegua | first2 = D | authorlink2 = David Hallegua | last3 = Chow | first3 = EJ | authorlink3 = | last4 = Wallace | first4 = D | authorlink4 = Daniel Wallace | last5 = Bonorris | first5 = G | authorlink5 = | last6 = Lin | first6 = HC | authorlink6 = Henry Lin | title = Eradication of small intestinal bacterial overgrowth decreases symptoms in chronic fatigue syndrome: A double blind, randomized study | journal = Gastroenterology | volume = 118 | issue = 4| pages = 414 | date = Apr 1, 2000 | doi = 10.1016/S0016-5085(00)83765-8| url = http://www.gastrojournal.org/article/S0016508500837658/abstract }}</ref> Research has found patients with CFS have alterations in microbiota, including lower levels of bifidobacteria and SIBO.<ref name="Logan2003">{{Cite journal | last1 = Logan | first1 = Alan C | last2 = Venket Rao | first2 = A | last3 = Irani | first3 = Dinaz | title = Chronic fatigue syndrome: lactic acid bacteria may be of therapeutic value | journal = Medical Hypotheses | volume = 60 | issue = 6 | pages = 915–923 | date = Jun 2003 | pmid = 12699726| url = http://www.ncbi.nlm.nih.gov/pubmed/12699726 }}</ref> Several studies have shown that up to 84% of patients with [[irritable bowel syndrome]] have SIBO<ref name="Dukowicz2007" /> and that symptoms improve after treatment<ref name="Pimentel2004">{{Cite journal | last1 = Pimentel | first1 = M | authorlink1 = Mark Pimentel | last2 = Wallace | first2 = D | authorlink2 = Daniel Wallace | last3 = Hallegua | first3 = D | authorlink3 = David Hallegua | last4 = Chow | first4 = EJ | authorlink4 = Evelyn Chow | last5 = Kong | first5 = Y | authorlink5 = Y Kong | last6 = Park | first6 = S | authorlink6 = S Park | last7 = Lin | first7 = HC | authorlink7 = Henry Lin | title = A link between irritable bowel syndrome and fibromyalgia may be related to findings on lactulose breath testing | journal = Annals of the Rheumatic Diseases | volume = 63 | issue = 4 | pages = 450–452 | date = Apr 2004 | pmid = 15020342 | doi = 10.1136/ard.2003.011502 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1754959/ }}</ref><ref name="LinHC2004">{{Cite journal | last1 = Lin | first1 = HC | authorlink1 = Henry Lin | title = Small intestinal bacterial overgrowth: A framework for understanding irritable bowel syndrome | journal = JAMA | volume = 292 | issue = 7| pages = 852–858 | date = Aug 18, 2004 | doi = 10.1001/jama.292.7.852 | url = http://jama.jamanetwork.com/article.aspx?articleid=199251 }}</ref>, while others fail to replicate these results.<ref name="Walters2005">{{Cite journal | last1 = Walters | first1 = B | authorlink1 = B Walters | last2 = Vanner | first2 = SJ | authorlink2 = S J Vanner | title = Detection of bacterial overgrowth in IBS using the lactulose H2 breath test: comparison with 14C-D-xylose and healthy controls | journal = The American Journal of Gastroenterology | volume = 100 | issue = 7| pages = 1566–1570 | date = Jul 2005 | pmid = 15984983 | doi = 10.1111/j.1572-0241.2005.40795.x | url = http://www.ncbi.nlm.nih.gov/pubmed/15984983 }}</ref><ref name="Parisi2003">{{Cite journal | last1 = Parisi | first1 = Giancarlo | last2 = Leandro | first2 = Gioacchino | last3 = Bottona | first3 = E | last4 = Carrara | first4 = M | last5 = Cardin | first5 = F | last6 = Faedo | first6 = A | last7 = Goldin | first7 = D | last8 = Pantalena | first8 = M | last9 = Tafner | first9 = G | last10 = Verdianelli | first10 = G | last11 = Zilli | first11 = M | last12 = AISGE Group | title = Small intestinal bacterial overgrowth and irritable bowel syndrome | journal = The American Journal of Gastroenterology | volume = 98 | issue = 11 | pages = 2572-2574 | date = Nov 2003 | pmid = 14638371 | doi = 10.1111/j.1572-0241.2003.08686.x | url = http://www.ncbi.nlm.nih.gov/pubmed/15984983 }}</ref> One study found that a 100% of [[fibromyalgia]] patients tested positive to a lactulose breath test, indicating SIBO, and that the degree of abnormality on the breath test correlated with the amount of pain reported.