Testing for Small Intestinal Bacterial Overgrowth (SIBO)

Transcription

1 Testing for Small Intestinal Bacterial Overgrowth (SIBO) Sharon Erdrich MHSc (Hons), DipNat, DipHerbMed, DipAroma, NZRN Sharon Erdrich 1

2 TOPICS 1. Intro to SiBO Clinical Presentation of SiBO 2. Options for Diagnosis 3. SiBO Treatment Guideline 4. Case Examples 2

3 SIBO definition SiBO = Small Intestinal Bacterial Overgrowth an increase in the number and/or alteration in the type of bacteria in the upper gastrointestinal tract Link between IBS & SIBO High prevalence of bloating in IBS (~92%) Gut-produced gases are a leading cause of bloating, pain and altered gut transit 84% of IBS patients have abnormal lactulose breath test 75% improvement of IBS symptoms after eradication of SIBO antibiotic-sensitive pathophysiology of IBS World J Gastroenterol 2010; 16(24): JAMA. 2004;292(7): Am J Gastroenterol. 2000; 95:

4 JAMA. 2004;292(7): Recent proposal that IBS be renamed Irritable Bowel Symptoms, as most cases of IBS have an underlying (and mostly treatable) cause. Brown, Ben (ND) 2018 ICNM London 4

5 Clinical Presentations Suggestive of SiBO Irritable Bowel symptoms Abdo pain Constipation and/or diarrhoea Urgency Burping, Reflux Food intolerances /acquired food allergies Includes suspected malabsorption syndromes Histadelia Intolerance to fermented foods Worse for probiotics, prebiotics or fibre supplementation Nutrient deficiencies - in spite of adequate intake (esp. iron, B12) Weight loss, weight gain in spite of appropriate intake

6 6 SiBO May be a Factor in: DIGESTIVE DYSFUNCTION Leaky gut GIT dysmotility (ANY) Burping/reflux Ileo-caecal reflux Crohn s disease/colitis Coeliac disease Malabsorption syndromes Worse for prebiotics Worse for probiotics DISEASES/CONDITIONS Cirrhosis, Fatty Liver Distal bowel problems Diabetes Fibromyalgia Immunodeficiency states Mood/psychiatric disorders MS, Alzheimers, Parkinson s Pancreatitis Pelvic inflammation (BV, UTI etc) Renal failure Rosacea, Psoriasis DIET HISTORY Better on Paleo diet/worse on Vegan Carbohydrate-rich diet Dairy intolerant Food confusion Fructose intolerant Gluten/grain intolerant Multiple Food intolerances Worse for fibre OTHER Brain fog Headache Joint pain, incl. arthritis 2018 Sharon Erdrich 6

7 SiBO can occur due to loss of function of Natural Defences Normal GI Secretions Gastric acid, Bile, Pancreatic enzymes Serotonin, Motilin & Others Affect motility Alteration in one or more of: Anatomy Normal motility Normal flora balance +/- Combination of any of a number of risk factors Immune function Normal flora Intestinal immunoglobulins World J Gastroenterol. 2010;16(24): Gastroenterol Hepatol (N Y) Feb; 3(2):

8 8 HISTORY Risk Factors for the Development of SIBO Past abdominal surgery Multiple abx in history Worse for antibiotics Better for antibiotics Onset following gastro/travel bug Small intestine diverticula Radiotherapy (to abdomen or pelvis) Use of opiates Use of gastric acid suppression Endometriosis ANATOMIC Small intestine diverticula Small intestine strictures (radiation, medications, Crohn's disease) Surgically created blind loops Resection of ileocecal valve Fistulas between proximal and distal bowel Gastric resection Mal-rotated bowel IRRITABLE BOWEL SYNDROME Multiple factors (eg Postinfectious, which can cause motility disorder) ORGAN SYSTEM DYSFUNCTION Cirrhosis, Fatty Liver Crohn's disease Coeliac disease Gastric resection Immunodeficiency states Malnutrition Pancreatitis Distal bowel problems MEDICATIONS Anticholinergics Gastric acid suppressants Opiates Recurrent antibiotics MOTILITY DISORDERS Gastroparesis Small bowel dysmotility Chronic intestinal pseudoobstruction Ileo-caecal reflux Trauma eg: abdominal or head injury MEDICATIONS Recurrent antibiotics Gastric acid suppression OTHER DISORDERS Diabetes Hypochlorhydria Recurrent vomiting (eg Bulimia) 2018 Sharon Erdrich ELDERLY Gastroenterol Hepatol (N Y) Feb; 3(2):

9 Stasis 9

10 MMC Dysfunction PHx of Clostridium, Giardia, Lyme disease Scleroderma Diabetes Hypothyroid conditions Pseudo-obstruction Abdominal surgery Chronic endometriosis Abdominal trauma Head injury Medications Opiates, Antibiotics, Anticholinergics Stress Adhesions between loops of small intestine Am. J. Gastroenterol ,

