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Aziz I, Törnblom H, Simrén M. Small intestinal bacterial overgrowth as a cause for irritable bowel syndrome: guilty or not guilty? Curr Opin Gastroenterol 2017; 33:196-202. [PMID: 28257307 DOI: 10.1097/mog.0000000000000348] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Small intestinal bacterial overgrowth (SIBO) has been proposed as a cause of irritable bowel syndrome (IBS). However, this relationship has been subject to controversy. This review aims to provide a current perspective on the SIBO-IBS hypothesis. RECENT FINDINGS Case-control studies evaluating the prevalence of SIBO in IBS and healthy individuals have shown conflicting results. Moreover, the tests available in routine clinical practice to diagnose SIBO are not valid and lack both sensitivity and specificity. Hence, interpreting the effect of interventions based on these tests is fraught with uncertainty. Furthermore, the SIBO-IBS hypothesis has paved the way to assess antibiotic therapy in nonconstipated IBS, with rifaximin, a nonabsorbable antibiotic, showing modest but significant clinical benefit. However, individuals were not tested for SIBO and the mechanism of action of rifaximin in IBS remains to be elucidated. Preliminary data suggest that rifaximin decreases microbial richness and previous studies have noted antibacterial interventions in IBS to reduce colonic fermentation and improve symptoms. The advent of rapid culture-independent molecular techniques is a promising tool that will seek to clarify and advance our understanding of the gut microbial function. SUMMARY The SIBO-IBS hypothesis lacks convincing evidence but remains under scrutiny. The mechanism resulting in symptom improvement after rifaximin treatment in some IBS individuals requires exploration. Novel molecular techniques provide an exciting and challenging opportunity to explore the host-gut microbiota interaction.
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Affiliation(s)
- Imran Aziz
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Rezaie A, Buresi M, Lembo A, Lin H, McCallum R, Rao S, Schmulson M, Valdovinos M, Zakko S, Pimentel M. Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus. Am J Gastroenterol 2017; 112:775-784. [PMID: 28323273 PMCID: PMC5418558 DOI: 10.1038/ajg.2017.46] [Citation(s) in RCA: 426] [Impact Index Per Article: 60.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 01/02/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Breath tests (BTs) are important for the diagnosis of carbohydrate maldigestion syndromes and small intestinal bacterial overgrowth (SIBO). However, standardization is lacking regarding indications for testing, test methodology and interpretation of results. A consensus meeting of experts was convened to develop guidelines for clinicians and research. METHODS Pre-meeting survey questions encompassing five domains; indications, preparation, performance, interpretation of results, and knowledge gaps, were sent to 17 clinician-scientists, and 10 attended a live meeting. Using an evidence-based approach, 28 statements were finalized and voted on anonymously by a working group of specialists. RESULTS Consensus was reached on 26 statements encompassing all five domains. Consensus doses for lactulose, glucose, fructose and lactose BT were 10, 75, 25 and 25 g, respectively. Glucose and lactulose BTs remain the least invasive alternatives to diagnose SIBO. BT is useful in the diagnosis of carbohydrate maldigestion, methane-associated constipation, and evaluation of bloating/gas but not in the assessment of oro-cecal transit. A rise in hydrogen of ≥20 p.p.m. by 90 min during glucose or lactulose BT for SIBO was considered positive. Methane levels ≥10 p.p.m. was considered methane-positive. SIBO should be excluded prior to BT for carbohydrate malabsorption to avoid false positives. A rise in hydrogen of ≥20 p.p.m. from baseline during BT was considered positive for maldigestion. CONCLUSIONS BT is a useful, inexpensive, simple and safe diagnostic test in the evaluation of common gastroenterology problems. These consensus statements should help to standardize the indications, preparation, performance and interpretation of BT in clinical practice and research.
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Affiliation(s)
- Ali Rezaie
- GI Motility Program, Division of Gastroenterology, Department of Medicine, Cedars-Sinai, Los Angeles, California, USA,Assistant Professor, Assistant Director, GI Motility Program, Cedars-Sinai Medical Center, 8730 Alden Drive, Suite 2E, Los Angeles, California 90048, USA. E-mail:
| | - Michelle Buresi
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anthony Lembo
- Beth Israel Deaconess Medical Center, Department of Medicine, Boston, Massachusetts, USA
| | - Henry Lin
- New Mexico VA Health Care System, Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Richard McCallum
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Satish Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Augusta University, Augusta, Georgia, USA
| | - Max Schmulson
- Laboratorio de Hígado, Páncreas y Motilidad (HIPAM)-Unit of Research in Experimental Medicine, Faculty of Medicine-Universidad Nacional Autónoma de México (UNAM), Department of Medicine, Mexico City, Mexico
| | - Miguel Valdovinos
- GI Motility and Neurogastroenteroly Unit, Department of Gastroenterology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Salam Zakko
- Connecticut Gastroenterology Institute, Department of Medicine, Bristol Hospital, Bristol, Connecticut, USA
| | - Mark Pimentel
- GI Motility Program, Division of Gastroenterology, Department of Medicine, Cedars-Sinai, Los Angeles, California, USA
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Krajicek EJ, Hansel SL. Small Intestinal Bacterial Overgrowth: A Primary Care Review. Mayo Clin Proc 2016; 91:1828-1833. [PMID: 27916156 DOI: 10.1016/j.mayocp.2016.07.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 07/24/2016] [Accepted: 07/27/2016] [Indexed: 02/07/2023]
Abstract
Gastrointestinal symptoms are commonly seen in the primary care setting.1 These patient presentations can be nonspecific, leading to a broad differential diagnosis. Small intestinal bacterial overgrowth is a clinical entity that can present with many of these nonspecific gastrointestinal symptoms. The recent interest in the microbiome by those in the medical and lay communities has made this syndrome all the more relevant. This review gives the primary care provider an up-to-date understanding of the etiology, risk factors and predisposing factors, presentation, diagnostic testing, and management of small intestinal bacterial overgrowth.
