Alternative Treatment Approaches to Small Intestinal Bacterial Overgrowth: A Systematic Review.

Background: Broad-spectrum antibiotics are the first-line treatment for small intestinal bacterial overgrowth (SIBO). However, many antibiotics have a considerable side-effect profile and SIBO commonly reoccurs after successful eradication with antibiotics. Alternative therapies such as probiotics, therapeutic diets, and herbal medicines have been used to individualize SIBO management, particularly in recalcitrant cases. Objectives: The objective of this review is to evaluate the role of alternative therapies in SIBO treatment. Data Sources: EMBASE, MEDLINE, and the Cochrane Central Register were systematically searched for clinical studies evaluating alternative therapies in the management of SIBO. Study Eligibility Criteria: Human studies in which an alternative intervention was used to treat SIBO were included. Alternative interventions were defined as an intervention that included a probiotic supplement, herbal preparation, or a dietary change. Randomized controlled trials (RCTs), nonrandomized clinical trials with or without a control, and crossover studies were included. Study Appraisal: The following information was extracted from the selected studies: study type, study participants, SIBO subtype, intervention, comparison, outcome measures, relevant results, relevant side effects, and Jadad score. Results: Eight studies met inclusion criteria. The studies evaluated probiotics (n = 5), therapeutic diet (n = 1), and herbal medicines (n = 2). Among these studies, there were four RCTs, two open-label single-arm studies, one randomized, double-blind crossover study, and one two-arm open-label study with crossover. Main results are summarized. Limitations: There may be studies not captured by the defined search criteria. Additionally, studies used different methodologies in both breath testing and measurement of clinical symptoms, making it difficult to draw conclusions on SIBO eradication and symptom improvement across studies. Conclusions and Implications: Our findings suggest preliminary evidence for a role of alternative therapies in the treatment of SIBO. However, robust clinical trials are generally lacking. Existing studies tend to be small and lack standardized formulations of treatment. Breath testing protocols and clinical symptom measurement greatly varied between studies. Large-scale, randomized, placebo-controlled trials are needed to further evaluate the best way to utilize alternative therapies in the treatment of SIBO.

Chinese herbal medicine for the treatment of small intestinal bacterial overgrowth (SIBO): A protocol for systematic review and meta-analysis.

BACKGROUND: Chinese medicine has a unique theory and the Chinese herbal medicine treatment is based on the integral concepts and syndrome differentiation of the Traditional Chinese Medicine system. Although antibiotics remain the mainstay of SIBO treatment, various alternative or adjunctive therapies are available, including prokinetic agents, dietary interventions, probiotics, and herbal combinations. There is accumulating evidence demonstrating the antimicrobial properties of a growing number of herbs including garlic, black cumin, cloves, cinnamon, thyme, all-spices, bay leaves, mustard, and rosemary. This has prompted an interest in herbal therapy for the treatment of SIBO. Currently, there is no systematic review focusing on efficacy of CHM in the treatment of SIBO with PCOS, so our meta-analysis aims to comprehensively explore it. Meanwhile we will provide high-quality evidence to help patients, clinicians as well as health policymakers select better treatment strategy of PCOS. METHODS: We will search the following sources without restrictions for date, language, or publication status: PubMed, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL) Cochrane Library, EMBASE and China National Knowledge Infrastructure. We will apply a combination of Medical Subject Heading (MeSH) and free-text terms incorporating database-specific controlled vocabularies and text words to implement search strategies. We will also search the ongoing trials registered in the World Health Organization's International Clinical Trials Registry Platform. Besides, the previous relevant reviews conducted on CHM for SIBO and reference lists of included studies will also be searched. RESULTS: This study will provide a reliable basis for the treatment of SIBO with CHM. CONCLUSIONS: The findings will be an available reference to evaluate the efficacy and safety of CHM in the treatment of SIBO. REGISTRATION NUMBER: INPLASY202080004.

