DDAR Blog

Small Intestinal Bacterial Overgrowth

Small Intestinal Bacterial Overgrowth

What is SIBO?

Small Intestine Bacterial Overgrowth (SIBO) is a chronic bacterial infection of the small intestine.  The infection is of bacteria that normally live in the gastrointestinal tract but have abnormally overgrown in a location not meant for so many bacteria. 

The Problem
The bacteria interfere with our normal digestion and absorption of food and are associated with damage to the lining or membrane of the Small Intestine.

  • They consume some of our food which over time leads to deficiencies in their favorite nutrients such as iron and B12, causing anemia.
  • They consume food unable to be absorbed due to lining damage of the small intestine, which creates more bacterial overgrowth.
  • After eating our food, they produce excess gas within our Small intestine. The gas causes abdominal bloating, abdominal pain, constipation, diarrhea or both (the symptoms of IBS).  Excess gas can also cause belching and flatulence.
  • They can cause fat absorption leading to deficiencies of vitamins A & D and fatty stools.
  • Through the damaged lining, larger food particles not able to be fully digested, enter into the body which the immune system reacts to.  This causes food allergies/ sensitivities.
  • Bacteria themselves can also enter the body/bloodstream.  Immune system reaction to bacteria and their cell walls causes chronic fatigue and body pain and burdens the liver.
  • Finally, the bacteria excrete acids which in high amounts can cause neurological and cognitive symptoms.

 

 In general, SIBO is substantially underdiagnosed. There are several reasons for this fact. Some patients may not seek healthcare or SIBO may not be properly diagnosed by medical investigations. SIBO might be asymptomatic or with non-specific symptoms only, and last but not least, all symptoms might be incorrectly ascribed to the underlying disease (leading to SIBO). Of course, diagnostic yield also depends on the methods used for investigation. According to different studies with the investigation of small sets of clinically healthy people as a control, findings consistent with SIBO were found in 2.5% to 22%.

For instance, the prevalence of SIBO in patients fulfilling diagnostic criteria for irritable bowel syndrome was 30%-85%.  The prevalence of SIBO in coeliac disease non-responding to a gluten-free diet was up to 50%. In liver cirrhosis, SIBO was diagnosed in more than 50% of cases. In a small group of elderly people (70 to 94 years old) with lactose malabsorption, SIBO was documented in 90%.  An interesting study was performed on asymptomatic morbidly obese subjects and SIBO was found in 17% as compared to 2.5% in non-obese persons

Diagnostic Testing:

Unfortunately there is no perfect test.  The small intestine (SI) is a hard place to get to.  If we want to see or sample the SI, endoscopy only reaches into the top portion, and colonoscopy only reaches into the end portion.   The middle portion, which is substantial (about 17 feet) is not accessible, other than by surgery.  And stool testing predominantly reflects the large intestine (LI).  Luckily, there is a non-invasive test which is commonly used in SIBO research; the Hydrogen Breath Test.

Hydrogen Breath Test

A hydrogen breath test can be used to diagnose several conditions:  H pylori infection, carbohydrate malabsorption (ex. lactose) and SIBO. Breath testing measures the hydrogen & methane gas produced by bacteria in the Small Intestine that has diffused into the blood, then lungs, for expiration.  Hydrogen & Methane are gases produced by bacteria, not by humans.  The gas is graphed over the SI transit time of 2 or 3 hours & compared to baseline.  Patients drink a sugar solution of glucose or lactulose after a 1 or 2 day preparatory diet.  The diet removes much of the food that would feed the bacteria, allowing for a clear reaction to the sugar drink. There are two (2) types of tests may be used: Lactulose or Glucose.

Lactulose Breath Test (LBT)

Humans can’t digest or absorb lactulose.  Only bacteria have the proper enzymes to do this.  After they consume lactulose, they make gas.  If there is an overgrowth, this will be reflected in the levels of Hydrogen and/or Methane. The advantage to this test is that it can diagnose overgrowth in the distal end of the Small Intestine, thought to be more common.  The disadvantage is that it cannot diagnose bacterial overgrowth as well as the Glucose Breath Test (GBT).

Glucose Breath Test (GBT)

 Both humans and bacteria absorb glucose.  Glucose is absorbed within the first three feet of the Small Intestine, therefore if the bacterial gases of Hydrogen and/or Methane are produced during this test, it reflects an overgrowth in the proximal/upper end of the SI (within the first two feet).

The advantage to this test is that it successfully and accurately diagnoses proximal overgrowth.  The disadvantage is that it cannot diagnose distal overgrowth, occurring in the latter 17 feet of the SI, which is thought to be more common.

How is the test performed?

The test is performed either at home with a take home kit or in a medical office that has a breath testing machine such as a hospital, doctors office, or clinic lab.  It takes 1-3 hours in the morning after a 12 hour fast the night before and a special diet the day before.  At home kits may be obtained from numerous laboratories. 

Which Test Is Best?

Physicians and studies use both glucose and lactulose.  We currently use the 3 hour lactulose test in our office and have good results with this method.

 

What IBD patients should know about the 2019 novel coronavirus (COVID-19)

 

The following is reprinted from the CCFA March 11, 2020 email blast to their provider network. 

We understand that there’s a lot of information in the news about the coronavirus (COVID-19) and you may be concerned. The CCFA Foundation is available to help you make sense of the information and take the precautions recommended by the Centers for Disease Controls and Prevention (CDC)

What special considerations do people with IBD need to keep in mind?

