İnce Bağırsakta Aşırı Bakteriyal Çoğalma
Özet
İnce bağırsakta aşırı bakteriyel çoğalma (SIBO), kolondan göç eden koliform bakterilerin ince bağırsakta anormal şekilde kolonize olmasıyla karakterize, karın ağrısı, şişkinlik ve malabsorbsiyonla seyreden bir sendromdur. Gastrointestinal motilite bozuklukları, anatomik anomaliler, PPI gibi ilaç kullanımları ve kronik inflamatuar hastalıklar SIBO gelişimine yol açan temel etiyolojik faktörlerdir. Tanısında nefes testleri non-invaziv bir yöntem olarak öne çıkarken, ince bağırsak aspirasyonu ve kültürü altın standart kabul edilmektedir. Tedavinin temelini genelde rifaksimin gibi antibiyotikler oluşturmakla birlikte, düşük FODMAP diyeti gibi diyet yaklaşımları da semptom yönetiminde kullanılmaktadır. Ancak, nüks oranlarının yüksek olması ve spesifik patolojilerin varlığı nedeniyle probiyotikler ile dışkı mikrobiyota nakli gibi alternatif yöntemlerin etkinliği ve güvenilirliği henüz kanıtlanmamış, hatta riskli bulunmuştur. Bu nedenle, kalıcı başarı sağlamak için altta yatan primer nedenlerin tespiti ve tedavisi esastır.
Small intestinal bacterial overgrowth (SIBO) is a clinical syndrome characterized by abnormal colonization of coliform bacteria in the small intestine, leading to abdominal pain, bloating, and malabsorption. Key etiological factors predisposing to SIBO include gastrointestinal motility disorders, anatomical abnormalities, chronic inflammatory conditions, and certain medications such as proton pump inhibitors. While hydrogen and methane breath tests serve as non-invasive diagnostic tools, small bowel aspiration and quantitative culture remain the definitive gold standard for confirmation. Antibiotic therapy, particularly using non-absorbable agents like rifaximin, constitutes the cornerstone of management, supplemented by dietary modifications such as a low-FODMAP diet. Nevertheless, recurrence rates remain significantly high, and the therapeutic efficacy of probiotics or fecal microbiota transplantation remains unproven and potentially unsafe. Ultimately, successfully identifying and treating the underlying primary causes is crucial to preventing relapse and achieving long-term resolution.
Referanslar
Sachdev AH, Pimentel M. Antibioticsforirritablebowelsyndrome: rationaleandcurrentevidence. CurrGastroenterolRep. 2012 Oct;14(5):439-45. doi: 10.1007/s11894-012-0284-2. PMID: 22945316.
Choung RS, Ruff KC, Malhotra A, et al. Clinical predictors of small intestinal bacterial overgrowth by duodenal aspirate culture. Aliment Pharmacol Ther. 2011 May;33(9):1059-67. doi: 10.1111/j.1365-2036.2011.04625.x. Epub 2011 Mar 13. PMID: 21395630.
Ghoshal UC, Srivastava D, Ghoshal U, et al. Breathtests in thediagnosis of smallintestinalbacterialovergrowth in patientswithirritablebowelsyndrome in comparisonwithquantitativeupper gut aspirateculture. Eur J GastroenterolHepatol. 2014 Jul;26(7):753-60. doi: 10.1097/MEG.0000000000000122. PMID: 24849768.
Tursi A. Gastrointestinalmotilitydisturbances in celiacdisease. J ClinGastroenterol. 2004;38:642-645.
Virally-Monod M, Tielmans D, Kevorkian JP, et al. (1998)Chronicdiarrhoeaanddiabetesmellitus: prevalence of smallintestinalbacterialovergrowth.DiabetesMetab 24: 530-536.
Tsuda A, Suda W, Morita H, et al. Influence of Proton-Pump Inhibitors on the Luminal Microbiota in the Gastrointestinal Tract. Clin Transl Gastroenterol. 2015 Jun 11;6(6):e89. doi: 10.1038/ctg.2015.20. PMID: 26065717; PMCID: PMC4816248.
Lombardo L, Foti M, Ruggia O, et al. Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy. Clin Gastroenterol Hepatol. 2010 Jun;8(6):504-8. doi: 10.1016/j.cgh.2009.12.022. Epub 2010 Jan 6. PMID: 20060064.
