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Is there a relationship between IBS and small intestinal bacterial overgrowth?


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IBS and small intestinal bacterial overgrowth (SIBO)

There is a striking similarity between the symptoms of IBS and a condition known as small intestinal bacterial overgrowth (SIBO).

The entire gastrointestinal tract, including the small intestine, normally contains bacteria. The number of bacteria is greatest in the colon (at least 1,000,000,000 bacteria per ml of fluid) and much lower in the small intestine (less than 10,000 bacteria per ml of fluid). Moreover, the types of bacteria within the small intestine are different from the types of bacteria within the colon. SIBO refers to a condition in which abnormally large numbers of bacteria (at least 100,000 bacteria per ml of fluid) are present in the small intestine, and the types of bacteria in the small intestine resemble more like the bacteria in the colon than the small intestine.

The symptoms of SIBO include excess gas, abdominal bloating and distension, diarrhea, and abdominal pain. A small number of patients with SIBO have chronic constipation rather than diarrhea. When the bacterial overgrowth is severe and prolonged, the bacteria may interfere with the digestion and/or absorption of food, and deficiencies of vitamins and minerals may develop. Loss of weight also may occur. The symptoms of SIBO tend to be chronic; a typical patient with SIBO can have symptoms that fluctuate in intensity over months, years, or even decades before the diagnosis is made.

It has been theorized that SIBO may be responsible for the symptoms in at least some patients with IBS. The estimates run as high as 50% of patients with IBS. Support for the SIBO theory of IBS comes from the observation that many patients with IBS are found to have an abnormal hydrogen breath test, a test used to diganose SIBO. In addition, some patients with IBS have improvement in their symptoms after treatment with antibiotics, the primary treatment for SIBO. Moreover, small, scientifically sound studies have shown that treatment with probiotics ("good" bacteria) improves the symptoms of IBS. Although there are several ways by which probiotics may exert their beneficial effect, one way is by affecting the existing bacteria in the small intestine. If this is indeed the mechanism of action, it would support the theory that SIBO is a cause of IBS. Nevertheless, it has not been determined if this is the mechanism of action of probiotics in IBS. Finally, it has been shown that treatment with antibiotics that kill or suppress intestinal bacteria improves the symptoms of IBS.

Although the theory that SIBO causes IBS is tantalizing and there is much anecdotal information that supports it, the rigorous scientific studies that are necessary to prove or disprove the theory have just begun. Nevertheless, many physicians have already begun to treat patients with IBS for SIBO.

Treatment of IBS based on the theory of small intestinal bacterial overgrowth.

The two most common treatments for SIBO in patients with IBS are oral antibiotics and probiotics. Probiotics are live bacteria that when ingested, result in a beneficial response to the individual. The most common probiotic bacteria are lactobacilli (also used in the production of yoghurt) and bifidobacteria, both of which are found in the intestine of normal individuals. 

Several antibiotics either alone or in combination are reported to be successful in treating SIBO in patients with IBS. Most physicians use standard doses of antibiotics for one to two weeks. Probiotics may be used alone, in combination with antibiotics, or for prolonged maintenance. When probiotics are used, it probably is best to use one of the several probiotics that have been studied in medical trials and shown to have an effect on the small intestine, (though not necessarily in SIBO). The commonly-sold probiotics in health-food stores may not be effective. Moreover, they often do not contain the stated bacteria or the bacteria are dead. 

Treatment with antibiotic versus probiotic.

There are no trials comparing antibiotics and probiotics; however, antibiotics have certain disadvantages. Physicians are reluctant to prescribe prolonged or repeated courses of antibiotics because of concern over long-term side effects of the antibiotics and emergence of bacteria that are resistant to the antibiotics.

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Archived: March 20, 2014

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Read the Original Article: Irritable Bowel Syndrome