IBS SIBO/SIFO Flashcards by Sarah Murray

Describe the clinical features of SIBO

small intestinal inflammation
maldigestion
malabsorption
Gas-bloat
• Flatulence
• Abdominal discomfort
• Diarrhea
• Steatorrhea
• Weight loss
• Symptoms from micronutrient deficiencies

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dominant types of SIBO

Hydrogen-dominant SIBO – associated
with diarrhea
• Methane-dominant SIBO – associated
with constipation (methane delays
intestinal transit, possibly acting as a
neuromuscular transmitter)
Hydrogen and Methane Recurrent-returns after 4 weeks of Rx
Hydrogen Sulfide Refractory-fails multiple rounds of therapy

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IBS and CFIDS

Fibromyalgia and CFIDS

• 78% and 77% of subjects, respectively, have SIBO

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Nutrient deficiencies associated with SIBO

Vitamins B12, A, D, E, K, iron, thiamine, niacin

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laboratory testing for the diagnosis of SIBO

Direct Tests Quantitative culture of luminal contents
Indirect Tests Breath tests: 14C d-xylose, hydrogen
Other diagnostic tests Urinary tests, serum test

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SIBO definition

Abnormally large numbers of
bacteria (at least 10,000 or 10 4 bacteria per
ml of duodenal aspirate) are present
in the small intestine
- AND -
• Decreased Biodiversity

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How does breath testing work?

Hydrogen breath testing (HBT)
after ingestion of lactulose or
glucose is the most commonly
used method, based on the
principle that exhaled hydrogen
and methane are solely
produced by bacterial
fermentation of carbohydrates.

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What gets malabsorbed in SIBO?

carbs - from damage to villi and mucosa

fat - from psedomembrane blocking and also bacteria deconj bile acids

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Malnutrition in SIBO

Unabsorbed fatty acids may form insoluble soaps with minerals such as Ca and Mg, leading to:
• Osteomalacia, night blindness, hypocalcemic tetany, and possibly metabolic bone disease

Vitamin B12 deficiency
• Bacteria utilize B12 and detach B12 from intrinsic factor
• Serum folate usually normal or elevated

Hypoproteinemia
• Protein-losing enteropathy or protein malabsorption

Bacterial metabolism of proteins to ammonia and fatty acids

Iron deficiency anemia (rare)

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Pathophysiologic Mechanisms of SIBO

Stomach-Small Bowel Etiologies
• Atrophic gastritis
• PPIs
• Advanced age
• Vagotomy
• Gastrectomy
• Gastric Bypass
• Myopathies
• CTD, Amyloid Chagas, RT
• Medications (i.e., opioids)

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IBS and SIBO

More than 1/3 of IBS patients tested positive for SIBO, and
the odds of SIBO in IBS were increased by nearly fivefold
IBS
• 78% of patients tested positive
• 48% of successfully treated patients no longer met Rome criteria for IBS

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type of SIBO associated with diarrhea

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type of SIBO associated with constipation

methane

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SIFO frequency in pts with GI Sx

About a quarter of patients with unexplained GI symptoms likely have SIFO.

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SIBO and SIFO overlap

55% of pts with SIBO also have SIFO

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SIBO etiologies

Etiologies:
• Achlorhydria
• Hypochlorhydria
• PPIs, opioids, (possible: levothyroxine)
• Stasis: dysmotility
• Malnutrition
• Collagen vascular disease
• Immune deficiency
• Surgery (loops, vagotomy)
• Advancing Age, Female
• Smoking
• Celiac disease, Crohn's disease
• Pancreatitis (moderate to severe)

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SIBO consequences

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Consequences:
• Carbohydrate/Fiber intolerance
• Bloating after meals
• Iron, Vitamin D, & B12 deficiencies
• Fat malabsorption
• Enteropathy
• Food allergies
• Systemic inflammation
• Autonomic dysfunction
• Chronic Fatigue, Restless legs
syndrome (RLS)
• Atherosclerosis
• Depression
• Rosacea