Strid H, Simrén M, Stotzer PO, et al. Patients with chronic renal failure have abnormal small intestinal motility and a high prevalence of small intestinal bacterial overgrowth. Digestion. 2003;67(3):129-37. doi: 10.1159/000071292. PMID: 12853724.
Fukui H, Wiest R. Changes of Intestinal Functions in Liver Cirrhosis. Inflamm Intest Dis. 2016 Apr;1(1):24-40. doi: 10.1159/000444436. Epub 2016 Mar 8. PMID: 29922655; PMCID: PMC5988129
Klaus J, Spaniol U, Adler G, et al. Small intestinal bacterial overgrowth mimicking acute flare as a pitfall in patients with Crohn's Disease. BMC Gastroenterol. 2009 Jul 30;9:61. doi: 10.1186/1471-230X-9-61. PMID: 19643023; PMCID: PMC2728727.
H.M. Ni Chonchubhair, Y. Bashir, et al. Conlon.The prevalence of small intestinal bacterial overgrowth in non-surgical patients with chronic pancreatitis and pancreatic exocrine insufficiency (PEI) Pancreatology (2018), 10.1016/j.pan.2018.02.010
Ghoshal UC, Ghoshal U. Small Intestinal Bacterial Overgrowth and Other Intestinal Disorders. Gastroenterol Clin North Am. 2017 Mar;46(1):103-120. doi: 10.1016/j.gtc.2016.09.008. PMID: 28164845.
Newberry C, Tierney A, Pickett-Blakely O. Lactulose hydrogen breath test result is associated with age and gender. Biomed Res Int 2016;2016:1064029.
Majewski M, McCallum RW. Results of small intestinal bacterial overgrowth testing in irritable bowel syndrome patients: clinical profiles and effects of antibiotic trial. Adv Med Sci. 2007;52:139-42. PMID: 18217406.
Pyleris E, Giamarellos-Bourboulis EJ, Tzivras D, et al. The prevalence of overgrowth by aerobic bacteria in the small intestine by small bowel culture: relationship with irritable bowel syndrome. Dig Dis Sci. 2012 May;57(5):1321-9. doi: 10.1007/s10620-012-2033-7. Epub 2012 Jan 20. PMID: 22262197.
Gandhi A, Shah A, Jones MP, et al. Methane positive small intestinal bacterial overgrowth in inflammatory bowel disease and irritable bowel syndrome: A systematic review and meta-analysis. Gut Microbes. 2021 Jan-Dec;13(1):1933313. doi: 10.1080/19490976.2021.1933313. PMID: 34190027; PMCID: PMC8253120.
Lauritano EC, Bilotta AL, Gabrielli M, et al. Association between hypothyroidism and small intestinal bacterial overgrowth. J Clin Endocrinol Metab. 2007 Nov;92(11):4180-4. doi: 10.1210/jc.2007-0606. Epub 2007 Aug 14. PMID: 17698907.
Li X, Feng X, Jiang Z, Jiang Z. Association of small intestinal bacterial overgrowth with Parkinson's disease: a systematic review and meta-analysis. Gut Pathog. 2021 Apr 16;13(1):25. doi: 10.1186/s13099-021-00420-w. PMID: 33863370; PMCID: PMC8051095.
Fialho A, Fialho A, Kochhar G, et al. Association Between Small Intestinal Bacterial Overgrowth by Glucose Breath Test and Coronary Artery Disease. Dig Dis Sci. 2018 Feb;63(2):412-421. doi: 10.1007/s10620-017-4828-z. Epub 2017 Nov 6. PMID: 29110161.
Rao SSC, Tan G, Abdulla H, et al. Does colectomy predispose to small intestinal bacterial (SIBO) and fungal overgrowth (SIFO)? Clin Transl Gastroenterol. 2018 Apr 25;9(4):146. doi: 10.1038/s41424-018-0011-x. PMID: 29691369; PMCID: PMC5915536.
Erdogan A, Rao SS. Small intestinal fungal overgrowth. Curr Gastroenterol Rep. 2015 Apr;17(4):16. doi: 10.1007/s11894-015-0436-2. PMID: 25786900.
Erdogan A, Rao SS, Gulley D, et al. Small intestinal bacterial overgrowth: duodenal aspiration vs glucose breath test. Neurogastroenterol Motil. 2015 Apr;27(4):481-9. doi: 10.1111/nmo.12516. Epub 2015 Jan 19. PMID: 25600077.