Small intestinal bacterial overgrowth (SIBO) and vitamin K-responsive coagulopathy: a previously unrecorded association.

A 17-year-old woman, with a history of three operations on the upper gut in early life and intermittent diarrhoea, presented with a history of epistaxis and leg ecchymosis for the previous 3 months. Initial investigation revealed mild anaemia, low serum albumin, moderately elevated aminotransferases and an exceedingly prolonged prothrombin time (PT) which was promptly shortened to normal by intravenous vitamin K. Additional investigations revealed a grossly abnormal glucose hydrogen breath test, a dilated duodenum and deficiencies of vitamins A, D and E. Repeated courses of antimicrobial agents caused prompt but transient shortening of PT and eventually a duodenal-jejunal anastomosis was performed. Since then, up to 36 months later, the patient has been in good general health and PT has been consistently normal with no vitamin K supplementation. Small intestinal bacterial overgrowth has previously been associated with several conditions but this is the first description of its association with vitamin K-responsive coagulopathy.

Small Intestinal Bacterial Overgrowth: Nutritional Implications, Diagnosis, and Management.

Small intestinal bacterial overgrowth (SIBO), characterized by the presence of excessive bacteria in the small intestine, is typically described as a malabsorptive syndrome occurring in the context of gut stasis syndromes. SIBO is now considered to be a disorder associated with diverse clinical conditions without classic risk factors for SIBO and a cause of several nonspecific gastrointestinal and nongastrointestinal symptoms. Because there is currently no gold standard for diagnosing SIBO, its prevalence and role in the pathogenesis of other diseases remain uncertain; as does optimal treatment of patients with relapsing symptoms.

Nutritional Interventions in Chronic Intestinal Pseudoobstruction.

Although chronic intestinal pseudo-obstruction (CIPO) is a rare disorder, it presents a wide spectrum of severity that ranges from abdominal bloating to severe gastrointestinal dysfunction. In the worst cases, patients may become dependent upon artificial nutrition via parenteral nutrition or choose to have an intestinal transplant. However, whatever the severity, a patient's quality of life can be seriously compromised. This article defines the disorder and discusses the spectrum of disease and challenges to providing adequate nutrition to help improve a patient's quality of life.

Integrative Treatment of Chronic Abdominal Bloating and Pain Associated With Overgrowth of Small Intestinal Bacteria: A Case Report.

Context • Small intestinal bacterial overgrowth (SIBO) is commonly defined as an increased number of bacteria and/or an abnormal type of bacteria in the small intestine. Conventional treatment for SIBO is typically focused on antibiotics to eradicate the bacterial overgrowth. Numerous studies have demonstrated the antimicrobial activity of herbs, and a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) has been shown to enhance antibiotic therapy. Objective • The current case study intended to evaluate the benefits of an alternative, multifaceted approach-including botanical and homeopathic therapies in conjunction with a low-FODMAP diet-in the treatment of SIBO and its associated symptoms. Design • The research team performed a case study. Setting • The study was conducted at SCNM Medical Center (Tempe, AZ, USA). Participant • The participant was a female patient at the SCNM Medical Center with chronic, daily, severe abdominal bloating and pain that particularly worsened after meals and by the end of the day. The patient also had a significant history of chronic constipation that had begun approximately 10 y prior to her experiencing the daily abdominal pain. Intervention • Based on a lactulose breath test for hydrogen and methane, the research team diagnosed the patient with a case of mild SIBO. The treatment approach was multifaceted, involving a low-FODMAP diet, antimicrobial botanical therapy, and homeopathic medicine. Results • The patient's abdominal pain and bloating resolved with the treatment of the SIBO, although her underlying constipation, which was likely associated with other factors, remained. Conclusions • This case study supports an alternative, multifaceted approach to the treatment of SIBO and commonly associated symptoms.

Consequences of Small Intestinal Bacterial Overgrowth in Obese Patients Before and After Bariatric Surgery.

