Skip to main content

Advertisement

Log in

Small bowel bacterial overgrowth: Presentation, diagnosis, and treatment

  • Published:
Current Treatment Options in Gastroenterology Aims and scope Submit manuscript

Opinion statement

Small bowel bacterial overgrowth (SBBO) syndrome is associated with excessive numbers of bacteria in the proximal small intestine. The pathology of this condition involves competition between the bacteria and the human host for ingested nutrients. This competition leads to intraluminal bacterial catabolism of nutrients, often with production of toxic metabolites and injury to the enterocyte. A complex array of clinical symptoms ensues, resulting in chronic diarrhea, steatorrhea, macrocytic anemia, weight loss, and less commonly, protein-losing enteropathy. Therapy is targeted at correction of underlying small bowel abnormalities that predispose to SBBO and appropriate antibiotic therapy. The symptoms and signs of SBBO can be reversed with this approach.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References and Recommended Reading

  1. Gregg CR, Toskes PP: Enteric bacterial flora and small bowel bacterial overgrowth syndrome. In Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, edn 7. Edited by Feldman M, Friedman LS, Sleisenger MH. Philadelphia: WB Saunders; 2002:1783–1793.

    Google Scholar 

  2. Hoffmann JC, Zeitz M: Small bowel disease in the elderly: diarrhoea and malabsorption. Best Pract Res Clin Gastroenterol 2002, 16:17–36.

    Article  PubMed  Google Scholar 

  3. Lewis SJ, Potts LF, Malhotra R, Mountford R: Small bowel bacterial overgrowth in subjects living in residential care homes. Age Aging 1999, 28:181–185.

    Article  CAS  Google Scholar 

  4. Riordan SM, McIver CJ, Wakefield D, et al.: Small intestinal bacterial overgrowth in the symptomatic elderly. Am J Gastroenterol 1997, 92:47–51.

    PubMed  CAS  Google Scholar 

  5. Desai A, Toskes PP: Bacterial overgrowth syndrome. Curr Treat Opt Infect Dis 2003, 5:189–196. A comprehensive review of current management strategies of the bacterial overgrowth syndrome.

    Google Scholar 

  6. Saltzman JR, Kowdley KV, Pedrosa MC, et al.: Bacterial overgrowth without clinical malbsorption in elderly hypochlorhydric patients. Gastroenterology 1994, 106:615–623.

    PubMed  CAS  Google Scholar 

  7. Husebye E, Skar V, Hoverstad T, Melby K: Fasting hypochlorhydria with gram positive gastric flora is highly prevalent in healthy old people. Gut 1992, 33:1331–1337.

    PubMed  CAS  Google Scholar 

  8. Lewis SJ, Franco S, Young G, O’Keefe SJ: Altered bowel function and duodenal bacterial overgrowth in patients treated with omeprazole. Aliment Pharmacol Ther 1996, 10:557–561.

    Article  PubMed  CAS  Google Scholar 

  9. Gough A, Andrews D, Bacon PA, Emery P: Evidence of omeprazole-induced small bowel bacterial overgrowth in patients with scleroderma. Br J Rheumatol 1995, 34:976–977.

    Article  PubMed  CAS  Google Scholar 

  10. Toskes PP: Small intestinal bacterial overgrowth, including blind loop syndrome. In Infections of the Gastrointestinal Tract, edn 2. Edited by Blaser M, Smith PD, Rardin JI, et al. Philadelphia: Lippincott Williams & Wilkins; 2002:291–300.

    Google Scholar 

  11. Levy J: The effects of antibiotic use on gastrointestinal function. Am J Gastroenterol 2000, 95(suppl 1):S8-S10.

    Article  PubMed  CAS  Google Scholar 

  12. Riordan SM, McIver CJ, Wakefield D, et al.: Serum immunoglobulin and soluble IL-2 receptor levels in small intestinal overgrowth with indigenous gut flora. Dig Dis Sci 1999, 44:939–944.

    Article  PubMed  CAS  Google Scholar 

  13. Kett K, Baklien K, Bakken A, et al.: Intestinal B-cell isotype response in relation to local bacterial load: evidence for imuunoglobulin A subclass adaptation. Gastroenterology 1995, 109:819–825.

    Article  PubMed  CAS  Google Scholar 

  14. Riordan SM, McIver CJ, Wakefield D, et al.: Luminal immunity in small-intestinal bacterial overgrowth and old age. Scand J Gastroenterol 1996, 31:1103–1109.