<ref name="Pimentel2004" /> == Risk factors == * Bowel resection * Bariatric surgery * Disordered motility * Disorders of the immune system * [[IgA]] deficiency * Low stomach acid * [[Proton pump inhibitor]]s * Immunosuppressants * Recurrent antibiotic use <ref name="Dukowicz2007"/> * [[Hashimoto's thyroiditis (hypothyroidism)|Hypothyroidism]] * T4-only thyroid hormone replacement * [[Gastroparesis]] * [[Celiac disease]]<ref name="Dukowicz2007"/> * Crohn's disease<ref name="Dukowicz2007"/> * Pancreatitis<ref name="Dukowicz2007"/> * Renal failure (kidney failure)<ref name="Dukowicz2007"/> * Old age<ref name="Dukowicz2007"/> == Diagnosis == SIBO is usually diagnosed via a [[Lactulose breath test]]. Sometimes it is diagnosed using a bacterial culture. But this is rare due to the difficulty and cost of retrieving a sample from the small intestine. SIBO cannot be diagnosed via stool testing.{{Citation needed| date = Jul 2022}} == Pathophysiology == SIBO appears to cause increased [[intestinal permeability]], also known as [[Leaky gut|Leaky Gut]]. It is believed that this enables lipopolysaccharides from bacteria, food particles, and other undesirable substances to enter the blood stream, ultimately leading to an inflammatory response.{{Citation needed| date = Jul 2022}} Bacteria commonly implicated in SIBO include [[Escherichia coli]], [[Streptococcus]], [[Lactobacillus]], [[Bacteroides]] and [[Enterococcus]].<ref name="Bouhnik2016">{{Cite journal | last1 = Bouhnik | first1 = Yoram | authorlink2 = | last2 = Alain | first2 = Sophie | authorlink3 = | last3 = Attar | first3 = Alain | authorlink4 = | last4 = Flourié | first4 = Bernard | authorlink5 = | last5 = Raskine | first5 = Laurent | authorlink6 = | last6 = Sanson-Le Pors | first6 = Marie José | authorlink7 = | last7 = Rambaud | first7 = Jean-Claude | authorlink8 = | title = Bacterial populations contaminating the upper gut in patients with small intestinal bacterial overgrowth syndrome | journal = The American Journal of Gastroenterology | volume = 94 | issue = 5 | pages = 1327–1331 | date = May 1999 | doi = 10.1111/j.1572-0241.1999.01016.x | url = http://www.nature.com/ajg/journal/v94/n5/full/ajg1999310a.html }}</ref> Higher levels of ''Enterococcus'' and ''Stretptococcus'' have been found in [[ME/CFS]] patients.<ref name="Sheedy2009">{{cite journal | last1 = Sheedy | first1 = John R | authorlink1 = John Sheedy | last2 = Wettenhall | first2 = Richard EH | authorlink2 = Richard Wettenhall | last3 = Scanlon | first3 = Denis | authorlink3 = Denis Scanlon | last4 = Gooley | first4 = Paul R | authorlink4 = Paul Gooley | last5 = Lewis | first5 = Donald P | authorlink5 = Donald Lewis | last6 = McGregor | first6 = Neil | authorlink6 = Neil McGregor | last7 = Stapleton | first7 = David I | authorlink7 = David Stapleton | last8 = Butt | first8 = Henry L | authorlink8 = Henry Butt | last9 = De Meirleir | first9 = Kenny L | authorlink9 = Kenny de Meirleir | title = Increased d-lactic Acid intestinal bacteria in patients with chronic fatigue syndrome | journal = In Vivo | volume = 23 | issue = 4 | pages = 621-8 | date = Jul 2009 | pmid = 19567398 | url = http://iv.iiarjournals.org/content/23/4/621.long }}</ref> == Health complications == The symptoms of SIBO can vary greatly depending on the severity and the species of bacteria populating the small intestine.<ref name="Parisi2003" /> Symptoms include bloating, abdominal distension, abdominal pain or discomfort, diarrhea, fatigue, weakness, and brain fog. It causes increased permeability of the small intestine.{{citation needed}} It can cause malabsorption of nutrients including iron and [[Vitamin B12]], resulting in [[microcytic anemia]] or [[megaloblastic anemia]]. ===Nutritional deficiencies=== Vitamin B12 malabsorption may be caused by competitive uptake of B12 by bacteria in the small intestine.