11 Flora Distribution in SiBO DISTRIBUTION OF INTESTINAL BACTERIAL FLORA IN NORMAL GUT 26cm 2.5m 3.5m AND IN SMALL INTESTINAL BACTERIAL OVERGROWTH JAMA. 2004;292(7):

12 Gut inflammation LPS Brush border damage Intestinal permeability Bile deconjugation THE SIBO CYCLE SIBO START HERE Predisposing Factors GI SYMPTOMS +/- extragastrointestinal manifestations GAS Food = Survival & Proliferation Fermentation Host eats carbohydrates Carbohydrates exposed to Bacteria prematurely 12

13 Clinical Presentation Postprandial bloating Abdominal distension Altered gut motility or normal Visceral hypersensitivity Abnormal brain-gut interaction (memory issues, brain fog, sleep problems etc) Autonomic dysfunction, and Immune activation JAMA. 2004;292(7): doi: /jama

14 Clinical Presentation Multiple food intolerances Commonly: apples, dairy, onion, cabbage, grains, legumes And/or confusion about what does/doesn t aggravate Carbohydrates &/or fats food not my friend Leaky gut - Changes in barrier function implications for nutrient absorption systemic manifestations associated with increased absorption of luminal endotoxins Calorie-deficit Alterations in body composition World J Gastroenterol Mar 7; 16(9):

15 Hyperpermeability is Caused by SiBO 15 Damage to the intestinal mucosa Bacteria, their biofilms and toxic by-products can all damage the lining of the small intestine Impairs nutrient absorption Increases intestinal hyperpermeability.

16 Clinical Presentation Weight loss Weight gain Inflammation Brush border damage Malabsorption Hyper-permeability Nutrient deficiencies Bile deconjugation Fat malabsorption 16

17 Bile Salt Malabsorption (BSM) Functional diarrhoea / IBS-D assoc w/ BSM (~25% to 50%) Bacterial overgrowth in jejunum Fat malabsorption Fat soluble vitamin deficiencies Urgency, early morning diarrhoea Burning on defaecation J Lip Res. 2006, 47; Gut and Liver. 2015, 9;3. 17

18 Why test for SiBO? Confirm presumptive diagnosis Determine the gas guides treatment protocol Determine the gas pattern indicates area of dysfunction (so collateral damage can be mitigated eg proximal more likely to be histadelic, simple carb intolerant) Enhances client understanding Increases compliance with treatment Can evaluate changes Measure of colonic flora activity

19 How to diagnose SIBO 1. Jejunal aspirate and culture 2. Hydrogen-Methane Breath testing Humans can not make Hydrogen or Methane ONLY produced by bacteria Any gases produced following ingestion of a sugar MUST be coming from bacterial fermentation, so testing at intervals can track this. 19

20 Indications for Breath testing Performance of breath tests 6. We suggest that the presence of bacterial overgrowth should be ruled out before performing lactose or fructose breath testing. (100% agreement) Am J Gastroenterol 2017; 112:

21 Why is the Gas Important? Hydrogen Associated with diarrhoea Visceral sensitiser 100% correlation to fibromyalgia Methane Normally produced by colonic flora Associated with constipation Hydrogen sulphide To date not measurable Olfaction is best diagnostic tool Can have any combination of the above. J Neurogastroenterol Motil, 2010, 16; 2 21

22 Choosing the Substrate GLUCOSE 98% specific for SIBO but just 27% sensitivity was compared to jejunal aspirate ie only correlates to proximal SIBO Hence the low sensitivity will give false negative if SiBO occurs after first few feet of SI. RECOMMENDATION: Glucose is best for those with significant reflux, eructation within mins of eating Never in diabetics MUST use if dairy ALLERGIC (not intolerant) Dose: 1g / kg up to 100g max dose. Eur J Gastroenterol Hepatol Jul;26(7):

23 Choosing the Substrate LACTULOSE a synthetic sugar Humans lack ability to digest (no enzyme) Dose: 10g (15mL) in mL water False positive is common depends on transit time of individual Enables observation of flora activity from mouth to colon 23

24 Testing for Malabsorption Breath tests are also used to diagnose: Lactose intolerance Fructose malabsorption Sucrose malabsorption Must rule out SIBO first These sugars normally absorbed in duodenum and proximal jejunum Testing protocol is similar ask! 24

25 Preparation for Breath Testing Am J Gastroenterol 2017; 112:

26 Preparation for Breath Testing Stop antibiotics 4 weeks before Stop herbal antimicrobials minimum 2 weeks before Stop pro & prebiotics minimum 1 week before Diet prep 24 hours non-fermentable, no residue Overnight fast 12 hours water only Test period 4 hours (3 hours of sample collection) 1. Arise one hour prior to testing No smoking or vigorous exercise 2. Baseline breath sample 3. Consume test substrate 4. Repeat breath collections at 20 min intervals (15 mins for glucose challenge) RECORD SYMPTOMS including gas/bowel movements during testing 26