    PubMed  CAS  Google Scholar 

  15. Wanitschke R, Ammon HV: Effects of dihydroxy bile acids and hydroxyl fatty acids on the absorption of oleic acid in the human jejunum. J Clin Invest 1978, 61:178–186.

    PubMed  CAS  Google Scholar 

  16. Giannella RA, Rout WR, Toskes PP: Jejunal brush border injury and impaired sugar and amino acid uptake in the blind loop syndrome. Gastroenterology 1974, 67:965–974.

    PubMed  CAS  Google Scholar 

  17. King CE, Toskes PP: Protein-losing enteropathy in the human and experimental rat blind loop syndrome. Gastroenterology 1981, 80:504–509.

    PubMed  CAS  Google Scholar 

  18. Saltzman JR, Russell RM: Nutritional consequences of intestinal bacterial overgrowth. Comp Ther 1994, 20:523–530.

    CAS  Google Scholar 

  19. Welkos SA, Toskes PP, Baer H, et al.: Importance of anaerobic bacteria in the cobalamin malabsorption of experimental rat blind loop syndrome. Gastroenterology 1981, 80:313–320.

    PubMed  CAS  Google Scholar 

  20. Justus PG, Fernandez A, Martin JL, et al.: Altered myoelectric activity in the experimental blind loop syndrome. J Clin Invest 1983, 72:1064–1071.

    Article  PubMed  CAS  Google Scholar 

  21. Husebye, Skar V, Hoverstad T, et al.: Abnormal intestinal motor patterns explain enteric colonization with gram-negative bacilli in late radiation enteropathy. Gastroenterology 1995, 109:1078–1089.

    Article  PubMed  CAS  Google Scholar 

  22. Rose S, Young MA, Reynolds JC: Gastrointestinal manifestations of scleroderma. Gastroenterol Clin North Am 1998, 27:563–564.

    Article  PubMed  CAS  Google Scholar 

  23. Virally-Monod M, Tielmans D, Kevorkian JP, et al.: Chronic diarrhea and diabetes mellitus: prevalence of small intestinal bacterial overgrowth. Diabetes Metab 1998, 23:530–536.

    Google Scholar 

  24. Trespi E, Ferrieri A: Intestinal bacterial overgrowth during chronic pancreatitis. Curr Med Res Opin 1999, 15:47–52.

    Article  PubMed  CAS  Google Scholar 

  25. Bauer TM, Schwacha H, Steinbruckner B, et al.: Small intestinal bacterial overgrowth in human cirrhosis is associated with systemic endotoxemia. Am J Gastroenterol 2002, 97:2364–2370.

    Article  PubMed  Google Scholar 

  26. Bauer TM, Steinbruckner B, Brinkmann FE, et al.: Small intestinal bacterial overgrowth in patients with cirrhosis: prevalence and relation with spontaneous bacterial peritonitis. Am J Gastroenterol 2001, 96:2962–2967.

    Article  PubMed  CAS  Google Scholar 

  27. Casafont Morencos F, de las Heras Castano G, Martin Ramos L, et al.: Small bowel bacterial overgrowth in patients with alcoholic cirrhosis. Dig Dis Sci 1996, 41:552–556.

    Article  PubMed  CAS  Google Scholar 

  28. Toskes PP: The changing nature of small intestine bacterial overgrowth. Curr Gastroenterol Rep 1999, 1:267–268.

    Article  PubMed  CAS  Google Scholar 

  29. Morencos FC, de las Heras Castano G, Martin Ramos L, et al.: Small bowel bacterial overgrowth in patients with alcoholic cirrhosis. Dig Dis Sci 1995, 40:1252–1256.

    Article  PubMed  CAS  Google Scholar 

  30. Fried M, Siegrist H, Frei R, et al.: Duodenal bacterial overgrowth during treatment in outpatients with omeprazole. Gut 1994, 35:23–26.

    PubMed  CAS  Google Scholar 

  31. Lewis SJ, Franco S, Young G, et al.: Altered bowel function and duodenal bacterial overgrowth in patients treated with omeprazole. Aliment Pharmacol Ther 1996, 10:557–561.

