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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

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    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge between Functional Organic Dichotomy

Uday C. Ghoshal, Ratnakar Shukla, Ujjala Ghoshal

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Department of Gastroenterology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Correspondence to: Uday C. Ghoshal, Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, India Tel: +91-522-249-4405, Fax: +91-522-266-8017, E-mail: udayghoshal@gmail.com

Received: March 14, 2016; Revised: July 7, 2016; Accepted: July 11, 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2017;11(2):196-208. https://doi.org/10.5009/gnl16126

Published online March 15, 2017, Published date March 15, 2017

Copyright © Gut and Liver.

Abstract

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The pathogenesis of irritable bowel syndrome (IBS), once thought to be largely psychogenic in origin, is now understood to be multifactorial. One of the reasons for this paradigm shift is the realization that gut dysbiosis, including small intestinal bacterial overgrowth (SIBO), causes IBS symptoms. Between 4% and 78% of patients with IBS and 1% and 40% of controls have SIBO; such wide variations in prevalence might result from population differences, IBS diagnostic criteria, and, most importantly, methods to diagnose SIBO. Although quantitative jejunal aspirate culture is considered the gold standard for the diagnosis of SIBO, noninvasive hydrogen breath tests have been popular. Although the glucose hydrogen breath test is highly specific, its sensitivity is low; in contrast, the early-peak criteria in the lactulose hydrogen breath test are highly nonspecific. Female gender, older age, diarrhea-predominant IBS, bloating and flatulence, proton pump inhibitor and narcotic intake, and low hemoglobin are associated with SIBO among IBS patients. Several therapeutic trials targeting gut microbes using antibiotics and probiotics have further demonstrated that not all symptoms in patients with IBS originate in the brain but rather in the gut, providing support for the micro-organic basis of IBS. A recent proof-of-concept study showing the high frequency of symptom improvement in patients with IBS with SIBO further supports this hypothesis.

Keywords: Bacterial overgrowth, Dysbiosis, Breath tests, Gastrointestinal microbiota, Probiotics, Rifaximin

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Gut and Liver 2017; 11(2): 196-208

Published online March 15, 2017 https://doi.org/10.5009/gnl16126

Copyright © Gut and Liver.

Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge between Functional Organic Dichotomy

Uday C. Ghoshal, Ratnakar Shukla, Ujjala Ghoshal

Department of Gastroenterology and Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Correspondence to:Uday C. Ghoshal, Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, India Tel: +91-522-249-4405, Fax: +91-522-266-8017, E-mail: udayghoshal@gmail.com

Received: March 14, 2016; Revised: July 7, 2016; Accepted: July 11, 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The pathogenesis of irritable bowel syndrome (IBS), once thought to be largely psychogenic in origin, is now understood to be multifactorial. One of the reasons for this paradigm shift is the realization that gut dysbiosis, including small intestinal bacterial overgrowth (SIBO), causes IBS symptoms. Between 4% and 78% of patients with IBS and 1% and 40% of controls have SIBO; such wide variations in prevalence might result from population differences, IBS diagnostic criteria, and, most importantly, methods to diagnose SIBO. Although quantitative jejunal aspirate culture is considered the gold standard for the diagnosis of SIBO, noninvasive hydrogen breath tests have been popular. Although the glucose hydrogen breath test is highly specific, its sensitivity is low; in contrast, the early-peak criteria in the lactulose hydrogen breath test are highly nonspecific. Female gender, older age, diarrhea-predominant IBS, bloating and flatulence, proton pump inhibitor and narcotic intake, and low hemoglobin are associated with SIBO among IBS patients. Several therapeutic trials targeting gut microbes using antibiotics and probiotics have further demonstrated that not all symptoms in patients with IBS originate in the brain but rather in the gut, providing support for the micro-organic basis of IBS. A recent proof-of-concept study showing the high frequency of symptom improvement in patients with IBS with SIBO further supports this hypothesis.

Keywords: Bacterial overgrowth, Dysbiosis, Breath tests, Gastrointestinal microbiota, Probiotics, Rifaximin

Fig 1.

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Figure 1.Schematic diagram showing the frequency of small intestinal bacterial overgrowth (SIBO) using quantitative jejunal aspirate culture, glucose and lactulose hydrogen breath tests (GHBT and LHBT, respectively) among patients with irritable bowel syndrome (IBS), gut defense mechanisms that prevent the development of SIBO, factors associated with SIBO among patients with IBS, and mechanisms of IBS symptom development. As shown in the figure, the frequency of SIBO in IBS patients using LHBT (early-peak criteria) is higher than that by using upper gut aspirate culture and GHBT (LHBT [45%]; upper gut aspirate culture [23%] and GHBT [26%]). Moreover, SIBO is more frequent in healthy controls using LHBT due to false positive test results (LHBT [21%], upper gut aspirate culture [1%] and GHBT [5%]).
GI, gastrointestinal; IBS-D, irritable bowel syndrome, diarrhea-predominan; PPI, proton pump inhibitor; CHO, carbohydrate.
Gut and Liver 2017; 11: 196-208https://doi.org/10.5009/gnl16126