<ref name="Dukowicz2007" /> It can also cause excess folic acid due to synthesis by bacteria in the small bowel.<ref name="Camilo1996">{{Cite journal | last1 = Camilo | first1 = E | last2 = Zimmerman | first2 = J | last3 = Mason | first3 = JB | last4 = Golner | first4 = B | last5 = Russell | first5 = R | last6 = Selhub | first6 = J | last7 = Rosenberg | first7 = IH | title = Folate synthesized by bacteria in the human upper small intestine is assimilated by the host | journal = Gastroenterology | volume = 110 | issue = 4| pages = 991–998 | date = Apr 1996 | pmid = 8613033 | url = http://www.ncbi.nlm.nih.gov/pubmed/8613033 }}</ref> In severe cases, malabsorption of fat-soluble vitamins ([[Vitamin A|A]],[[Vitamin D|D]],[[Vitamin E|E]] and [[Vitamin K|K]]) due to the deconjugation of [[bile salts]] can cause neuropathies and immune dysfunction. SIBO can also cause carbohydrate and protein malabsorption.<ref name="Dukowicz2007" /> == Treatment == Treatment generally involves some combination of antibiotics, dietary changes, pro-kinetic agents, and probiotics.{{Citation needed| date = August 2022}} Treatment via antibiotics is most common. {{citation needed}}. === Antibiotics === Any antibiotic that is active in the small intestine may potentially affect the bacterial flora and therefore SIBO. However, certain antibiotics are used preferentially when treatment is explicitly targeting SIBO. These antibiotics may be synthetic or herbal, though synthetic antibiotics appears to be used most often.{{Citation needed| date = Aug 2022}} Treatment with antibiotics carries the risk of wiping out both abnormal and normal bacteria, which may cause problems similar to those that are trying to be cured, such as diarrhea.<ref>{{Cite web|url=https://www.mayoclinic.org/diseases-conditions/small-intestinal-bacterial-overgrowth/diagnosis-treatment/drc-20370172 | title = Small intestinal bacterial overgrowth (SIBO) - Diagnosis and treatment|website=Mayo Clinic|language=en|access-date=2022-08-03}}</ref> ==== Synthetic ==== * [[Rifxaimin]] is the most commonly used antibiotic used for SIBO treatment. It is effective on hydrogen producing bacteria, but not methane producing bacteria. Only a small percentage of the drug is absorbed by the body, and its activity is mostly limited to the small intestine. <ref name="Bures2010">{{Cite journal | last1 = Bures | first1 = Jan | last2 = Cyrany | first2 = Jiri | last3 = Kohoutova | first3 = Darina | last4 = Förstl | first4 = Miroslav | last5 = Rejchrt | first5 = Stanislav | last6 = Kvetina | first6 = Jaroslav | last7 = Vorisek | first7 = Viktor | last8 = Kopacova | first8 = Marcela | title = Small intestinal bacterial overgrowth syndrome | journal = World Journal of Gastroenterology : WJG | volume = 16 | issue = 24| pages = 2978–2990 | date = Jun 28, 2010 | pmid = 20572300 | doi = 10.3748/wjg.v16.i24.2978 | url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2890937/ }}</ref> * [[Neomycin]] is sometimes given in addition to Rifaximin when methane-producing bacteria are present.<ref>{{Cite journal | last = Low | first = Kimberly | last2 = Hwang | first2 = Laura | last3 = Hua | first3 = Johnson | last4 = Zhu | first4 = Amy | last5 = Morales | first5 = Walter | last6 = Pimentel | first6 = Mark | date = Sep 2010 | title = A combination of rifaximin and neomycin is most effective in treating irritable bowel syndrome patients with methane on lactulose breath test|url=https://www.ncbi.nlm.nih.gov/pubmed/19996983|journal=Journal of Clinical Gastroenterology|volume=44|issue=8|pages=547–550|doi=10.1097/MCG.0b013e3181c64c90|issn=1539-2031|pmid=19996983}}</ref> However, one study comparing two herbal formulations to standard treatment found herbs to be as or more effect as antibiotics for eradicating SIBO.