Type of SIBO that needs antibiotics

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methane

best initial diet for SIBO

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low FODMAP

Herbs for “weeding” SIBO

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berberine
oregano oil
wormwood

Non pharmacologic prokinetics (to use for SIBO)

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Iberogast (adaptogenic herbal formula):
Ginger root
Tryptophan:
Magnesium citrate:
Ascorbic acid or Sodium Ascorbate
Vitamin D: Minimum D3 5,000 IU qd
Swedish bitters:
D-Limonene: 1000 mg BID
Triphala
Chinese Herbs (TJ 43)
Acupuncture & acupressure
Deep breathing/stress reduction
Exercise

Pharmacologic prokinetics

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LDN
metoclopramide
low dose erythromycin
Prucalopride

Non-pharm Tx options for SIBO

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Iberogast (adaptogenic herbal formula):
Ginger root
Tryptophan:
Magnesium citrate:
Ascorbic acid or Sodium Ascorbate
Vitamin D: Minimum D3 5,000 IU qd
Swedish bitters:
D-Limonene: 1000 mg BID
Triphala
Chinese Herbs (TJ 43)
Acupuncture & acupressure
Deep breathing/stress reduction
Exercise

low FODMAP - high or low prebiotics?

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LOW

Rifaximin dose for SIBO

400 mg bid or tid

Predisposing factors for methane pos

Geographical area Higher in Africa Lower in USA-Europe Socioeconomic status High in lower socioeconomic situations Gender Higher in females than in males Age Age < 3 yr: undetectable Age 3-15 yr: increases and reached adults level by adolescence Family clustering Similar levels between sibling, parents and children but not in spouses

Neomycin

when adding to rifaximin, better rates for SIBO | dose 500 mg po BID

Botanical formulation for methane-dominant SIBO

Peppermint Leaf Quebracho extract Saponins from Horse Chestnut

probiotics and SIBO - effectiveness for prevention/Tx

``` do not PREVENT but are effective for Tx of SIBO (~50%) more effective (80+%) when paired with antibiotics ```

Phases of low FODMAP Diet

1. Elimination: 4-6 weeks of eliminating all FODMAPs; symptoms should diminish during this time. 2. Reintroduction: Continue FODMAP diet. FODMAPs are reintroduced one sub-group at a time for 6-8 weeks with close monitoring for symptoms to re-emerge. 3. Personalized Maintenance: Begin normalizing diet and avoid only the high FODMAP foods that triggered symptoms

PE findings of SIBO

Abdominal distension, Nonspecific findings: abdominal distension, small intestinal succession splash [Taylor et al. 1991], scarring associated with prior surgeries, severe cases may have latent tetany, polyneuropathy and skin manifestations (rosacea)

Other lab findings in SIBO

Anemia, low vitamin B12, signs of malnutrition (lymphopenia, low serum pre-albumin and transferrin), elevated serum folate and vitaminK levels (bacteria produce these)

How is methane produced in SIBO?

bacteria overgrowth --> produce hydrogen --> archea bacteria produce methane --> 20-50% exhaled

false positive breath testing if

too fast transit

Specific GI d/o associated with SIBO

``` • SB diverticulosis • Fistula, strictures • Ileo-cecal valve resection • Common Variable Immunodeficiency • Hypogammaglobulinemia • T cell Deficiency • Celiac Disease • Cirrhosis • Chronic pancreatitis ```

Causes of SIFO

Small intestinal dysmotility and use of PPIs

Tx duration for SIFO

A 2–3 week course of antifungal therapy is recommended and may be effective in improving symptoms, but evidence for eradication is lacking.

Which type of breath testing is most sensitive

lactulose

Which type of breath testing is most specific

glucose

Adding methane to breath testing

``` • The measurement of methane in addition to hydrogen may improve the diagnostic yield of breath testing. (20% to 30% of the general population produces methane as the main by-product of carbohydrate fermentation) ```

best antibiotics for SIBO

neomycin and rifaximin

IBS SIBO/SIFO Flashcards

(41 cards)