Jacobs C, Coss Adame E, Attaluri A, et al. Dysmotility and proton pump inhibitor use are independent risk factors for small intestinal bacterial and/or fungal overgrowth. Aliment Pharmacol Ther. 2013 Jun;37(11):1103-11. doi: 10.1111/apt.12304. Epub 2013 Apr 10. PMID: 23574267; PMCID: PMC3764612.
Zaidel O, Lin HC. Uninvited guests: The impact of small intestinal bacterial overgrowth on nutritional status. Pract Gastroenterol 2003;7:27–34.
Rao SSC, Rehman A, Yu S, Andino NM. Brain fogginess, gas and bloating: a link between SIBO, probiotics and metabolic acidosis. Clin Transl Gastroenterol. 2018 Jun 19;9(6):162. doi: 10.1038/s41424-018-0030-7. PMID: 29915215; PMCID: PMC6006167.
Quigley EMM, Murray JA, Pimentel M. AGA ClinicalPractice Update on Small IntestinalBacterialOvergrowth: ExpertReview. Gastroenterology. 2020 Oct;159(4):1526-1532. doi: 10.1053/j.gastro.2020.06.090. Epub 2020 Jul 15. PMID: 32679220.
Rezaie A, Nikfar S, Abdollahi M. Theplace of antibiotics in management of irritablebowelsyndrome: A systematic review and meta-analysis. Arch Med Sci 2010;6:49–55.
Rezaie A, Buresi M, Lembo A,et al. Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus. Am J Gastroenterol. 2017 May;112(5):775-784. doi: 10.1038/ajg.2017.46. Epub 2017 Mar 21. PMID: 28323273; PMCID: PMC5418558.
Erdogan ALY, Badger C, Hall P, et al. What is theoptimalthresholdfor an increase in hydrogenandmethanelevelswithglucosebreath test (GBT) fordetection of smallintestinalbacterialovergrowth (SIBO)? Gastroenterology 2014;146:S-532.
Khoshini R, Dai SC, Lezcano S, et al. A systematicreview of diagnostictestsforsmallintestinalbacterialovergrowth. DigDisSci 2008;53:1443–54.
Bhagatwala JSA, Leelasinjaroen P, Tetangco E, et al. Investigation of smallintestinalbacterialovergrowth (SIBO) in diabeticsusingfructosebreath test. Gastroenterology 2018;154:53–4.
Lin ECK, Pichetshote N, Rezaie A, et al. Measurement of hydrogensulfideduringbreathtestingcorrelatestopatientsymptoms. Gastroenterology 2017;152:205–6.
Kalantar-Zadeh K, Berean KJ, Ha N, et al. A human pilot trial of ingestible electronic capsules capable of sensing different gases in the gut. Nat Electronics 2018;1:79–87.
Singh S, Allan N, Wahl C, et al. Development of a swallowable diagnostic capsule to monitor gastrointestinal health. Paper presented at: AGA 2019. Gastroenterology 2019;156(Suppl 1):s-376.
Pimentel M, Saad RJ, Long MD, Rao SSC. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol. 2020 Feb;115(2):165-178. doi: 10.14309/ajg.0000000000000501. PMID: 32023228.
Gatta L, Scarpignato C. Systematic review with meta-analysis: Rifaximin is effective and safe for the treatment of small intestine bacterial overgrowth. Aliment Pharmacol Ther 2017;45:604–16.
Deng L, Liu Y, Zhang D, Li Y, Xu L. Prevalence and treatment of small intestinal bacterial overgrowth in postoperative patients with colorectal cancer. Mol Clin Oncol. 2016 May;4(5):883-887. doi: 10.3892/mco.2016.807. Epub 2016 Mar 7. PMID: 27123301; PMCID: PMC4840787.
Zhang Y, Feng Y, Cao B, et al. Effects of SIBO and rifaximin therapy on MHE caused by hepatic cirrhosis. Int J Clin Exp Med 2015;8:2954–7.
Castiglione F, Rispo A, Di Girolamo E, et al. Antibiotic treatment of small bowel bacterial overgrowth in patients with Crohn's disease. Aliment Pharmacol Ther. 2003 Dec;18(11-12):1107-12. doi: 10.1046/j.1365-2036.2003.01800.x. PMID: 14653830.
Sajjad A, Mottershead M, Syn WK, et al. Ciprofloxacin suppresses bacterial overgrowth, increases fasting insulin but does not correct low acylated ghrelin concentration in non-alcoholic steatohepatitis. Aliment Pharmacol Ther. 2005 Aug 15;22(4):291-9. doi: 10.1111/j.1365-2036.2005.02562.x. PMID: 16097995.
