Diarrhea pp 189-207 | Cite as

Bacterial Overgrowth

  • Rosemary J. Young
  • Jon A. Vanderhoof
Chapter
Part of the Clinical Gastroenterology book series (CG)

Summary

The human gastrointestinal tract typically contains 300–500 bacterial species. Most bacterial species are acquired during the birth process and although some changes to the flora may occur during later stages of life, the composition of the intestinal microflora remains relatively constant. Small bowel bacterial overgrowth (SBBO) is defined as an excessive increase in the number of bacteria in the upper gastrointestinal tract leading to the development of symptoms. Etiologic factors in the development of SBBO include anatomic abnormalities, functional abnormalities including altered intestinal motility, and multifactorial issues such as malnutrition of the host and abnormalities of the immune system. Symptoms of SBBO include abdominal cramping, bloating, diarrhea, dyspepsia, and/or weight loss. Systemic distribution of bacterial antigen–antibody complexes may cause rashes, arthritis, and nephritis. Colitis or ileitis may also occur due to SBBO. Although diagnosis of bacterial overgrowth is classically based upon demonstration of an increase of bacterial content by aspiration and culture of upper intestinal fluids, these methods have several limitations. For this reason, a variety of non-invasive diagnostic tests have been devised for the diagnosis of SBBO. A hydrogen breath test is the most common method used. Alternative tests include the measurement of the byproducts of luminal bacteria metabolism in urine or blood and small bowel biopsies demonstrating often inflammatory changes. Treatment of SBBO commonly involves rotating broad-spectrum oral antibiotics. When significant intestinal inflammation is present, anti-inflammatory therapy with sulfasalazine or corticosteroids may be used. Regular toileting and colonic flushing with may also be used. Surgical corrections of anatomic abnormalities, such as stricture, fistula, diverticuli, are often helpful. Segments of dilated, poorly peristaltic bowel may be corrected with lengthening operations. Probiotic therapy in SBBO may be effective in reducing the use of antibiotic therapy and controlling symptoms; however, conclusive studies are needed. Nutritional support is an essential part of the management of SBBO both as a therapeutic measure and in the prevention of malnutrition.