BACKGROUND AND AIMS: Small intestinal bacterial overgrowth (SIBO) has been described in obese patients. The aim of this study was to prospectively evaluate the prevalence and consequences of SIBO in obese patients before and after bariatric surgery. PATIENTS AND METHODS: From October 2001 to July 2009, in obese patients referred for bariatric surgery (BMI >40 kg/m2 or >35 in association with comorbidities), a glucose hydrogen (H2) breath test (BT) was performed before and/or after either Roux-en-Y gastric bypass (RYGBP) or adjustable gastric banding (AGB) to assess the presence of SIBO. Weight loss and serum vitamin concentrations were measured after bariatric surgery while a multivitamin supplement was systematically given. RESULTS: Three hundred seventy-eight (mean ± SD) patients who performed a BT before and/or after surgery were included: before surgery, BT was positive in 15.4 % (55/357). After surgery, BT was positive in 10 % (2/20) of AGB and 40 % (26/65) of RYGBP (p < 0.001 compared to preoperative situation). After RYGBP, patients with positive BT had similar vitamin levels, a lower caloric intake (983 ± 337 vs. 1271 ± 404 kcal/day, p = 0.014) but a significant lower weight loss (29.7 ± 5.6 vs. 37.7 ± 12.9 kg, p = 0.002) and lower percent of total weight loss (25.6 ± 6.0 vs. 29.2 ± 6.9 %, p = 0.044). CONCLUSION: In this study, SIBO is present in 15 % of obese patients before bariatric surgery. This prevalence does not increase after AGB while it rises up to 40 % of patients after RYGBP and it is associated with lower weight loss.

The treatment of gastroparesis, constipation and small intestinal bacterial overgrowth syndrome in patients with Parkinson's disease.

INTRODUCTION: Parkinson's disease (PD) affects the nerves of the entire gastrointestinal (GI) tract and may result in profound gastrointestinal (GI) dysfunction leading to poor patient outcomes. Common GI disturbances in patients with PD include gastroparesis (GP), constipation and small intestinal bacterial overgrowth syndrome (SIBO). In particular, GP is difficult to treat due to the limited options available and precautions, contraindications and adverse effects associated with the approved treatments. Moreover, some commonly used medications can worsen pre-existing PD. AREAS COVERED: Our review will focus on treatment options for GP and SIBO with motilin agonists, dopamine receptor antagonists, Ghrelin agonists muscarinic agonists, 5-HT4 receptor agonists, antibiotics, probiotics and herbal formulation such as iberogast. Constipation occurs in the majority of patients with PD and fortunately many treatments are now available. Our review is based on original papers or reviews selected from PUBMED search and Cochrane reviews. EXPERT OPINION: Motility disorders of the GI tract are found frequently in patients with PD and treating the underlying GI disorders caused by PD with various prokinetics and laxatives is paramount in achieving improvements in patient's motor function. Various prokinetics and laxatives are now available to provide some relief of the GI morbidity caused by PD leading even to better absorption of even the PD treatments.

Environmental enteric dysfunction: an overview.

BACKGROUND: Environmental enteric dysfunction (EED) refers to an incompletely defined syndrome of inflammation, reduced absorptive capacity, and reduced barrier function in the small intestine. It is widespread among children and adults in low- and middle-income countries. Understanding of EED and its possible consequences for health is currently limited. OBJECTIVE: A narrative review of the current understanding of EED: epidemiology, pathogenesis, therapies, and relevance to child health. METHODS: Searches for key papers and ongoing trials were conducted using PUBMED 1966-June 2014; ClinicalTrials.gov; the WHO Clinical Trials Registry; the Cochrane Library; hand searches of the references of retrieved literature; discussions with experts; and personal experience from the field. RESULTS: EED is established during infancy and is associated with poor sanitation, certain gut infections, and micronutrient deficiencies. Helicobacter pylori infection, small intestinal bacterial overgrowth (SIBO), abnormal gut microbiota, undernutrition, and toxins may all play a role. EED is usually asymptomatic, but it is important due to its association with stunting. Diagnosis is frequently by the dual sugar absorption test, although other biomarkers are emerging. EED may partly explain the reduced efficacy of oral vaccines in low- and middle-income countries and the increased risk of serious infection seen in children with undernutrition. CONCLUSIONS: Despite its potentially significant impacts, it is currently unclear exactly what causes EED and how it can be treated or prevented. Ongoing trials involve nutritional supplements, water and sanitation interventions, and immunomodulators. Further research is needed to better understand this condition, which is of likely crucial importance for child health and development in low- and middle-income settings.

