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IFM GI > IBS SIBO/SIFO > Flashcards

IBS SIBO/SIFO Flashcards

1
Q

Describe the clinical features of SIBO

A 
small intestinal inflammation
maldigestion
malabsorption
Gas-bloat
• Flatulence
• Abdominal discomfort
• Diarrhea
• Steatorrhea
• Weight loss
• Symptoms from micronutrient deficiencies
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2
Q

dominant types of SIBO

A 
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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3
Q

IBS and CFIDS

A

Fibromyalgia and CFIDS

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

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4
Q

Nutrient deficiencies associated with SIBO

A

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

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5
Q

laboratory testing for the diagnosis of SIBO

A

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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6
Q

SIBO definition

A 
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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7
Q

How does breath testing work?

A 
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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8
Q

What gets malabsorbed in SIBO?

A

carbs - from damage to villi and mucosa

fat - from psedomembrane blocking and also bacteria deconj bile acids

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9
Q

Malnutrition in SIBO

A

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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10
Q

Pathophysiologic Mechanisms of SIBO

A 
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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11
Q

IBS and SIBO

A

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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12
Q

type of SIBO associated with diarrhea

A

H2

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13
Q

type of SIBO associated with constipation

A

methane

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14
Q

SIFO frequency in pts with GI Sx

A

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

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15
Q

SIBO and SIFO overlap

A

55% of pts with SIBO also have SIFO

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16
Q

SIBO etiologies

A 
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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17
Q

SIBO consequences

A 
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
18
Q

Type of SIBO that needs antibiotics

A

methane

19
Q

best initial diet for SIBO

A

low FODMAP

20
Q

Herbs for “weeding” SIBO

A

berberine
oregano oil
wormwood

21
Q

Non pharmacologic prokinetics (to use for SIBO)

A
  • 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
22
Q

Pharmacologic prokinetics

A

LDN
metoclopramide
low dose erythromycin
Prucalopride

23
Q

Non-pharm Tx options for SIBO

A
  • 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
24
Q

low FODMAP - high or low prebiotics?

A

LOW

25
Q

Rifaximin dose for SIBO

A

400 mg bid or tid

26
Q

Predisposing factors for methane pos

A

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

27
Q

Neomycin

A

when adding to rifaximin, better rates for SIBO

dose 500 mg po BID

28
Q

Botanical formulation for methane-dominant SIBO

A

Peppermint Leaf
Quebracho extract
Saponins from Horse Chestnut

29
Q

probiotics and SIBO - effectiveness for prevention/Tx

A 
do not PREVENT
but are effective for Tx of SIBO (~50%)
more effective (80+%) when paired with antibiotics
30
Q

Phases of low FODMAP Diet

A
  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
31
Q

PE findings of SIBO

A

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)

32
Q

Other lab findings in SIBO

A

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

33
Q

How is methane produced in SIBO?

A

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

34
Q

false positive breath testing if

A

too fast transit

35
Q

Specific GI d/o associated with SIBO

A 
• SB diverticulosis
• Fistula, strictures
• Ileo-cecal valve resection
• Common Variable
Immunodeficiency
• Hypogammaglobulinemia
• T cell Deficiency
• Celiac Disease
• Cirrhosis
• Chronic pancreatitis
36
Q

Causes of SIFO

A

Small intestinal dysmotility and use of PPIs

37
Q

Tx duration for SIFO

A

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

38
Q

Which type of breath testing is most sensitive

A

lactulose

39
Q

Which type of breath testing is most specific

A

glucose

40
Q

Adding methane to breath testing

A 
• 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)
41
Q

best antibiotics for SIBO

A

neomycin and rifaximin

IFM GI (8 decks)

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