Key Words

Small bowel bacterial overgrowth SIBO Microflora Chronic diarrhea Breath test 

References

  1. 1.
    Tappenden KA, Deutsch AS. The physiological relevance of the intestinal microbiota—contributions to human health. J Am Coll Nutr 2007 Dec;26(6):679S–683S.PubMedGoogle Scholar
  2. 2.
    Bouhnik Y, Alain S, Attar A, Flourie 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;94: 1327–1331.PubMedCrossRefGoogle Scholar
  3. 3.
    Mackie RI, Sghir A, Gaskins HR. Developmental microbial ecology of the neonatal gastrointestinal tract. Am J Clin Nutr 1999;69:1035S–1045S.PubMedGoogle Scholar
  4. 4.
    Ouwehand A, Isolauri E, Salminen S. The role of the intestinal microflora for the development of the immune system in early childhood. Eur J Nutr 2002;41 (Suppl 1):I32.PubMedGoogle Scholar
  5. 5.
    Berg RD. The indigenous gastrointestinal microflora. Trends Microbiol 1996; 4:430–435.PubMedCrossRefGoogle Scholar
  6. 6.
    Shi HN, Walker A. Bacterial colonization and the development of intestinal defenses. Can J Gastroenterol 2004 Aug;18(8):493–500.PubMedGoogle Scholar
  7. 7.
    Rana SV, Bhardwaj SB. Small Intestinal bacterial overgrowth. Scand J Gastro 2008;43(9):1030–1037.CrossRefGoogle Scholar
  8. 8.
    Falk PG, Hooper LV, Midtvedt T, Gordon JI. Creating and maintaining the gastrointestinal ecosystem: what we know and need to know from gnotobiology. Microbiol Mol Biol Rev 1998;62:1157–1170.PubMedGoogle Scholar
  9. 9.
    Sullivan A, Törnblom H, Lindberg G, Hammarlund B, Palmgren AC, Einarsson C, Nord CE. The micro-flora of the small bowel in health and disease. Anaerobe 2003 Feb;9(1):11–14.PubMedCrossRefGoogle Scholar
  10. 10.
    Wedlake L, Thomas K, McGough C, Andreyev HJ. Small bowel bacterial overgrowth and lactose intolerance during radical pelvic radiotherapy: an observational study. Eur J Cancer 2008 Oct;44(15):2212–2217.PubMedCrossRefGoogle Scholar
  11. 11.
    DiBaise J, Young R, Vanderhoof J. Enteric microbial flora, bacterial overgrowth, and short-bowel syndrome. Clin Gastroenterol Hepatol 2006;4(1):11–20.PubMedCrossRefGoogle Scholar
  12. 12.
    Salzedas-Netto AA, Silva RM, Martins JL, Menchaca-Diaz JL, Bugni GM, Watanabe AY, Silva FJ, Fagundes-Neto U, Morais MB, Koh IH. Can bacterial translocation be a beneficial event? Transplant Proc 2006 Jul–Aug; 38(6): 1836–1837.PubMedCrossRefGoogle Scholar
  13. 13.
    Williams C, McColl KE. Review article: proton pump inhibitors and bacterial overgrowth. Aliment Pharmacol Ther 2006 Jan 1;23(1):3–10.PubMedCrossRefGoogle Scholar
  14. 14.
    Duval-Iflah Y, Berard H, Baumer P, Guillaume P, Raibaud P, Joulin Y, Lecomte JM. Effects of racecadotril and loperamide on bacterial proliferation and on the central nervous system of the newborn gnotobiotic piglet. Aliment Pharmacol Ther 1999 Dec;13(Suppl 6):9–14.PubMedGoogle Scholar
  15. 15.
    Machado WM, Miranda JR, Morceli J, Padovani CR. The small bowel flora in individuals with cecoileal reflux. Arq Gastroenterol 2008 Jul–Sep;45(3):212–218.PubMedCrossRefGoogle Scholar
  16. 16.
    Wedlake L, Thomas K, McGough C, Andreyev HJ. Small bowel bacterial overgrowth and lactose intolerance during radical pelvic radiotherapy: an observational study. Eur J Cancer 2008 Oct;44(15):2212–2217.PubMedCrossRefGoogle Scholar
  17. 17.
    Ramakrishna BS, Venkataraman S, Mukhopadhya A. Tropical malabsorption. Postgrad Med J 2006 Dec;82(974):779–787.PubMedCrossRefGoogle Scholar
  18. 18.
    Schiffrin EJ, Parlesak A, Bode C, Bode JC, van’t Hof MA, Grathwohl D, Guigoz Y. Probiotic yogurt in the elderly with intestinal bacterial overgrowth: endotoxaemia and innate immune functions. Br J Nutr 2009 Apr;101(7):961–966.PubMedCrossRefGoogle Scholar
  19. 19.
    Cuoco L, Montalto M, Jorizzo RA, Santarelli L, Arancio F, Cammarota G, Gasbarrini G. Eradication of small intestinal bacterial overgrowth and oro-cecal transit in diabetics. Hepatogastroenterology 2002 Nov–Dec;49(48):1582–1586.PubMedGoogle Scholar