    Article  PubMed  CAS  Google Scholar 

  32. Smith GM, Chesner IM, Asquith P, Leyland MJ: Small intestinal bacterial overgrowth in patients with chronic lymphocytic leukaemia. J Clin Pathol 1990, 43:57–59.

    PubMed  CAS  Google Scholar 

  33. Holt P: Diarrhea and malabsorption in the elderly. Gastroenterol Clin North Am 2001, 30:427–444.

    Article  PubMed  CAS  Google Scholar 

  34. Giannella RA, Toskes PP: Gastrointestinal bleeding and iron absorption in the experimental blind loop syndrome. Am J Clin Nutr 1976, 29:754–757.

    PubMed  CAS  Google Scholar 

  35. Pimentel M, Chow EJ, Lin HC: Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome. Am J Gastroenterol 2000, 95:3503–3506.

    Article  PubMed  CAS  Google Scholar 

  36. Jones MP, Craig R, Olinger E: Small intestinal bacterial overgrowth is associated with irritable bowel syndrome: the cart lands squarely in front of the horse. Am J Gastroenterol 2001, 96:3204–3205.

    Article  PubMed  CAS  Google Scholar 

  37. Riordan SM, McIver CJ, Duncombe VM, et al.: Small intestinal bacterial overgrowth and the irritable bowel syndrome. Am J Gastroenterol 2001, 96:2506–2508.

    Article  PubMed  CAS  Google Scholar 

  38. Simren M, Ringstrom G, Agerfarz P, et al.: Small intestinal bacterial overgrowth is not of major importance in the irritable bowel syndrome [abstract]. Gastroenterology 2003, 124(suppl 1):A-163.

    Google Scholar 

  39. Kumar A, Forsmark C, Toskes PP: Small bowel bacterial overgrowth, the changing face of an old disease [abstract]. Gastroenterology 1996, 110:A340.

    Google Scholar 

  40. Romagnuolo J, Schiller D, Bailey RJ: Using breath tests wisely in a gastroenterology practice: an evidencebased review of indications and pitfalls in interpretation. Am J Gastroenterol 2002, 97:1113–1126. An evidence-based review of the physiologic basis of various breath tests and their applications, indications, and limitations in investigating a wide range of gastrointestinal diseases.

    Article  PubMed  Google Scholar 

  41. Lewis SJ, Young G, Mann M, et al.: Improvement in specificity of [14C]d-xylose breath test for bacterial overgrowth. Dig Dis Sci 1997, 42:1587–1592.

    Article  PubMed  CAS  Google Scholar 

  42. Riordan SM, McIver CJ, Walker BM, et al.: The lactulose breath hydrogen test and small intestinal bacterial overgrowth. Am J Gastroenterol 1996, 91:1795–1803.

    PubMed  CAS  Google Scholar 

  43. King CE, Toskes PP, Guilarte TR, et al.: Comparison of one gram 14C-xylose breath test to the 14C-bile acid breath test in patients with small intestine bacterial overgrowth. Dig Dis Sci 1980, 25:53–58.

    Article  PubMed  CAS  Google Scholar 

  44. Ferguson J, Walker K, Thomson AB: Limitations in the use of 14C-glycocholate breath and stool bile acid determinations in patients with chronic diarrhea. J Clin Gastroenterol 1986, 8:258–262.

    Article  PubMed  CAS  Google Scholar 

  45. Valdovinos M, Camilleri M, Thomforde G, et al.: Reduced accuracy of 14C-D-xylose breath test for detecting bacterial overgrowth in gastrointestinal motility disorders. Scand J Gastroenterol 1993, 28:963–968.

    PubMed  CAS  Google Scholar 

  46. Riordan S, McIver C, Duncombe V, et al.: Factors influencing the 1-gram 14C-D-xylose breath test for bacterial overgrowth. Am J Gastroenterol 1995, 90:1455–1460.

    PubMed  CAS  Google Scholar 

  47. King CE, Toskes PP: Comparison of the 1-gram 14C xylose, 10-gram lactulose H2, and 80-gram glucose-H2 breath tests in patients with small intestine bacterial overgrowth. Gastroenterology 1986, 91:1447–1451.

    PubMed  CAS  Google Scholar 

  48. Bishop WP: Breath hydrogen testing for small bowel bacterial overgrowth-a lot of hot air? J Pediatr Gastroenterol Nutr 1997, 25:245–246.

