Small intestinal bacterial overgrowth syndrome

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Mazia Fatima, MBBS [2]

Small intestinal bacterial overgrowth syndrome
ICD-10 K63
ICD-9 579.9
DiseasesDB 29209
MedlinePlus 000222
eMedicine med/198 

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Overview

Small intestinal bacterial overgrowth (SIBO) was first discovered by Barber and Hummel in 1939. There is no established system for the classification of small intestinal bacterial overgrowth(SIBO).The pathogenesis of small intestinal bacterial overgrowth (SIBO) is characterized by an increased microbial load in the small intestine. Disruption of protective homeostatic mechanisms can increase the risk of SIBO. Bacterial colonization causes an inflammatory response in the intestinal mucosa. Damage to the intestinal mucosa leads to malabsorption of bile acids, carbohydrates, proteins and vitamins resulting in symptoms of diarrhea and weight loss. On gross pathology, mucosal edema, loss of normal vascular pattern, patchy erythema, friability and ulceration of the small intestinal wall is associated with small intestinal bacterial overgrowth (SIBO). On microscopic histopathological analysis small intestine and colon are normal in most patients with SIBO. Findings include blunting of the intestinal villi, thinning of the mucosa and crypts, increased intraepithelial lymphocytes. Small intestinal bacterial overgrowth (SIBO) must be differentiated from other diseases that cause chronic diarrhea. Small intestinal bacterial overgrowth is more commonly observed among elderly patients. Small intestinal bacterial overgrowth (SIBO) affects men and women equally.There is no racial predilection for small intestinal bacterial overgrowth (SIBO). Early clinical features include bloating, flatulence, abdominal pain. If left untreated, patients with small intestinal bacterial overgrowth (SIBO) may progress to develop diarrhea, dyspepsia and weight loss. Prognosis is generally good and associated with frequent relapses and symptom-free periods. The diagnosis of small intestinal bacterial overgrowth (SIBO) is made when at least one of the following diagnostic criteria are met : a positive carbohydrate breath test, bacterial concentration of >103 units/mL in a jejunal aspirate culture. Physical examination may be remarkable for distended abdomen with positive succussion splash as a result of distended bowel loops, peripheral edema due to malabsorption. Small intestinal bacterial obstruction(SIBO) may also be diagnosed using breath tests. The mainstay of therapy for small intestinal bacterial overgrowth(SIBO) is antibiotic therapy. Surgical approach can only be performed for patients with strictures, fistulae, and diverticula or any other structural abnormality resulting in obstruction and resultant bacterial overgrowth. Effective measures for the prevention of small bowel bacterial overgrowth syndrome include avoiding medications like narcotics and benzodiazepines that decrease intestinal motility, avoid achlorhydria in high-risk patients. Consider antibiotic prophylaxis for patients with four or more episodes of recurrent small bowel bacterial overgrowth syndrome within one year.

Historical Perspective

Classification

  • There is no established system for the classification of small intestinal bacterial overgrowth(SIBO).

Pathophysiology

Causes

Differentiating [disease name] from other Diseases

  • Small intestinal bacterial overgrowth (SIBO) must be differentiated from other diseases that cause chronic diarrhea.

The following table outlines the major differential diagnoses of chronic diarrhea.[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]

Abbreviations: GI: Gastrointestinal, CBC: Complete blood count, WBC: White blood cell, RBC: Red blood cell, Plt: Platelet, Hgb: Hemoglobin, ESR: Erythrocyte sedimentation rate, CRP: C–reactive protein, IgE: Immunoglobulin E, IgA: Immunoglobulin A, ETEC: Escherichia coli enteritis, EPEC: Enteropathogenic Escherichia coli, EIEC: Enteroinvasive Escherichia coli, EHEC: Enterohemorrhagic Escherichia coli, EAEC: Enteroaggregative Escherichia coli, Nl: Normal, ASCA: Anti saccharomyces cerevisiae antibodies, ANCA: Anti–neutrophil cytoplasmic antibody, DNA: Deoxyribonucleic acid, CFTR: Cystic fibrosis transmembrane conductance regulator, SLC10A2: Solute carrier family 10 member 2, SeHCAT: Selenium homocholic acid taurine or tauroselcholic acid, IEL: Intraepithelial lymphocytes, MRCP: Magnetic resonance cholangiopancreatography, ANA: Antinuclear antibodies, AMA: Anti-mitochondrial antibody, LDH: Lactate dehydrogenase, CPK: Creatine phosphokinase, PCR: Polymerase chain reaction, ELISA: Enzyme–linked immunosorbent assay, LT: Heat–labile enterotoxin, ST: Heat–stable enterotoxin, RT-PCR: Reverse–transcriptase polymerase chain reaction, CD4: Cluster of differentiation 4, HIV: Human immunodeficiency virus, RUQ: Right-upper quadrant, VIP: Vasoactive intestinal peptide, GI: Gastrointestinal, FAP: Familial adenomatous polyposis, HNPCC: Hereditary nonpolyposis colorectal cancer, MTP: Microsomal triglyceride transfer protein, Scl‑70: Anti–topoisomerase I, TSH: Thyroid-stimulating hormone, T4: Thyroxine, T3: Triiodothyronine, DTR: Deep tendon reflex, RNA: Ribonucleic acid