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Affiliation(s)
| | - Stephanie L Hansel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Abdalla SM, Kalra G, Moshiree B. Motility Evaluation in the Patient with Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2016; 26:719-38. [PMID: 27633599 DOI: 10.1016/j.giec.2016.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with inflammatory bowel disease (IBD) suffer frequently from functional bowel diseases (FBD) and motility disorders. Management of FBD and motility disorders in IBD combined with continued treatment of a patient's IBD symptoms will likely lead to better clinical outcomes and improve the patient's quality of life. The goals of this review were to summarize the most recent literature on motility disturbances in patients with IBD and to give a brief overview of the ranges of motility disturbances, from reflux disease to anorectal disorders, and discuss their diagnosis and specific management.
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Affiliation(s)
- Sherine M Abdalla
- Department of Medicine, Jackson Memorial Hospital, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Central Building, 600D, Miami, FL 33136, USA
| | - Gorav Kalra
- Department of Medicine, Jackson Memorial Hospital, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB, 11th Floor, Miami, FL 33136, USA
| | - Baha Moshiree
- Department of Medicine, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB Suite 971, Miami, FL 33136, USA.
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Camilleri M, Katzka DA. Enhancing High Value Care in Gastroenterology Practice. Clin Gastroenterol Hepatol 2016; 14:1376-84. [PMID: 27215366 PMCID: PMC5028260 DOI: 10.1016/j.cgh.2016.05.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 04/29/2016] [Accepted: 05/03/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUNG & AIMS The objective of this review is to identify common areas in gastroenterology practice where studies performed provide an opportunity for enhancing value or lowering costs. METHODS We provide examples of topics in gastroenterology where clinicians could enhance value by either using less invasive testing, choosing a single best test, or by using patient symptoms to guide additional testing. RESULTS The topics selected for review are selected in esophageal, pancreatic, and colorectal cancer; functional gastrointestinal diseases (irritable bowel syndrome, bacterial overgrowth, constipation); immune-mediated gastrointestinal diseases; and pancreaticobiliary pathology. We propose guidance to alter practice based on current evidence. CONCLUSIONS These studies support the need to review current practice and to continue performing research to further validate the proposed guidance to enhance value of care in gastroenterology and hepatology.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - David A Katzka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Triantafyllou K, Pimentel M. Understanding Breath Tests for Small Intestinal Bacterial Overgrowth. Clin Gastroenterol Hepatol 2016; 14:1362-3. [PMID: 26968465 DOI: 10.1016/j.cgh.2016.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 03/01/2016] [Accepted: 03/02/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Mark Pimentel
- GI Motility Program, Cedars-Sinai Medical Center, Los Angeles, California
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Craig RM. Small Intestinal Bacterial Overgrowth. Clin Gastroenterol Hepatol 2016; 14:1223. [PMID: 26923735 DOI: 10.1016/j.cgh.2016.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 02/22/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Robert M Craig
- Professor Emeritus Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Effects of Rifaximin on Transit, Permeability, Fecal Microbiome, and Organic Acid Excretion in Irritable Bowel Syndrome. Clin Transl Gastroenterol 2016; 7:e173. [PMID: 27228404 PMCID: PMC4893683 DOI: 10.1038/ctg.2016.32] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 04/19/2016] [Indexed: 12/19/2022] Open
Abstract
Objectives: Rifaximin relieves irritable bowel syndrome (IBS) symptoms, bloating, abdominal pain, and loose or watery stools. Our objective was to investigate digestive functions in rifaximin-treated IBS patients. Methods: In a randomized, double-blind, placebo-controlled, parallel-group study, we compared the effects of rifaximin, 550 mg t.i.d., and placebo for 14 days in nonconstipated IBS and no evidence of small intestinal bacterial overgrowth (SIBO). All subjects completed baseline and on-treatment evaluation of colonic transit by scintigraphy, mucosal permeability by lactulose–mannitol excretion, and fecal microbiome, bile acids, and short chain fatty acids measured on random stool sample. Overall comparison of primary response measures between treatment groups was assessed using intention-to-treat analysis of covariance (ANCOVA, with baseline value as covariate). Results: There were no significant effects of treatment on bowel symptoms, small bowel or colonic permeability, or colonic transit at 24 h. Rifaximin was associated with acceleration of ascending colon emptying (14.9±2.6 h placebo; 6.9±0.9 h rifaximin; P=0.033) and overall colonic transit at 48 h (geometric center 4.0±0.3 h placebo; 4.7±0.2 h rifaximin; P=0.046); however, rifaximin did not significantly alter total fecal bile acids per g of stool or proportion of individual bile acids or acetate, propionate, or butyrate in stool. Microbiome studies showed strong associations within subjects, modest associations with time across subjects, and a small but significant association of microbial richness with treatment arm (rifaximin vs. treatment). Conclusions: In nonconstipated IBS without documented SIBO, rifaximin treatment is associated with acceleration of colonic transit and changes in microbial richness; the mechanism for reported symptomatic benefit requires further investigation.
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