small intestinal bacterial overgrowth.docVIP

Small intestinal bacterial overgrowth: histopathologic features and clinical correlates in an underrecognized entity. Small intestinal bacterial overgrowth (SIBO) is a common cause of chronic diarrhea. (1) Small intestinal bacterial overgrowth results from colonization of the proximal small bowel by gram-negative aerobic and anaerobic bacteria that are normally restricted to the colon or, less frequently, from overgrowth of oropharyngeal flora. A predisposition to SIBO exists in diverse conditions where there is altered anatomy from prior surgery (eg, blind loop syndrome) or stricture or where there is impaired gut motility and prolonged orocecal transit time. Small intestinal bacterial overgrowth has also been reported in progressive systemic sclerosis, jejunal diverticulosis, 33% of patients with portal hypertension, 36% of those with chronic renal failure, 59% of uncomplicated acute colonic diverticulosis, 54% of overt hypothyroidism, 44% of acromegaly, and 96% of Crohn disease with small-bowel strictures. (2-9) Studies in the pediatric population have documented SIBO in 37.5% of children living in an urban slum (ie, environmental enteropathy), 56% of patients with pancreatic insufficiency due to cystic fibrosis, 61% of infants receiving parenteral nutrition because of short bowel syndrome, and commonly following many other types of bowel surgery in the neonatal period. (10-13) In the elderly, SIBO is a common but underrecognized cause of malnutrition, especially among disabled older adults, among whom, 26% suffer from SIBO. (14-16) Several methods have been used to detect SIBO, but each has its disadvantages. The gold standard for diagnosis is a small intestinal aspirate culture showing growth of at least [10.sup.5] colony-forming units of bacteria per milliliter (CFU/mL) of duodenal or jejunal fluid. (17) Cultures of small-bowel mucosal biopsies can be substituted when there are inadequate luminal secretions. (18) Noninvasive breath tests may be used to make