  20. 20.
    Bajaj JS, Zadvornova Y, Heuman DM, Hafeezullah M, Hoffmann RG, Sanyal AJ, Saeian K. Association of proton pump inhibitor therapy with spontaneous bacterial peritonitis in cirrhotic patients with ascites. Am J Gastroenterol 2009 May;104(5):1130–1134.PubMedCrossRefGoogle Scholar
  21. 21.
    van Saene HK, Taylor N, Damjanovic V, Sarginson RE. Microbial gut overgrowth guarantees increased spontaneous mutation leading to polyclonality and antibiotic resistance in the critically ill. Curr Drug Targets 2008 May;9(5):419–421.PubMedCrossRefGoogle Scholar
  22. 22.
    Othman M, Agüero R, Lin HC. Alterations in intestinal microbial flora and human disease. Curr Opin Gastroenterol 2008 Jan;24(1):11–16.PubMedCrossRefGoogle Scholar
  23. 23.
    Bhangle SD, Kramer N, Rosenstein ED. Spondyloarthropathy after ampullary carcinoma resection: “post-Whipple” disease. J Clin Rheumatol 2009 Aug;15(5): 241–243.PubMedCrossRefGoogle Scholar
  24. 24.
    Montalto M, Santoro L, Dalvai S, Curigliano V, D’Onofrio F, Scarpellini E, Cammarota G, Panunzi S, Gallo A, Gasbarrini A, Gasbarrini G. Fecal calprotectin concentrations in patients with small intestinal bacterial overgrowth. Dig Dis 2008;26(2):183–186.PubMedCrossRefGoogle Scholar
  25. 25.
    Sentongo TA, Azzam R, Charrow J. Vitamin B12 status, methylmalonic acidemia, and bacterial overgrowth in short bowel syndrome. J Pediatr Gastroenterol Nutr 2009 Apr;48(4):495–497.PubMedCrossRefGoogle Scholar
  26. 26.
    Spinucci G, Guidetti M, Lanzoni E, Pironi L. Endogenous ethanol production in a patient with chronic intestinal pseudo-obstruction and small intestinal bacterial overgrowth. Eur J Gastroenterol Hepatol 2006 Jul;18(7):799–802.PubMedCrossRefGoogle Scholar
  27. 27.
    O’Keefe SJ. Bacterial overgrowth and liver complications in short bowel intestinal failure patients. Gastroenterology 2006 Feb;130(2 Suppl 1):S67–S69.PubMedCrossRefGoogle Scholar
  28. 28.
    Kaufman SS, Loseke CA, Lupo JV, Young RJ, Murray ND, Pinch LW, Vanderhoof JA. Influence of bacterial overgrowth and intestinal inflammation on duration of parenteral nutrition in children with short bowel syndrome. J Pediatr 1997 Sep;131(3):356–361.PubMedCrossRefGoogle Scholar
  29. 29.
    Yale SH, Musana AK, Kieke A, Hayes J, Glurich I, Chyou PH. Applying case definition criteria to irritable bowel syndrome. Clin Med Res 2008 May;6(1):9–16.PubMedCrossRefGoogle Scholar
  30. 30.
    Collins SM, Vallance B, Barbara G, Borgaonkar M. Putative inflammatory and immunological mechanisms in functional bowel disorders. Bailliere’s Best Pract Res Clin Gastroenterol 1999 Oct;13(3):429–436.CrossRefGoogle Scholar
  31. 31.
    Lin HC. Small intestinal bacterial overgrowth: a framework for understanding irritable bowel syndrome. JAMA 2004;292:852–858.PubMedCrossRefGoogle Scholar
  32. 32.
    Abu-Shanab A, Quigley EM. Diagnosis of small intestinal bacterial overgrowth: the challenges persist! Expert Rev Gastroenterol Hepatol 2009 Feb;3(1):77–87.PubMedCrossRefGoogle Scholar
  33. 33.
    Lee HR, Pimentel M. Bacteria and irritable bowel syndrome: the evidence for small intestinal bacterial overgrowth. Curr Gastroenterol Rep 2006 Aug;8(4): 305–311.PubMedCrossRefGoogle Scholar
  34. 34.
    Gilkin RJ Jr. The spectrum of irritable bowel syndrome: a clinical review. Clin Ther 2005 Nov;27(11):1696–1709.PubMedCrossRefGoogle Scholar
  35. 35.
    Barbara G, Stanghellini V, Brandi G, Cremon C, Di Nardo G, De Giorgio R, Corinaldesi R. Interactions between commensal bacteria and gut sensorimotor function in health and disease. Am J Gastroenterol 2005 Nov;100(11):2560–2568.PubMedCrossRefGoogle Scholar
  36. 36.
