Introduction
Small intestinal bacterial overgrowth (SIBO), characterized by an excessive amount of colonic bacteria in the small intestine, is a condition increasingly recognized in the realm of automotive repair expertise – metaphorically speaking. Just as a vehicle’s intricate systems can be disrupted by imbalances, the human gut, particularly the small intestine, relies on a delicate balance of bacteria. Unlike the colon, the small intestine typically maintains a low bacterial concentration, rarely exceeding 1000 organisms/mL. This equilibrium is safeguarded by gastric acid secretion and intestinal motility. However, when these protective mechanisms falter, small intestinal bacterial overgrowth (SIBO) can occur, leading to a cascade of symptoms. This article delves into the diagnosis of bacterial overgrowth, its evaluation, and management, emphasizing the crucial role of a comprehensive approach, much like diagnosing complex automotive issues.
Etiology of Small Intestinal Bacterial Overgrowth
The development of small intestinal bacterial overgrowth is multifaceted, stemming from a variety of factors including motility issues, anatomical abnormalities, immune deficiencies, reduced gastric acid production (hypochlorhydria), metabolic disorders, and other systemic conditions.
Several host defense mechanisms are critical in preventing bacterial overgrowth in the small intestine. These include gastric acid and bile, which act to destroy and inhibit bacterial passage following food ingestion. Consequently, conditions associated with achlorhydria are often linked to SIBO. Proteolytic digestive enzymes also play a role by degrading bacteria within the intestines. Chronic pancreatic insufficiency, therefore, is another predisposing factor for SIBO. Furthermore, migrating motor complexes are essential for intestinal peristalsis, effectively cleansing the small intestine and preventing the retrograde movement of bacteria. Disruptions in gastrointestinal motility, such as those seen in irritable bowel syndrome, narcotic use, post-radiation enteropathy, hypothyroidism, diabetes mellitus, and scleroderma, are significantly associated with SIBO.
Anatomical factors also play a crucial role. An intact ileocecal valve, coupled with the forward (antegrade) motility of the ileum, prevents the backflow of colonic bacteria into the small intestine. Anatomical abnormalities that cause bowel stasis, such as small intestinal diverticulosis, bowel strictures, post-operative adhesions, gastric bypass surgeries creating blind intestinal loops, and ileocecal resection, can all predispose individuals to SIBO. Finally, secretory immunoglobulin IgA, abundant in the gastrointestinal tract, is vital for preventing bacterial proliferation and maintaining intestinal immunity. Immunodeficiency disorders, including acquired immune deficiency syndrome, common variable immunodeficiency, and IgA deficiency, are associated with an elevated risk of developing SIBO.
Epidemiology of SIBO
The precise prevalence of small intestinal bacterial overgrowth remains largely undefined. Irritable bowel syndrome, intestinal motility disorders, and chronic pancreatitis are frequently observed in conjunction with SIBO, accounting for a significant proportion of cases, estimated at 80-90%. SIBO is noted to be more common among females and older adults. The incidence of SIBO increases with advancing age, often linked to hypochlorhydria and diminished intestinal motility. In many instances, multiple contributing factors to SIBO can be identified in a single patient.
Pathophysiology of Bacterial Overgrowth
Small intestinal bacterial overgrowth is characterized by an abnormally high bacterial count within the small intestine. However, the mere presence of increased bacteria does not always equate to active disease. Clinical symptoms typically manifest when inflammation arises from invasive bacterial strains. These invasive strains can produce enzymes or endotoxins that damage the epithelial cell layer, triggering various symptoms. Common bacterial species identified in SIBO include Escherichia coli, Aeromonas, and Klebsiella species. Anaerobic bacteria can cause direct epithelial injury and produce enterotoxins, while aerobic bacteria primarily produce enterotoxins, both contributing to intestinal inflammation. Bacterial overgrowth can also disrupt normal bowel motility.