Lisowska A, Pogorzelski A, Oracz G, et al. Oral antibiotic therapy improves fat absorption in cystic fibrosis patients with small intestine bacterial overgrowth. J Cyst Fibros. 2011 Dec;10(6):418-21. doi: 10.1016/j.jcf.2011.06.008. Epub 2011 Jul 20. PMID: 21767998.
Lewis SJ, Potts LF, Malhotra R, et al. Small bowel bacterial overgrowth in subjects living in residential care homes. Age Ageing. 1999 Mar;28(2):181-5. doi: 10.1093/ageing/28.2.181. PMID: 10350416.
Ghoshal UC, Srivastava D, Misra A, et al. A proof-of-concept study showing antibiotics to be more effective in irritable bowel syndrome with than without small-intestinal bacterial overgrowth: a randomized, double-blind, placebo-controlled trial. Eur J Gastroenterol Hepatol. 2016 Mar;28(3):281-9. doi: 10.1097/MEG.0000000000000557. PMID: 26731696.
Lauritano EC, Gabrielli M, Scarpellini E, et al. Small intestinal bacterial overgrowth recurrence after antibiotic therapy. Am J Gastroenterol. 2008 Aug;103(8):2031-5. doi: 10.1111/j.1572-0241.2008.02030.x. PMID: 18802998.
Dionne J, Ford AC, Yuan Y, et al. A Systematic Review and Meta-Analysis Evaluating the Efficacy of a Gluten-Free Diet and a Low FODMAPs Diet in Treating Symptoms of Irritable Bowel Syndrome. Am J Gastroenterol. 2018 Sep;113(9):1290-1300. doi: 10.1038/s41395-018-0195-4. Epub 2018 Jul 26. PMID: 30046155.
McIntosh K, Reed DE, Schneider T, et al. FODMAPs alter symptoms and the metabolome of patients with IBS: a randomised controlled trial. Gut. 2017 Jul;66(7):1241-1251. doi: 10.1136/gutjnl-2015-311339. Epub 2016 Mar 14. Erratum in: Gut. 2019 Jul;68(7):1342. PMID: 26976734.
Husebye E, Hellström PM, Sundler F, et al. Influence of microbial species on small intestinal myoelectric activity and transit in germ-free rats. Am J Physiol Gastrointest Liver Physiol. 2001 Mar;280(3):G368-80. doi: 10.1152/ajpgi.2001.280.3.G368. PMID: 11171619.
Leventogiannis K, Gkolfakis P, Spithakis G,et al. Effect of a Preparation of Four Probiotics on Symptoms of Patients with Irritable Bowel Syndrome: Association with Intestinal Bacterial Overgrowth. Probiotics Antimicrob Proteins. 2019 Jun;11(2):627-634. doi: 10.1007/s12602-018-9401-3. Erratum in: Probiotics Antimicrob Proteins. 2018 Mar 28;: PMID: 29508268; PMCID: PMC6541575.
Kumar K, Saadi M, Ramsey FV, et al. Effect of Bifidobacterium infantis 35624 (Align) on the Lactulose Breath Test for Small Intestinal Bacterial Overgrowth. Dig Dis Sci. 2018 Apr;63(4):989-995. doi: 10.1007/s10620-018-4945-3. Epub 2018 Feb 3. PMID: 29397491.
Rao SSC, Rehman A, Yu S, et al. Brain fogginess, gas and bloating: a link between SIBO, probiotics and metabolic acidosis. Clin Transl Gastroenterol. 2018 Jun 19;9(6):162. doi: 10.1038/s41424-018-0030-7. PMID: 29915215; PMCID: PMC6006167.
U.S. Food and Drug Administration. Important safety alert regarding use of fecal microbiota for transplantation and risk of serious adverse reactions due to transmission of multi-drug resistant organisms. 2019 (https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/important-safety-alert-regarding-use-fecal-microbiota-transplantation-and-risk-serious-adverse). Accessed June 28, 2019.
Chang BW, Rezaie A. Irritable Bowel Syndrome-Like Symptoms Following Fecal Microbiota Transplantation: A Possible Donor-Dependent Complication. Am J Gastroenterol. 2017 Jan;112(1):186-187. doi: 10.1038/ajg.2016.472. PMID: 28050036.