Cause Clinical manifestation Lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Symptoms GI signs
Duration Diarrhea Fever Abdominal pain Weight loss
Stool exam CBC Other lab findings
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Crohn's disease + + + + ± + + + + Nl
  • Abnormal immune response to self antigens
Ulcerative colitis + + + + ± + + + + Nl
  • Abnormal immune response to self antigens
Celiac disease + ± ± + + Nl Nl Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Cystic fibrosis + + ± + + Nl Nl Nl
Chronic pancreatitis + + + + + Nl Nl Nl Nl
Bile acid malabsorption + + + + Nl Nl Nl Nl
Microscopic colitis + + + + Nl Nl Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Infective colitis + + + + + + + + + Nl
Ischemic colitis + + + + + + + + + Nl
Lactose intolerance + + + + Nl Nl Nl
  • Lactose tolerance test
  • Genetic testing
  • Reduction of lactase enzyme activity or inability to produce persistent lactase
  • Congenital lactase deficiency
  • Secondary lactose malabsorption
Irritable bowel syndrome + ± ± ± Nl Nl Nl Nl Nl
  • Unknown
  • Diagnosis of exclusion
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Whipple's disease + + + ± + + Nl ↓/↑
Tropical sprue + + + + + + + + Nl Nl Nl
  • Diagnosis of exclusion
Small bowel bacterial overgrowth + + + + + + Nl Nl Nl
  • Diagnosis of exclusion
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Salmonellosis + + + + + + + + Nl Nl
Escherichia coli enteritis EPEC + + + + + + + + + Nl Nl Nl
EAEC + + + + + + + Nl
Aeromonas + + + + + + + + Nl Nl Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Mycobacterium avium complex + + + + + + + + Nl Nl
CMV colitis + + + ± + + + Nl
  • Viral antigen assay
Nl Nl
HIV + + + + + + Nl Nl
  • HIV virologic (viral load) test
  • Immunoassay
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Entamoeba histolytica + + + + + + + + + Nl Nl Nl
  • Antigen testing
  • Serology
Giardia + + + + + + Nl Nl Nl Nl
  • Antigen detection assays
Cryptosporidium + + + + + Nl
  • Positive stool microscopy
Nl Nl Nl
  • Polymerase chain reaction
Microsporidia + + + + + + Nl
  • Positive stool microscopy
Nl Nl Nl
  • Decreased CD4 count
  • Antigen detection assays
Isospora + + + + + + + + + + Nl Nl Nl
  • Detecting oocysts in the feces
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Carcinoid tumor + + + + + + Nl Nl Nl
VIPoma + + + + + + Nl Nl Nl
  • Primary secretory tumor
  • Blood VIP levels
  • Followed by imaging
Zollinger–Ellison syndrome + + + + + + Nl Nl
Somatostatinoma + + + + Nl Nl Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Lymphoma + + + + + + + Nl Nl Nl
  • Primary tumor of GI tract
Colorectal cancer + + + + + + + Nl Nl Nl
Medications + + + ± ± + + ↑/↓ Nl Nl
  • Elevated plasma level of drug
  • Clinical evaluation after discontinuation of the drugs
Factitious diarrhea + + + + + ↑/↓ Nl Nl Nl
  • Clinical evaluation after discontinuation of the drugs
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Heavy metal ingestion + + + + Nl Nl Nl Nl
  • Elevated plasma heavy metal level
  • Plasma level of heavy metal
Organophosphate poisoning + + + + Nl Nl Nl Nl
  • Clinical diagnosis
Opium withdrawal + + + + Nl Nl Nl Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Short bowel syndrome + + + + + Nl Nl
Radiation enteritis + + + + + + + + + Nl Nl Nl
Dumping syndrome + + + + Nl Nl Nl Nl
Cause Duration Diarrhea Fever Abdominal pain Weight loss GI signs Stool exam CBC Other lab findings Extra intestinal findings Cause/Pathogenesis Gold standard diagnosis
Acute Chronic Watery Bloody Fatty WBC RBC Ova/Parasite Osmotic gap Other WBC Hgb Plt
Abetalipoproteinemia + + + + + Nl Nl Nl Nl
Hyperthyroidism + + ± + + Nl Nl Nl Nl
Diabetic neuropathy + + + + + Nl Nl Nl
Systemic sclerosis + + ± + + + + Nl Nl Nl
  • Clinical diagnosis
  • Followed by serologic tests

Epidemiology and Demographics

Age

  • Small intestinal bacterial overgrowth is more commonly observed among elderly patients.

Gender

  • Small intestinal bacterial overgrowth (SIBO) affects men and women equally.

Race

  • There is no racial predilection for small intestinal bacterial overgrowth (SIBO).

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

Symptoms

  • Symptoms of small intestinal bacterial overdose (SIBO) may include the following:

Physical Examination

Laboratory Findings

Imaging Findings

  • In CT abdomen/MRI may demonstrate associated strictures, malrotation, fistulae.
  • Small intestinal bacterial overgrowth can result in small bowel obstruction that presents as small bowel feaces sign on abdominal CT.
  • Small bowel faeces sign is the presence of particulate faeculent material mingled with gas bubbles in the lumen of the small intestine , it is believed to be the result of delayed intestinal transit.
Small bowel faeces signCase courtesy of Dr Ian Bickle, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/29769">rID: 29769</a>

Other Diagnostic Studies

Breath Tests

Treatment

Medical Therapy

Surgery

Prevention

References

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