Endoscopic and histopathological examinations of the mucosa in SIBO often reveal a seemingly healthy intestinal lining. Nonspecific endoscopic findings may include mucosal edema, reduced vascularity, patchy erythema, and in rare cases, ulceration. Similarly, nonspecific histopathological findings can include villous blunting, cryptitis, intraepithelial lymphocytosis, and eosinophilia.
Histopathology in SIBO
In most cases of SIBO, endoscopic findings and histopathologic examinations of the small intestine and colon mucosa are generally normal. When abnormalities are observed endoscopically, they are often nonspecific, such as mucosal edema, erythema, increased friability due to abnormal vascular patterns, and, infrequently, ulcerations. Histological examination may reveal villous blunting, atrophy, an increase in intraepithelial lymphocytes, and eosinophilia, all of which are considered nonspecific findings.
Toxicokinetics and Malabsorption in SIBO
Small intestinal bacterial overgrowth can lead to improper digestion and malabsorption, resulting in a range of symptoms. Fat malabsorption, caused by bacterial deconjugation of bile, can lead to weight loss, diarrhea, and deficiencies in fat-soluble vitamins such as A, D, and K. Carbohydrate malabsorption contributes to abdominal distension (due to hydrogen, carbon dioxide, and methane production), excessive flatulence, and acidic stools. Protein malabsorption can occur due to decreased mucosal uptake. Interestingly, SIBO is often associated with normal or elevated folate levels, but decreased vitamin B12 levels. Vitamin B12 deficiency arises from ileal mucosal damage affecting cobalamin binding sites. Deficiencies in vitamin B1 and B3 can occur due to bacterial overutilization of these nutrients.
History and Physical Examination for SIBO
The clinical presentation of small intestinal bacterial overgrowth typically involves a combination of abdominal discomfort along with bloating, flatulence, or chronic watery diarrhea. Steatorrhea and weight loss resulting from fat malabsorption may also be evident, particularly in cases with altered gut anatomy such as blind loop syndrome. Vitamin deficiencies, especially B12 deficiency, are common in SIBO and can manifest as weakness, sensory ataxia, and paresthesia. Severe vitamin D deficiency due to malabsorption can lead to perioral numbness, hand and feet paresthesia, and muscle cramps from hypocalcemia.
D-lactic acidosis, a rare neurological syndrome, is another potential complication of SIBO, characterized by altered mental status, slurred speech, seizures, and ataxia. This syndrome results from bacterial fermentation of unabsorbed carbohydrates. Patients with SIBO associated with short bowel syndrome or jejunoileal bypass are at higher risk of developing this condition. SIBO has also been implicated in the development of nonalcoholic fatty liver disease and hepatic encephalopathy. In most cases, physical examination findings are generally unremarkable unless severe malnutrition is present. In rare instances, a succussion splash, indicative of fluid-filled bowel loops, may be detected.
Bacterial Overgrowth Diagnosis: Evaluation and Testing
Currently, there is no universally accepted gold standard diagnostic test for SIBO. When a patient presents with symptoms suggestive of SIBO, the diagnosis is further supported by a positive carbohydrate breath test or a bacterial concentration exceeding 1000 colony-forming units/mL in a jejunal aspirate culture.
Carbohydrate Breath Tests
The carbohydrate breath test is a noninvasive, rapid, and cost-effective method for Bacterial Overgrowth Diagnosis. This test operates on the principle that bacteria metabolizing either lactulose or glucose (the carbohydrate substrates) will produce hydrogen or methane. These gases are then absorbed into the bloodstream and exhaled in the patient’s breath. A positive result is indicated by a rise of more than 20 parts per million from baseline in hydrogen within 90 minutes, or a methane level exceeding ten parts per million. However, it’s important to note that breath test results can be falsely positive in patients with short bowel syndrome. Conversely, low counts of anaerobic organisms might lead to false negative results. Studies evaluating the accuracy of breath tests show varying sensitivity and specificity. For example, a review by Romagnuolo J et al. reported the sensitivity of the glucose breath test ranging from 20-93% and specificity from 45-86%. Similarly, the lactose breath test showed a sensitivity of 17-68% and specificity of 44-86%. Despite these limitations, breath tests can be valuable for bacterial overgrowth diagnosis in appropriate clinical settings, especially when risk factors are absent.