    Article  PubMed  CAS  Google Scholar 

  49. Corazza GR, Menozzi MG, Strocchi A, et al.: The diagnosis of small bowel bacterial overgrowth: reliability of jejunal culture and inadequacy of breath hydrogen testing. Gastroenterology 1990, 98:302–309.

    PubMed  CAS  Google Scholar 

  50. MacMahon M, Gibbons N, Mullins E, et al.: Are hydrogen breath tests valid in the elderly? Gerontology 1996, 42:40–45.

    CAS  Google Scholar 

  51. Wagner D, Bolt D, Currington C, et al.: Clinical utility of the sorbitol breath test (SBT) to detect small intestinal bacterial overgrowth (SIBO) in the elderly [abstract]. Gastroenterology 2003, 124(suppl 1):A-165.

    Google Scholar 

  52. Bouhnik Y, Alain S, Attar A, et al.: Bacterial populations contaminating the upper gut in patients with small intestinal bacterial overgrowth syndrome. Am J Gastroenterol 1999, 94:1327–1331.

    Article  PubMed  CAS  Google Scholar 

  53. Toledo TK, DiPalma JA: Antibiotics are effective in the treatment of bacterial overgrowth-related diarrhea. Am J Gastroenterol 2000, 95:3644–3645.

    PubMed  CAS  Google Scholar 

  54. Attar A, Flourie B, Rambaud JC, et al.: Antibiotic efficacy in small intestinal bacterial overgrowth-related chronic diarrhea: a crossover, randomized trial. Gastroenterology 1999, 117:794–797.

    Article  PubMed  CAS  Google Scholar 

  55. Wang X, Soltesz V, Axelson J, et al.: Cholecystokinin increases small intestinal motility and reduces enteric bacterial overgrowth and translocation in rats with surgically induced acute liver failure. Digestion 1996, 57:67–72.

    Article  PubMed  CAS  Google Scholar 

  56. Pardo A, Bartoli R, Lorenzo-Zuniga V, et al.: Effect of cisapride on intestinal bacterial overgrowth and bacterial translocation in cirrhosis. Hepatology 2000, 31:858–863.

    Article  PubMed  CAS  Google Scholar 

  57. Madrid AM, Hurtado C, Venegas M, et al.: Long-term treatment with cisapride and antibiotics in liver cirrhosis: effect on small intestinal motility, bacterial overgrowth, and liver function. Am J Gastroenterol 2001, 96:1251–1255. A provocative study that suggests a possible role for prokinetics in the treatment of small bowel bacterial overgrowth.

    Article  PubMed  CAS  Google Scholar 

  58. Soudah HC, Hasler WL, Owyang C: Effect of octreotide on intestinal motility and bacterial overgrowth in scleroderma. N Engl J Med 1991, 325:1461–1467.

    Article  PubMed  CAS  Google Scholar 

  59. Edmunds MC, Chen JD, Soykan I, et al.: Effect of octreotide on gastric and small bowel motility in patients with gastroparesis. Aliment Pharmacol Ther 1998, 12:167–174.

    Article  PubMed  CAS  Google Scholar 

  60. Verne GN, Eaker EY, Hardy E, et al.: Effect of octreotide and erythromycin on idiopathic and sclerodermaassociated intestinal pseudoobstruction. Dig Dis Sci 1995, 40:1892–1901.

    Article  PubMed  CAS  Google Scholar 

  61. Stotzer PO, Blomberg L, Conway PL, et al.: Probiotic treatment of small intestinal bacterial overgrowth by Lactobacillus fermentum KLD. Scand J Iinfect Dis 1996, 28:615–619.

    CAS  Google Scholar 

  62. Rolfe RD: The role of probiotic cultures in the control of gastrointestinal health. J Nutr 2000, 130(suppl 2):396S-402S. A succinct review of the controversial role of probiotics in the prevention and treatment of a diverse spectrum of gastrointestinal disorders.

    PubMed  CAS  Google Scholar 

  63. Gregg CR: Enteric bacterial flora and bacterial overgrowth syndrome. Semin Gastrointest Dis 2002, 13:200–209.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Singh, V.V., Toskes, P.P. Small bowel bacterial overgrowth: Presentation, diagnosis, and treatment. Curr Treat Options Gastro 7, 19–28 (2004). https://doi.org/10.1007/s11938-004-0022-4

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11938-004-0022-4

Keywords

Navigation