Short- and long-term effects of a lactose-restricted diet and probiotics in children with chronic abdominal pain: a retrospective study.

OBJECTIVE: To determine the short- and long-term effect of treatment in children with chronic abdominal pain (CAP). METHODS: A database with the results of H(2) breath test of children with CAP was created. All children with an abnormal test result were included and classified as small intestinal bacterial overgrowth (SIBO) or lactose intolerant (LTI). SIBO was treated with probiotics and LTI with a lactose-restricted diet. CAP was evaluated 5 months and 15 months after the test. RESULTS: 37 children (41%) were included. 17 LTI children (94%) improved after 5 months and 11 children (61%) after 15 months (P<0.05). Seven SIBO children improved after 5 months and 4 children after 15 months. In the combination group all 4 children improved after 5 months and 3 children after 15 months. CONCLUSION: Children with CAP caused by LTI or SIBO had less CAP after 5 months. This positive effect persists only in half of the children.

Difficulty in walking 10 years after gastric surgery.

A 65-year-old gentleman presented with a history of abdominal distension and difficulty in walking 10 years after a Polya partial gastrectomy. Clinical history and neurological examination suggested an axonal sensory neuropathy. A computed tomographic scan of the abdomen showed a large afferent jejunal loop, and a hydrogen breath test confirmed small-bowel bacterial overgrowth secondary to the blind loop syndrome. Serological tests revealed low copper levels, which are a cause of a myeloneuropathy. The trace element deficiency occurred as a consequence of small-bowel bacterial overgrowth, and with antibiotic treatment of the bacterial overgrowth and copper supplementation his symptoms markedly improved.

Bacterial overgrowth syndrome in myotonic muscular dystrophy is potentially treatable.

Over one third of patients with myotonic muscular dystrophy type 1 (DM1) have gastrointestinal complaints. The cause is multifactorial, and treatment options are limited. Twenty DM1 patients with gastrointestinal symptoms were screened over a 2-year period using glucose breath hydrogen testing (GBHT) to evaluate the prevalence of small intestinal bacterial overgrowth (SIBO). Sixty-five percent of patients had a positive GBHT, and diarrhea was the most common presenting symptom. Ciprofloxacin was the most common antibiotic used for treatment, and 70% of patients reported a good response to the initial course of treatment. Although the causes of gastrointestinal symptoms in patients with DM1 are multifactorial, small intestinal bacterial overgrowth is an important diagnostic consideration that is easily diagnosed using glucose breath hydrogen testing and often shows a good response to treatment with common antibiotics.

Rosacea treatments: What's new and what's on the horizon?

Rosacea is a common, chronic, cutaneous disorder presenting with recurrent episodes of facial flushing, erythema, papules, pustules and telangiectasias. It is a multifactorial disease and its various clinical presentations probably represent the consequence of combined different triggers upon a specific background. Its management is largely based on long-established treatments empirically tailored to the specific presenting symptoms and no real breakthrough has occurred to date. However, recent insights into the still rather obscure pathophysiology of rosacea seem to open the way for etiologically oriented treatments. These may include, on the one side, the more effective application of traditional drugs, such as tetracyclines and metronidazole, to specifically selected patients or, on the other side, new therapeutic options, such as vitamin D receptor antagonists. It is to be remarked that the quality of most studies evaluating rosacea treatment is rather poor, mainly due to a lack of proper standardization. For a major breakthrough to occur in the management of rosacea, we need both a better understanding of its pathogenesis and the adherence of future clinical trials to clearly defined grading and inclusion criteria, which are crucial for investigators to correctly compare and interpret the results of their work.