Jejunal Aspirate Culture
A bacterial concentration of less than 103 colony forming units/mL in jejunal aspirate is considered diagnostic of SIBO. However, this method is invasive, time-consuming, and expensive, as it requires an upper endoscopy to obtain the sample. Furthermore, the results can be inconsistent and may yield false results due to patchy bacterial overgrowth or contamination from oropharyngeal flora during the procedure.
Additional Laboratory Findings
Other laboratory findings can support a bacterial overgrowth diagnosis, including assessments of vitamin levels and markers of malnutrition. Once SIBO is suspected, further investigations to determine the underlying cause are warranted. Anatomical and mucosal abnormalities can be evaluated using abdominal imaging and endoscopies. Testing for disorders of gastrointestinal motility, pancreatic insufficiency, and immunodeficiencies should be considered based on individual patient presentation. In some cases, endoscopy with small bowel biopsy may be performed.
Imaging and Endoscopy
In patients without specific risk factors for SIBO, upper and lower endoscopies are often performed to rule out other conditions such as atrophic gastritis and Crohn’s disease. If endoscopies are normal, imaging studies may be conducted to exclude partial obstruction, diverticula, fistula, or other inflammatory conditions. Magnetic resonance enterography can enhance the detection of small intestinal bowel strictures but is associated with higher costs.
A comprehensive evaluation of the potential causes of SIBO is crucial, as it can be associated with conditions like cirrhosis, kidney disease, chronic pancreatitis, and immunodeficiency disorders. Other abnormal laboratory results commonly observed in SIBO include macrocytic anemia, low levels of vitamin B12, thiamine, and niacin, elevated folate and vitamin K levels, and increased fecal fat content. In rare instances, microcytic anemia or hypoalbuminemia may be reported.
Treatment and Management of SIBO
The primary treatment for SIBO is antibiotic therapy aimed at eradicating bacterial overgrowth and replenishing any nutritional deficiencies. Antibiotics commonly used include metronidazole, ciprofloxacin, tetracycline, amoxicillin-clavulanate, neomycin, and rifaximin, with rifaximin being the most extensively studied. For patients with hydrogen-predominant bacterial overgrowth, rifaximin at a dosage of 1650 mg/day for two weeks is considered an effective treatment. In cases of methane-predominant bacterial overgrowth, a combination of neomycin at 1000 mg/day and rifaximin at 1650 mg/day for two weeks has shown to be effective. Concurrent vitamin and mineral deficiencies, such as vitamin B12, iron, thiamine, niacin, and other fat-soluble vitamins, should be appropriately addressed.
Recurrence of SIBO is observed in approximately 45 percent of patients following antibiotic treatment, with higher recurrence rates in older adults, individuals who have undergone appendectomy, and those with chronic use of proton pump inhibitors. For patients experiencing early recurrence (within three months), a second course of antibiotics is typically administered. In cases of late recurrence (beyond three months), antibiotics are prescribed only if carbohydrate breath testing is positive. Recurrent SIBO can be treated with either the same initial antibiotic or an alternative antibiotic.
An elemental diet can be considered for patients who cannot tolerate antibiotics or who do not respond to antibiotic treatment after two courses. While limited observational studies suggest that elemental diets can induce remission of SIBO symptoms, factors such as poor palatability and high cost can limit their practical use. One observational study reported that 80% of patients achieved remission (normalization of breath tests and symptom resolution) within two weeks of elemental diet therapy.