<ref name="Chedid2014">{{Cite journal | last1 = Chedid | first1 = Victor | last2 = Dhalla | first2 = Sameer | last3 = Clarke | first3 = John O | last4 = Roland | first4 = Bani Chander | last5 = Dunbar | first5 = Kerry B | last6 = Koh | first6 = Joyce | last7 = Justino | first7 = Edmundo | last8 = Tomakin | first8 = Eric | last9 = Mullin | first9 = Gerard E | title = Herbal Therapy Is Equivalent to Rifaximin for the Treatment of Small Intestinal Bacterial Overgrowth | journal = Global Advances in Health and Medicine | volume = 3 | issue = 3| pages = 16–24 | date = May 2014 | pmid = 24891990 | doi = 10.7453/gahmj.2014.019 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030608/ }}</ref> * [[Metronidazole]] ==== Herbal ==== * [[Oregano]] * [[Allicin]] === Diet === Diets have been used and/or shown to be helpful in treating or controlling SIBO include: * [[GAPS diet|GAPS Diet]] * [[Low FODMAP diet|Low FODMAP Diet]] * [[Specific carbohydrate diet|Specific Carbohydrate Diet]] * [[Elemental diet|Elemental Diet]] === Pro-kinetic Agents === Experts also recommend the use of [[prokinetic drugs]] or herbs for those for whom dysmotility is an issue.<ref name="Dukowicz2007" /> These agents include: * [[Low dose naltrexone|Low Dose Naltrexone]] (LDN) === Probiotics === The role of probiotics in treatment is controversial. One school of thought is that SIBO is not due to a "bad" bacteria, but rather a simple overgrowth of ordinary / healthy bacteria. Therefore, it would follow that probiotics would be counterproductive to treating and managing SIBO. Another school of thought is that SIBO is caused or worsened by the presence of a "bad" bacteria, or a bad mix of bacteria. Therefore, it would follow that probiotics that increase the level of "good" bacteria, or promote a healthier mix of bacteria, would be helpful in treating or managing SIBO. [[Lactobacillus casei]] has been found to improve breath hydrogen scores after six weeks of treatment.<ref name="Barrett2008">{{Cite journal | last1 = Barrett | first1 = Jacqueline S | last2 = Canale | first2 = Kim EK | last3 = Gearry | first3 = Richard B | last4 = Irving | first4 = Peter M | last5 = Gibson | first5 = Peter R | title = Probiotic effects on intestinal fermentation patterns in patients with irritable bowel syndrome | journal = World Journal of Gastroenterology : WJG | volume = 14 | issue = 32| pages = 5020–5024 | date = Aug 28, 2008 | pmid = 18763284 | doi = 10.3748/wjg.14.5020 | url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742929/ }}</ref> There is also evidence for [[VSL #3]] in the treatment of SIBO.<ref name="Meier2003">{{Cite journal | last1 = Meier | first1 = Rémy | last2 = Burri | first2 = Emanuel | last3 = Steuerwald | first3 = Michael | title = The role of nutrition in diarrhoea syndromes | journal = Current Opinion in Clinical Nutrition and Metabolic Care | volume = 6 | issue = 5| pages = 563–567 | date = Sep 2003 | pmid = 12913674 | doi = 10.1097/01.mco.0000087972.83880.d3 | url = http://www.ncbi.nlm.nih.gov/pubmed/12913674 }} </ref> However, some probiotics may exacerbate SIBO, in particular those containing [[D-Lactate]] producing strains. === Increasing Stomach Acid === In cases where SIBO is caused by low stomach acid, treatment may include dietary supplements that increase stomach acid, such as [[Betaine|Betaine Hydrochloride]].{{Citation needed | date = Jul 2022}} == See also == *[[Gastrointestinal system]] *[[Dysbiosis]] *[[Probiotics]] *[[Dr Markov's chronic bacterial intoxication syndrome (CBIS) theory of ME/CFS]] (Dr Markov has evidence that ME/CFS is caused by a dysbiosis in the kidneys) == Learn more == * June 29, 2018, [https://universityhealthnews.com/daily/digestive-health/sibo-treatment-with-herbs-is-as-effective-as-antibiotics-combine-with-a-sibo-diet-for-even-better-results/ SIBO Treatment with Herbs Is as Effective as Antibiotics]. University Health News == References == {{Reflist}} [[Category:Diagnoses]] [[Category:Signs and symptoms]] [[Category:Digestive signs and symptoms]] [[Category:Digestive system]]
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