    Frissora CL, Cash BD. Review article: the role of antibiotics vs. conventional pharmacotherapy in treating symptoms of irritable bowel syndrome. Aliment Pharmacol Ther 2007 Jun 1;25(11):1271–1281.PubMedCrossRefGoogle Scholar
  37. 37.
    Bausserman M, Michail S. The use of Lactobacillus GG in irritable bowel syndrome in children: a double-blind randomized control trial. J Pediatr 2005 Aug;147(2):197–201.PubMedCrossRefGoogle Scholar
  38. 38.
    Spiegel BM, Chey WD, Chang L. Bacterial overgrowth and irritable bowel syndrome: unifying hypothesis or a spurious consequence of proton pump inhibitors? Am J Gastroenterol 2008 Dec;103(12):2972–2976.PubMedCrossRefGoogle Scholar
  39. 39.
    Vakil N. Acid inhibition and infections outside the gastrointestinal tract. Am J Gastroenterol 2009 Mar;104(Suppl 2):S17–S20.PubMedCrossRefGoogle Scholar
  40. 40.
    Macfarlane GT, Blackett KL, Nakayama T, Steed H, Macfarlane S. The gut microbiota in inflammatory bowel disease. Curr Pharm Des 2009;15(13):1528–1536.PubMedCrossRefGoogle Scholar
  41. 41.
    Willing B, Halfvarson J, Dicksved J, Rosenquist M, Järnerot G, Engstrand L, Tysk C, Jansson JK. Twin studies reveal specific imbalances in the mucosa-associated microbiota of patients with ileal Crohn’s disease. Inflamm Bowel Dis 2009 May;15(5):653–660.PubMedCrossRefGoogle Scholar
  42. 42.
    Rubin DT, Kornblunth A. Role of antibiotics in the management of inflammatory bowel disease: a review. Rev Gastroenterol Disord 2005;5(Suppl 3):S10–S15.PubMedGoogle Scholar
  43. 43.
    Smith PA. Nutritional therapy for active Crohn’s disease. World J Gastroenterol 2008 Jul 21;14(27):4420–4423.PubMedCrossRefGoogle Scholar
  44. 44.
    Kerckhoffs AP, Visser MR, Samsom M, van der Rest ME, de Vogel J, Harmsen W, Akkermans LM. Critical evaluation of diagnosing bacterial overgrowth in the proximal small intestine. J Clin Gastroenterol 2008 Nov–Dec;42(10):1095–1102.CrossRefGoogle Scholar
  45. 45.
    Kerlin P, Wong L. Breath hydrogen testing in bacterial overgrowth of the small intestine. Gastroenterology 1988;95(4):982–988.PubMedGoogle Scholar
  46. 46.
    Corazza G, Menozzi M, 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;98(2):302–309.PubMedGoogle Scholar
  47. 47.
    Soffer EE. Small bowel dysmotility. Curr Treat Options Gastroenterol 1998 Dec;1(1):8–14.PubMedCrossRefGoogle Scholar
  48. 48.
    Strocchi A, Sorge M, Pranzo L. Intraindividual variability in H2 production capacity. Gastroenterol Int 1988;1:593.Google Scholar
  49. 49.
    King CE, Toskes PP, King CE, et al. Comparison of the one-gram D-[14C]xylose breath test to the [14C]bile acid breath test in patients with small-intestine bacterial overgrowth. Gastroenterology 1986;91:1447–1451.PubMedGoogle Scholar
  50. 50.
    Lewis JL, Young G, Mann M, et al. Improvement in the specificity of [14C]D-xylose breath test for bacterial overgrowth. Dig Dis Sci 1997;42:1587–1592.PubMedCrossRefGoogle Scholar
  51. 51.
    Klein P. 13C breath tests: visions and realities. J Nutr 2001;131:1637S–1642S.PubMedGoogle Scholar
  52. 52.
    Kerckhoffs AP, Visser MR, Samsom M, van der Rest ME, de Vogel J, Harmsen W, Akkermans LM Critical evaluation of diagnosing bacterial overgrowth in the proximal small intestine. J Clin Gastroenterol 2008 Nov–Dec;42(10):1095–1102.PubMedCrossRefGoogle Scholar
  53. 53.
    Mack DR. d(–)Lactic acid-producing probiotics, d(–)lactic acidosis and infants. Can J Gastroenterol 2004;18:671–675.PubMedGoogle Scholar
  54. 54.
    Kirsch M. “Bacterial overgrowth”. Am J Gastroenterol 1990;85(3):231–237.PubMedGoogle Scholar
  55. 55.
    Farivar S, Fromm H, Schindler D, Schmidt FW. Sensitivity of bile acid breath test in the diagnosis of bacterial overgrowth in the small intestine with and without the stagnant (blind) loop syndrome. Dig Dis Sci 1979 Jan;24(1):33–40.PubMedCrossRefGoogle Scholar
  56. 56.
    Quigley E, Quera R. Small intestinal bacterial overgrowth: roles of antibiotics, prebiotics, and probiotics. Gastroenterology 2006;130(2 Suppl 1):S78–S90.PubMedCrossRefGoogle Scholar