Addressing the underlying cause of SIBO is crucial for preventing recurrent symptoms. Antibiotic prophylaxis (5-10 days every two weeks or monthly) may be considered for patients experiencing more than 4 episodes per year. Antibiotics are generally rotated every two to three months in prophylactic regimens. SIBO-associated colitis and ileitis typically resolve with SIBO treatment. If severe symptoms persist, further evaluation for inflammatory bowel disease is warranted. If symptoms do not improve after two courses of antibiotic treatment, alternative diagnoses should be considered.
Probiotics, low FODMAP diets, and statins have not been proven to be effective in resolving SIBO, although some patients may experience symptomatic improvement. These approaches are not considered effective as standalone treatments for SIBO.
Differential Diagnosis of SIBO
When evaluating bacterial overgrowth, it is important to consider other diagnoses that present with chronic diarrhea. Conditions such as irritable bowel syndrome (IBS), celiac disease (CD), and inflammatory bowel disease (IBD) share overlapping symptoms with SIBO. Irritable bowel syndrome is characterized by recurrent abdominal pain related to bowel movements and changes in stool frequency or form. Celiac disease and SIBO can have similar clinical presentations; however, celiac disease is typically identified by positive celiac serologies and a negative carbohydrate breath test. Both Crohn’s disease and SIBO can manifest with patchy mucosal inflammation. However, Crohn’s disease may also involve transmural inflammation and granulomas on biopsy, as well as perianal involvement with anal fissures and fistulas.
Prognosis of Bacterial Overgrowth
The prognosis for SIBO is largely dependent on the underlying condition causing the bacterial overgrowth. In most cases, the prognosis is favorable, with hospital admissions rarely required and complications being uncommon.
Complications of Untreated SIBO
Severe and chronic small intestinal bacterial overgrowth can lead to significant weight loss and severe malnutrition, resulting in substantial morbidity and mortality. Early bacterial overgrowth diagnosis and treatment are crucial to manage nutrient maldigestion and prevent malnourishment. If left untreated, SIBO can progress to intestinal failure.
SIBO is also associated with increased ammonia production, which can precipitate hepatic encephalopathy in patients with pre-existing liver disease. D-lactic acidosis, characterized by confusion and ataxia from bacterial fermentation of unabsorbed carbohydrates, can occur in SIBO cases associated with short bowel syndrome or jejunal bypass. The role of SIBO in non-alcoholic steatohepatitis remains unclear and requires further research.
Consultations for SIBO
Patients experiencing unexplained chronic diarrhea or exhibiting signs and symptoms of significant malnutrition should be referred to a gastroenterologist for further evaluation and bacterial overgrowth diagnosis and management.
Deterrence and Patient Education for SIBO
For patients diagnosed with small intestinal bacterial overgrowth, further investigation to determine the underlying etiology is essential to prevent recurrent SIBO. Optimizing the management of conditions associated with abnormal intestinal motility, such as Crohn’s disease, irritable bowel syndrome, post-radiation enteropathy, diabetes mellitus, hypothyroidism, and scleroderma, is crucial. Prokinetic agents can be useful as adjunctive therapy in these patients. Medications that decrease intestinal motility, like opioids, and proton pump inhibitors, which can cause achlorhydria, should be avoided where possible in susceptible individuals. Surgical interventions may be considered for patients with anatomical abnormalities and recurrent SIBO. The role of chronic antibiotic prophylaxis is limited, and probiotics have not been shown to be effective in prevention. While challenging to maintain, an elemental diet may have a role in certain cases.
Enhancing Healthcare Team Outcomes in SIBO Management
Small intestinal bacterial overgrowth is a condition that is often under-recognized, yet it carries significant potential for morbidity and mortality. Optimal management of SIBO necessitates an interprofessional team approach, involving primary care physicians, gastroenterologists, surgeons, dieticians, pharmacists, and nurses. Early bacterial overgrowth diagnosis and recognition lead to more favorable outcomes and can prevent severe malnutrition. Once SIBO is diagnosed and antibiotic treatment is initiated, further management should focus on addressing the underlying cause to prevent recurrences.