[Pellagra and panniculitis induced by chronic bacterial colonisation of the small intestine]. / Colonisation bactérienne chronique de l'intestin grêle révélée par un érythème pellagroïde et une panniculite.

INTRODUCTION: Pellagra is an exceptional disorder in France. The classical description of pellagra associates a photoinduced rash with neurological impairment and intestinal dysfunction. Without adapted treatment, the progression is fatal. CASE REPORT: A 62 year-old women developed a photoinduced rash, composed of circular and erythematous elements with pustular edges. She also had panniculitis, peripheral neuropathy, depressive mood and diarrhea. Her medical past was marked by epilepsy treated with sodium valproate and hydantoin. Biological exams revealed lowered plasma levels of vitamins PP, B1, B6 and zinc, secondary to intestinal impairment induced by bacteria proliferating in the small intestine. The rash resolved with vitamin PP and zinc supplementation. The bacterial colonisation was improved by long-term, sequential antibiotics. DISCUSSION: We report a rare clinical form of pellagroid rash. The rash was induced by chronic malabsorption resulting from excessive bacterial proliferation in the diverticules of the small intestine. The antiepileptic treatment could have facilitated vitamin PP et zinc deficiency. Panniculitis was related to the bacterial proliferation. We discuss in this paper the relationship between some vitamin deficiencies, their clinical manifestations and the direct role of intestinal bacterial proliferation in the cutaneous manifestations.

[Value of small bowel double contrast enema in clinical interventions]. / Die Wertigkeit des Dünndarmdoppelkontrasteinlaufes im klinischen Einsatz.

The double contrast enema is the most effective morphological screening method for the evaluation of the whole small bowel. Its sensitivity is 85%, its specifity 96.7%. In specific clinical problems the number of pathological roentgen findings rises: from 34.4% when all indications are taken into consideration to 58% in indications specific to the small intestine such as Morbus Crohn or the malabsorption syndrome. Search for tumours and the double contrast of the small bowel in unclear gastro-intestinal bleeding are unproductive. The weak point of this screening method is the lower part of the small intestine. Therefore, the selective peroral or retrograde analysis of the terminal ileum supplement the contrast method. A precondition for good results is an adequate technical standard. Besides the clinical results some technical results are therefore discussed such as contrast medium quantities, examination and X-ray time, radiation exposure and influences on the image quality.

Blind loop syndrome, vitamin E malabsorption, and spinocerebellar degeneration.

A 72-year-old man had severe malabsorption, progressive retinopathy, and spinocerebellar degeneration 32 years after gastric surgery, blind loop formation, and intestinal bacterial overgrowth. Clinical and pathologic features were typical of vitamin E deficiency; vitamin E was nearly undetectable in serum and profoundly low in adipose tissue. Vitamin E blood levels initially improved on treatment with antibiotics; after additional vitamin E supplementation, there was clinical improvement.

The blind pouch syndrome.

The blind pouch syndrome is a series of symptoms associated with blind pouch formation, secondary to a side-to-side intestinal anastomosis. The diagnosis is easily suspected in a patient with anemia, episodes of diarrhea, intermittent crampy abdominal pain, weight loss and a history of a previous abdominal operation. The effectiveness of intubation-infusion barium studies of the small intestine in demonstrating obscure lesions therein, undetected by conventional methods, should be used for a prompt and precise diagnosis preoperatively. Surgical correction by means of resection of involved lateral anastomosis with end-to-end anastomosis has been successful, eliminating future complications.