Table 1 Prevalence of Small Intestinal Bacterial Overgrowth among Patients with Irritable Bowel Syndrome

Study no.Prevalence of SIBO in casesPrevalence of SIBO in controlsMethane producers in casesMethane producers in controlsCountryYearReference
Culture of jejunal aspirate (≥105 CFU/mL colonic-type bacteria)
 17/162 (4)1/26 (4)NDNDSweden2007Posserud et al.52
 24/12 (33)0/9NDNDThe Netherlands2008Kerckhoffs et al.53
 315/80 (18)0/102/15 (13)NDIndia2014Ghoshal et al.39
 442/112 (37)NDNDNDGreece2012Pyleris et al.54
Culture of jejunal aspirate (≥103 CFU/mL colonic-type bacteria)
 562/139 (44.6)NDNDNDUnited States2015Erdogan et al.27
Lactulose hydrogen breath test
 6157/202 (78)NDNDNDUnited States2000Pimentel et al.40
 764/98 (65)NDNDNDItaly2005Nucera et al.37
 839/390 (10)NDNDNDCanada2005Walters and Vanner55
 935/89 (39)1/13 (8)NDNDChina2014Zhao et al.56
 1025/40 (63)NDNDNDCanada2011Yu et al.45
 1134/76 (45)16/40 (40)19/76 (25)10/40 (25)Korea2010Park et al.57
 1228/43 (65)4/56 (7)4/43 (9)0Italy2009Scarpellini et al.58
 1355/127 (43)NDNDNDItaly2008Carrara et al.59
 1489/258 (34.5)NDNDNDUnited States2009Mann and Limoges-Gonzales60
 1560/175 (34.3)45/150 (30)NDNDIndia2008Rana et al.61
 1622/119 (18.4)NDNDNDPakistan2011Yakoob et al.62
Glucose hydrogen breath test
 1725/225 (11.1)1/100 (1)NDNDIndia2012Rana et al.67
 1893/204 (46)ND27/204 (13)NDUnited States2007Majewski and McCallum63
 19105/331 (32)7/105 (7)NDNDRome2014Moraru et al.70
 2014/59 (24)1/37 (2.7)5/59 (9)9/37 (24)India2011Sachdeva et al.64
 2111/129 (8.5)1/51 (2)NDNDIndia2010Ghoshal et al.51
 2244/96 (45.8)NDNDNDItaly2006Cuoco and Salvangnini65
 2320/65 (31)4/102 (4)NDNDItaly2005Lupascu et al.66
 248/72 (11.1)NDNDNDRome2013Moraru et al.50
 2549/200 (24.5)3/50 (6)NDNDItaly2010Lombardo et al.143
 2638/139 (27.3)NDNDNDUnited States2015Erdogan et al.27
 2711/175 (6.2)1/150 (0.66)NDNDIndia2012Rana et al.97
 2840/107 (37.3)14/107 (13)NDNDIran2015Abbasi et al.68

Data are presented as number (%).

SIBO, small intestinal bacterial overgrowth; CFU, colony forming unit; ND, not done.

Table 2 Clinical Trials of Antibiotics among Patients with Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome

Study no.Antibiotics (dosage)Duration, dayStudy subjectClinical outcomeReference
1Rifaximin (1,600 mg/day) vs rifaximin (1,200 mg/day)780 Patients with SIBORate of normalization of GHBT was greater with higher dose of rifaximin than lower dose (80% vs 58%, p<0.05).Scarpellini et al.108
2Rifaximin (group 1, 600; group 2, 800; group 3, 1,200 mg/day)790 Patients with SIBO and 30 patients in each groupRate of normalization of GHBT was higher in group 3 than group 1 and 2 (60% vs 17%, p<0.001; 60% vs 27%, p<0.01).Lauritano et al.112
3Neomycin (n=55) or placebo (n=56)7111 Patients with IBSNeomycin reduced the symptoms of IBS more often than placebo (35% vs 11%, p<0.05) and normalized lactulose hydrogen breath test result.Pimentel et al.113
4Ciprofloxacin (500 mg, twice daily)107 Patients with SIBOCiprofloxacin decreased viable bacterial counts in five patients (71%), while four (57%) still fulfilled criteria for SIBO. Three patients (43%) reported at least 25% improvement in IBS symptoms.Posserud et al.52
5Norfloxacin (800 mg/day) or placebo1080 IBS patientsNorfloxacin significantly reduced the symptom scores among patients with SIBO than without but not with placebo at 1 month. Symptoms resolved to turn Rome III negative more often in SIBO patients receiving norfloxacin than placebo at 1 month (7/8, 87.5 vs 0/7, p=0.004).Ghoshal et al.114

SIBO, small intestinal bacterial overgrowth; GHBT, glucose hydrogen breath test; IBS, irritable bowel syndrome.
Gut and Liver

Vol.17 No.6
November, 2023

Frequency : Bimonthly

pISSN 1976-2283
eISSN 2005-1212

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