Nursing staff plays a vital role in monitoring treatment effectiveness and patient progress during initial treatment, as well as ensuring patient compliance. Regular monitoring of calorie intake and weight assessments, both during and after treatment, is essential to ensure adequate nutritional recovery. Nurses should proactively monitor these aspects and report any concerns to the treating clinician. Pharmacists can contribute by assisting with antibiotic selection, verifying dosing parameters, and conducting medication reconciliation. They can also collaborate with clinicians and nurses regarding potential drug-condition interactions, particularly concerning opioids and PPIs. Effective SIBO management requires a collaborative, interprofessional team approach, with physicians, specialists, specialty-trained nurses, and pharmacists working together across disciplines to achieve the best possible patient outcomes. The overall prognosis is significantly influenced by the effective management of the underlying condition. If the etiology remains unaddressed, the long-term prognosis can be less favorable.
Review Questions
(Original review questions would be included here if provided in the source material. As they are not explicitly part of the text provided, they are omitted in this rewritten article.)
References
(The original references are maintained as they are crucial for the article’s credibility and EEAT.)
1.Rao SSC, Bhagatwala J. Small Intestinal Bacterial Overgrowth: Clinical Features and Therapeutic Management. Clin Transl Gastroenterol. 2019 Oct;10(10):e00078. [PMC free article: PMC6884350] [PubMed: 31584459]
2.Khoshini R, Dai SC, Lezcano S, Pimentel M. A systematic review of diagnostic tests for small intestinal bacterial overgrowth. Dig Dis Sci. 2008 Jun;53(6):1443-54. [PubMed: 17990113]
3.Bures J, Cyrany J, Kohoutova D, Förstl M, Rejchrt S, Kvetina J, Vorisek V, Kopacova M. Small intestinal bacterial overgrowth syndrome. World J Gastroenterol. 2010 Jun 28;16(24):2978-90. [PMC free article: PMC2890937] [PubMed: 20572300]
4.Vantrappen G, Janssens J, Hellemans J, Ghoos Y. The interdigestive motor complex of normal subjects and patients with bacterial overgrowth of the small intestine. J Clin Invest. 1977 Jun;59(6):1158-66. [PMC free article: PMC372329] [PubMed: 864008]
5.Roland BC, Ciarleglio MM, Clarke JO, Semler JR, Tomakin E, Mullin GE, Pasricha PJ. Low ileocecal valve pressure is significantly associated with small intestinal bacterial overgrowth (SIBO). Dig Dis Sci. 2014 Jun;59(6):1269-77. [PubMed: 24795035]
6.Riordan SM, McIver CJ, Wakefield D, Duncombe VM, Thomas MC, Bolin TD. Small intestinal mucosal immunity and morphometry in luminal overgrowth of indigenous gut flora. Am J Gastroenterol. 2001 Feb;96(2):494-500. [PubMed: 11232696]
7.Jones RM, Neish AS. Recognition of bacterial pathogens and mucosal immunity. Cell Microbiol. 2011 May;13(5):670-6. [PubMed: 21352463]
8.Mackie RI, Sghir A, Gaskins HR. Developmental microbial ecology of the neonatal gastrointestinal tract. Am J Clin Nutr. 1999 May;69(5):1035S-1045S. [PubMed: 10232646]
9.Choung RS, Ruff KC, Malhotra A, Herrick L, Locke GR, Harmsen WS, Zinsmeister AR, Talley NJ, Saito YA. Clinical predictors of small intestinal bacterial overgrowth by duodenal aspirate culture. Aliment Pharmacol Ther. 2011 May;33(9):1059-67. [PubMed: 21395630]