  57. 57.
    Vanderhoof JA, Young RJ, Murray N, Kaufman SS. Treatment strategies for small bowel bacterial overgrowth in short bowel syndrome. J Pediatr Gastroenterol Nutr 1998;27:155–160.PubMedCrossRefGoogle Scholar
  58. 58.
    Montalto M, Santoro L, Dalvai S, Curigliano V, D’Onofrio F, Scarpellini E, Cammarota G, Panunzi S, Gallo A, Gasbarrini A, Gasbarrini G. Fecal calprotectin concentrations in patients with small intestinal bacterial overgrowth. Dig Dis 2008;26(2):183–186.PubMedCrossRefGoogle Scholar
  59. 59.
    Personal communication. Courtesy of Kathleen Gura, PharmD. Children’s Hospital Boston, 2009.Google Scholar
  60. 60.
    Vanderhoof JA, Young RJ, Thompson JS. New and emerging therapies for short bowel syndrome in children. Paediatr Drugs 2003;5(8):525–531.PubMedCrossRefGoogle Scholar
  61. 61.
    Di Stefano M, Miceli E, Missanelli A, Mazzocchi S, Corazza GR. Absorbable vs. non-absorbable antibiotics in the treatment of small intestine bacterial overgrowth in patients with blind-loop syndrome. Aliment Pharmacol Ther 2005;21:985–992.PubMedCrossRefGoogle Scholar
  62. 62.
    DiBaise JK, Young RJ, Vanderhoof JA. Intestinal rehabilitation and the short bowel syndrome: part 2. Am J Gastroenterol 2004;99:1823–1832.PubMedCrossRefGoogle Scholar
  63. 63.
    Di Stefano M, Miceli E, Missanelli A, Mazzocchi S, Corazza GR. Absorbable vs. non-absorbable antibiotics in the treatment of small intestine bacterial overgrowth in patients with blind-loop syndrome. Aliment Pharmacol Ther 2005;21: 985–992.PubMedCrossRefGoogle Scholar
  64. 64.
    Lauritano EC, Gabrielli M, Lupascu A, et al. Rifaximin dose-finding study for the treatment of small intestinal bacterial overgrowth. Aliment Pharmacol Ther 2005;22:31.PubMedCrossRefGoogle Scholar
  65. 65.
    Sen S, Mullan MM, Parker TJ, Woolner JT, Tarry SA, Hunter JO. Effect of Lactobacillus plantarum 299v on colonic fermentation and symptoms of irritable bowel syndrome. Dig Dis Sci 2002;47:2615–2620.PubMedCrossRefGoogle Scholar
  66. 66.
    Urbancsek H, Kazar T, Mezes I, Neumann K. Results of a double-blind, randomized study to evaluate the efficacy and safety of Antibiophilus in patients with radiation-induced diarrhoea. Eur J Gastroenterol Hepatol 2001;13:391–396.PubMedCrossRefGoogle Scholar
  67. 67.
    Nightingale JM. The medical management of intestinal failure: methods to reduce the severity. Proc Nutr Soc 2003 Aug;62(3):703–710.PubMedCrossRefGoogle Scholar
  68. 68.
    Bongaerts GP, Severijnen RS. Arguments for a lower carbohydrate-higher fat diet in patients with a short small bowel. Med Hypotheses 2006;67(2):280–282. Epub 2006 Apr 17.PubMedCrossRefGoogle Scholar
  69. 69.
    Vanderhoof JA, Grandjean CJ, Kaufman SS, Burkley KT, Antonson DL. The medical management of intestinal failure: methods to reduce the severity. Proc Nutr Soc 2003 Aug;62(3):703–710.CrossRefGoogle Scholar
  70. 70.
    Kollman KA, Lien EL, Vanderhoof JA. Dietary lipids influence intestinal adaptation after massive bowel resection. J Pediatr Gastroenterol Nutr 1999 Jan;28(1): 41–45.PubMedCrossRefGoogle Scholar
  71. 71.
    Thompson JS. Surgical rehabilitation of intestine in short bowel syndrome. Surgery 2004;135(5):465–470.PubMedCrossRefGoogle Scholar
  72. 72.
    Reinshagen K, Zahn K, Buch C, Zoeller M, Hagl CI, Ali M, Waag KL. The impact of longitudinal intestinal lengthening and tailoring on liver function in short bowel syndrome. Eur J Pediatr Surg 2008 Aug;18(4):249–253.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Rosemary J. Young
    • 3
  • Jon A. Vanderhoof
    • 1
    • 2
  1. 1.Children’s HospitalBostonUSA
  2. 2.Harvard Medical SchoolBostonUSA
  3. 3.Boys Town National Research HospitalBoys TownUSA

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