People with IBD who are taking medications that suppress their immune system (such as certain biologic/biosimilar medications, immunomodulators, and steroids) are generally at increased risk for infection. However, there are preventive actions you can take to protect yourself from exposure to the virus and prevent the spread of the disease. The CDC recommends the following ways to limit your risk of infection:
• Avoid having close contact with people who are sick.
• Do not touch your nose, eyes, and mouth if you have not washed your hands.
• Wash your hands with soap and water for at least 20 seconds. To ensure you wash for the appropriate amount of time, sing “Mary Had a Little Lamb” or another short song.
• If soap and water are not available to you, use a hand sanitizer that contains at least 60% alcohol. Check the label to confirm the amount of alcohol.


Here are some other actions to take if you are feeling ill or you think you may have been exposed COVID-19:
• Stay home if you are feeling sick
• Contact your doctor
• Cover your cough or sneeze with a tissue, and throw it in the trash
• Clean and disinfect frequently touched objects
• Wear a facemask if you are showing symptoms or have been diagnosed with COVID-19. Wearing a mask will reduce the potential spread of the virus to others.

If you or your loved one are taking medications that suppress the immune system, remember that it is important to talk to your healthcare team about the risks of other infections.  
The Foundation will update this information as the CDC and public health departments provide additional information and guidance. You can find additional information on COVID-19 on the CDC and World Health Organization's websites.

Link to the CCFA information: https://www.crohnscolitisfoundation.org/coronavirus-update/adults

Update on Ranitidine/Zantac

As you may have read, the FDA recently released a warning regarding Ranitidine a medication frequently used for heartburn.  They reported that they found low levels of a carcinogenic impurity called NDMA (N-nitodimetylamine) in some ranitidine medications including the brand name version, Zantac.  Recently, this same impurity was found in other blood pressure medications that were recalled. NDMA is classified as a probable carcinogen for humans and is often found as a contaminant from the environment in water and food.  It likely only causes harm when ingested in large quantities.  The FDA did not recommend a recall of Ranitidine or recommend patient discontinue the medication at this time.  

However, as there are similarly effective medications on the market, we recommend transitioning to a different medication within the same class.  Famotidine, which has the brand name of Pepcid, has a similar mechanism of action and effectiveness. If feasible, we recommend switching to an equivalent dose of Famotidine.  Famotidine, like Ranitidine is available over-the -counter but also is at times prescribed. If we have prescribed Ranitidine for you in the past, please contact us to change the prescription to Famotidine.

Ranitidine 75 mg          Famotidine 10mg

Ranitidine 150mg         Famotidine 20mg

Ranitidine 300mg         Famotidine 40mg

As stated above, NDMA likely only causes harm in large quantities so you should not panic or become concerned about your safety. Our recommendation to switch medications is only being performed in an abundance of caution.  Please contact us if you have any questions or we can be of help.  

 

May is Hepatitis Awareness Month

Hepatitis Awareness Month

May has been designated as Hepatitis Awareness Month.  The Center for Disease Control and Prevention (CDC) in concert with all public and private healthcare providers, are working to shed light on this hidden epidemic by raising awareness of viral hepatitis and encouraging at risk populations to get tested. 

Hepatitis means inflammation of the liver, most often caused by one of several viruses.  In the United States, the most common types of viral hepatitis are Hepatitis A (HAV), Hepatitis B (HBV) and Hepatitis C (HCV), Unlike Hepatitis A, which does not cause a long-term infection, Hepatitis B and C can become chronic, lifelong infections. More than 4 Million Americans are living with Chronic Hepatitis B or Hepatitis C, but most do not know they are infected.  Chronic viral hepatitis can lead to serious liver problems, including liver cancer.  According to the CDC, at least half of the new cases of liver cancer are from chronic Hepatitis C infection. Every year 15,000 Americans die from liver cancer or chronic liver disease associated with viral hepatitis.  The number of new cases of liver cancer is highest amongst Asian and Pacific Islanders and is increasing among African Americans, baby boomers and men. 

Hepatitis A infections have dramatically declined in the United States over the past 20 years, due in large part to vaccination efforts.   The HAV vaccine is recommended for all children starting at 1 year of age; men who have sexual contact with other men; users of IV and non-injected illegal drugs; people with chronic liver disease and people working with HAV in research laboratories.

An estimated 1.2 million people in the United States are living with HBV infection.  According to the CDC, one in 12 Asian Americans is infected with HBV, and nearly two in three do not know they are infected.  Asian & Pacific Islanders make up 5% of the US population and account for more that 50% of the Americans with HBV.  Although people with HBV often have no symptoms, up to 25% of people with Hepatitis B will develop serious liver problems.   The CDC recommends HBV vaccination for all people born in Asia and the Pacific Islands; all infants; all children under the age of 19; people with sex partners who have HBV; sexually active people who are not in a long term monogamous relationship; people who share needles or other drug –injection equipment; healthcare workers; people with end-stage renal disease; residents of facilities for developmentally disabled persons; people with chronic liver disease; and people with HIV infection.

Hepatitis C ranges in severity from a mild illness lasting a few weeks to a serious lifelong illness that attacks the liver. Many people can live with HCV for decades without having any symptoms. Left untreated, HCV can cause serious liver damage and liver failure. Chronic HCV is the leading cause of liver cancer and liver transplants.  According to the CDC, all people born between 1945 and 1965 are five times more likely to be infected with HCV than other adults. There are an estimate 3.2 million Americans with chronic HCV.  The CDC recommends that all baby boomers get tested for HCV infection.  They also recommend testing for current or former injection drug users; persons treated for blood clotting problems before1987; persons who received blood transfusions before July 1992; persons with abnormal liver tests or liver disease;  health care workers who are exposed to blood from a needlestick puncture and persons with hIV.  

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DDAR Blog

5/12/20

Small Intestinal Bacterial Overgrowth

What is SIBO?

Small Intestine Bacterial Overgrowth (SIBO) is a chronic bacterial infection of the small intestine.  The infection is of...

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