10.Kirsch M. Bacterial overgrowth. Am J Gastroenterol. 1990 Mar;85(3):231-7. [PubMed: 2178395]
11.Bouhnik Y, Alain S, Attar A, Flourié B, Raskine L, Sanson-Le Pors MJ, Rambaud JC. Bacterial populations contaminating the upper gut in patients with small intestinal bacterial overgrowth syndrome. Am J Gastroenterol. 1999 May;94(5):1327-31. [PubMed: 10235214]
12.Hoog CM, Lindberg G, Sjoqvist U. Findings in patients with chronic intestinal dysmotility investigated by capsule endoscopy. BMC Gastroenterol. 2007 Jul 18;7:29. [PMC free article: PMC1940016] [PubMed: 17640373]
13.Greenson JK. The biopsy pathology of non-coeliac enteropathy. Histopathology. 2015 Jan;66(1):29-36. [PubMed: 25234408]
14.Klaus J, Spaniol U, Adler G, Mason RA, Reinshagen M, von Tirpitz C C. Small intestinal bacterial overgrowth mimicking acute flare as a pitfall in patients with Crohn’s Disease. BMC Gastroenterol. 2009 Jul 30;9:61. [PMC free article: PMC2728727] [PubMed: 19643023]
15.Shindo K, Machida M, Koide K, Fukumura M, Yamazaki R. Deconjugation ability of bacteria isolated from the jejunal fluid of patients with progressive systemic sclerosis and its gastric pH. Hepatogastroenterology. 1998 Sep-Oct;45(23):1643-50. [PubMed: 9840121]
16.Pai RK. A practical approach to small bowel biopsy interpretation: celiac disease and its mimics. Semin Diagn Pathol. 2014 Mar;31(2):124-36. [PubMed: 24815938]
17.Lakhani SV, Shah HN, Alexander K, Finelli FC, Kirkpatrick JR, Koch TR. Small intestinal bacterial overgrowth and thiamine deficiency after Roux-en-Y gastric bypass surgery in obese patients. Nutr Res. 2008 May;28(5):293-8. [PubMed: 19083422]
18.Quigley EM, Abu-Shanab A. Small intestinal bacterial overgrowth. Infect Dis Clin North Am. 2010 Dec;24(4):943-59, viii-ix. [PubMed: 20937459]
19.Bongaerts GP, Tolboom JJ, Naber AH, Sperl WJ, Severijnen RS, Bakkeren JA, Willems JL. Role of bacteria in the pathogenesis of short bowel syndrome-associated D-lactic acidemia. Microb Pathog. 1997 May;22(5):285-93. [PubMed: 9160298]
20.Schnabl B, Brenner DA. Interactions between the intestinal microbiome and liver diseases. Gastroenterology. 2014 May;146(6):1513-24. [PMC free article: PMC3996054] [PubMed: 24440671]
21.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 May;112(5):775-784. [PMC free article: PMC5418558] [PubMed: 28323273]
22.Ghoshal UC, Ghoshal U, Das K, Misra A. Utility of hydrogen breath tests in diagnosis of small intestinal bacterial overgrowth in malabsorption syndrome and its relationship with oro-cecal transit time. Indian J Gastroenterol. 2006 Jan-Feb;25(1):6-10. [PubMed: 16567886]
23.Romagnuolo J, Schiller D, Bailey RJ. Using breath tests wisely in a gastroenterology practice: an evidence-based review of indications and pitfalls in interpretation. Am J Gastroenterol. 2002 May;97(5):1113-26. [PubMed: 12014715]
24.King CE, Toskes PP. Comparison of the 1-gram [14C]xylose, 10-gram lactulose-H2, and 80-gram glucose-H2 breath tests in patients with small intestine bacterial overgrowth. Gastroenterology. 1986 Dec;91(6):1447-51. [PubMed: 3770368]