27 Prep Diet Guidelines ONE DAY ALLOWED: eggs, fish, chicken/meat, white rice, white rice noodles, white bread (milk-free: a good quality sourdough is best), clear meat broth (NOT bone broth). Salt, pepper, oil/butter for cooking. Small amount of hard cheese for flavour. Black tea, coffee, herb tea (not liquorice) STOP all non-essential medication NO: fruit, veges, wholegrains, legumes, nuts, seeds, milk, processed meat,

28 What s in the Test Kit: Cardboard box to protect samples Pre-paid bag (CourierPost) to send samples to the lab. Bubble bags to pack test tubes in for sending to the lab. Diet instructions & Client forms to send in with sample. Lactulose (15ml) Breath collection device 10 test-tubes 10 labels Laxative Herbal Tea (Alpine tea) ONLY for those with constipation, who did not have a bowel motion the day before the prep diet.

29 The Collection Device 1 BREATHE into this end lips sealed around outside Rubber-covered needle Test tube in ready position. 2 BREATHE until this bag is full Continue breathing OUT. Push test tube fully onto the needle. Count to 3. Remove. Label. Repeat every 20 mins

30 The SiBO Breath Test 1. Test sugar consumed after collecting baseline sample 4. Hydrogen, methane & carbon dioxide are measured in the breath Medication restrictions/washout periods after antibiotics, unusual diarrhoea Prep period hours Restricted diet low residue = low fermentable Overnight fast (water only) 2. If present, SI bacteria ferment the sugar, producing hydrogen and/or methane gas 3. Gases are absorbed into the blood stream and transported to the lungs 30

31 How Samples are Analysed 8-day window for sample analysis Samples extracted by the Alveolac Quintron Breath Tracker Uses gas chromatography Gold standard in breath testing Evaluates Methane Hydrogen Carbon dioxide Corrects automatically based on CO 2 content 31

32 Interpreting Results First principle ONLY bacteria produce these gases Second principle Elevated baselines considered abnormal As long as prep diet was adhered to Third principle Increases after 100 minutes most likely indicate colonic fermentation Fourth principle The rise in gas or gases must be significant 32

33 Interpreting Results Am J Gastroenterol 2017; 112:

34 Interpreting Results Various criteria in the literature Currently Diagnosis based on what happens in the first 90 minutes Hydrogen Rise of 20 ppm (c.f. lowest preceding value) Methane Any methane at or above 10 A rise of 12ppm (c.f. lowest preceding value) Combined Rise of 15 ppm in methane + hydrogen EXPECT: Double peak (but not required) aids understanding of locality EXPECT: A rise after mins (colonic fermentation) 34

35 An (almost) Normal Breath Test Slightly elevated baselines No significant change until after 100mins Good colonic increase NB symptoms:? Lactose intolerance

36 Looks normal but is missing a significant colonic rise Reasonable baselines Flatline until 3 hour mark Moderate increase only The expected colonic rise is late and less than expected Abnormal test.

37 DISTAL SIBO Low baselines Flatline for 40mins = duodenum and proximal jejunum are intact Large increase +57ppm H2 & + 13ppm CH4 at 60 mins Sustained rise FALLS in the colon DISTAL SIBO

38 Missing data not enough CO2 in test tube Elevated baseline, invalid sample?flatline IMP: Gases produced in colon were passed (sample #1) Absent colonic rise.? Hydrogen-sulphide (evaluate food sensitivities/stool/gas odour), OR Inadequate colonic flora 38

39 POSITIVE SIBO Elevated baseline esp CH4 Significant increase CH4 + H2 at 40 mins (+39ppm) Increases continue to peak at 100mins Significant symptoms during testing Abnormal test Mixed gas SIBO

40 Invalid Sample Not enough CO2 in the test tube

41 Methane-Positive SIBO NB: consensus document did not specify methane increase for bacterial overgrowth (just that 10ppm or more was abnormal) Note: immediate increase +45ppm CH4 within 20 mins of consumption of lactulose. + 45ppm CH4 from mins Decrease, then +24ppm CH4 between samples 3 & 4 Flat-line hydrogen (H2 used by methanogenic bacteria) C + H2 + H2 = CH4 THIS CASE: Proximal SiBO & Distal SiBO 2018 Sharon Erdrich 41

42 Glucose challenge note the decrease in gases as the substrate is absorbed Testing at 15-minute intervals Extremely elevated baselines Big drop after swallowing (?oral flora) Calculate from LOWEST value Combined gases = mins total H2 + CH4 = 63 Increase = +17ppm POSITIVE 42

43 43 Hydrogen-positive, Distal SIBO BO 3 x day BSC #6-7 Note the presumed transit at sample #7

44 Successful Treatment Read the data, not the graph Same client positive SIBO at 20 mins (severe histadelia) Very high methane Note the resizing of the graph Successful treatment of proximal SiBO & reduction of methane levels Absent colonic rise

45 For an more in-depth understanding of SiBO, visit the education portal you can download the full seminar. Join our closed facebook group for practitioners only NZ Clinicians for Gut Health