25.Corazza GR, Menozzi MG, Strocchi A, Rasciti L, Vaira D, Lecchini R, Avanzini P, Chezzi C, Gasbarrini G. The diagnosis of small bowel bacterial overgrowth. Reliability of jejunal culture and inadequacy of breath hydrogen testing. Gastroenterology. 1990 Feb;98(2):302-9. [PubMed: 2295385]
26.Shah SC, Day LW, Somsouk M, Sewell JL. Meta-analysis: antibiotic therapy for small intestinal bacterial overgrowth. Aliment Pharmacol Ther. 2013 Oct;38(8):925-34. [PMC free article: PMC3819138] [PubMed: 24004101]
27.Pimentel M, Chang C, Chua KS, Mirocha J, DiBaise J, Rao S, Amichai M. Antibiotic treatment of constipation-predominant irritable bowel syndrome. Dig Dis Sci. 2014 Jun;59(6):1278-85. [PubMed: 24788320]
28.Lauritano EC, Gabrielli M, Scarpellini E, Lupascu A, Novi M, Sottili S, Vitale G, Cesario V, Serricchio M, Cammarota G, Gasbarrini G, Gasbarrini A. Small intestinal bacterial overgrowth recurrence after antibiotic therapy. Am J Gastroenterol. 2008 Aug;103(8):2031-5. [PubMed: 18802998]
29.Pimentel M, Constantino T, Kong Y, Bajwa M, Rezaei A, Park S. A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Dig Dis Sci. 2004 Jan;49(1):73-7. [PubMed: 14992438]
30.Lembo A, Pimentel M, Rao SS, Schoenfeld P, Cash B, Weinstock LB, Paterson C, Bortey E, Forbes WP. Repeat Treatment With Rifaximin Is Safe and Effective in Patients With Diarrhea-Predominant Irritable Bowel Syndrome. Gastroenterology. 2016 Dec;151(6):1113-1121. [PubMed: 27528177]
31.Ghoshal UC, Shukla R, Ghoshal U. Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge between Functional Organic Dichotomy. Gut Liver. 2017 Mar 15;11(2):196-208. [PMC free article: PMC5347643] [PubMed: 28274108]
32.Losurdo G, Marra A, Shahini E, Girardi B, Giorgio F, Amoruso A, Pisani A, Piscitelli D, Barone M, Principi M, Di Leo A, Ierardi E. Small intestinal bacterial overgrowth and celiac disease: A systematic review with pooled-data analysis. Neurogastroenterol Motil. 2017 Jun;29(6) [PubMed: 28191721]
33.Shah A, Morrison M, Burger D, Martin N, Rich J, Jones M, Koloski N, Walker MM, Talley NJ, Holtmann GJ. Systematic review with meta-analysis: the prevalence of small intestinal bacterial overgrowth in inflammatory bowel disease. Aliment Pharmacol Ther. 2019 Mar;49(6):624-635. [PubMed: 30735254]
34.Ziegler TR, Cole CR. Small bowel bacterial overgrowth in adults: a potential contributor to intestinal failure. Curr Gastroenterol Rep. 2007 Dec;9(6):463-7. [PubMed: 18377796]
35.Bohm M, Siwiec RM, Wo JM. Diagnosis and management of small intestinal bacterial overgrowth. Nutr Clin Pract. 2013 Jun;28(3):289-99. [PubMed: 23614961]
36.Compare D, Pica L, Rocco A, De Giorgi F, Cuomo R, Sarnelli G, Romano M, Nardone G. Effects of long-term PPI treatment on producing bowel symptoms and SIBO. Eur J Clin Invest. 2011 Apr;41(4):380-6. [PubMed: 21128930]
37.Zhong C, Qu C, Wang B, Liang S, Zeng B. Probiotics for Preventing and Treating Small Intestinal Bacterial Overgrowth: A Meta-Analysis and Systematic Review of Current Evidence. J Clin Gastroenterol. 2017 Apr;51(4):300-311. [PubMed: 28267052]
Disclosure: Sufian Sorathia declares no relevant financial relationships with ineligible companies.
Disclosure: Venu Chippa declares no relevant financial relationships with ineligible companies.
Disclosure: John Rivas declares no relevant financial relationships with ineligible companies.
