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Small Intestinal Bacterial Overgrowth (SIBO)

By

Atenodoro R. Ruiz, Jr.

, MD, The Medical City, Pasig City, Philippines

Last full review/revision Feb 2021| Content last modified Feb 2021
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Small intestinal bacterial overgrowth can result from alterations in intestinal anatomy or gastrointestinal motility, or lack of gastric acid secretion. This condition can lead to vitamin deficiencies, fat malabsorption, and undernutrition. Diagnosis is by breath test or quantitative culture of intestinal fluid aspirate. Treatment is with oral antibiotics.

Under normal conditions, the proximal small bowel contains < 105 bacteria/mL, mainly gram-positive aerobic bacteria. This low bacterial count is maintained by normal peristalsis, normal gastric acid secretion, mucus, secretory IgA, and an intact ileocecal valve.

Etiology of Bacterial Overgrowth Syndrome

Anatomic alterations of the stomach and/or small intestine promote stasis of intestinal contents, leading to bacterial overgrowth. Conditions that cause or require anatomic alterations include small-bowel diverticulosis, surgical blind loops, postgastrectomy states (especially in the afferent loop of a Billroth II), strictures, or partial obstruction.

Intestinal motility disorders associated with diabetic neuropathy, systemic sclerosis, amyloidosis, hypothyroidism, and idiopathic intestinal pseudo-obstruction can also impair bacterial clearance. Achlorhydria and idiopathic changes in intestinal motility may cause bacterial overgrowth in older people.

Pathophysiology of Bacterial Overgrowth Syndrome

The most common species in SIBO include streptococci Streptococcal Infections Streptococci are gram-positive aerobic organisms that cause many disorders, including pharyngitis, pneumonia, wound and skin infections, sepsis, and endocarditis. Symptoms vary with the organ... read more Streptococcal Infections , Bacteroides, Escherichia Escherichia coli Infections The gram-negative bacterium Escherichia coli is the most numerous aerobic commensal inhabitant of the large intestine. Certain strains cause diarrhea, and all can cause infection when they invade... read more , Lactobacillus, Klebsiella, and Aeromonas. The excess bacteria consume nutrients, including carbohydrates and vitamin B12, leading to caloric deprivation and vitamin B12 deficiency Vitamin B12 Deficiency Dietary vitamin B12 deficiency usually results from inadequate absorption, but deficiency can develop in vegans who do not take vitamin supplements. Deficiency causes megaloblastic anemia, damage... read more . However, because the bacteria produce folate, this deficiency is rare. The bacteria deconjugate bile salts, causing failure of micelle formation and subsequent fat malabsorption. Severe bacterial overgrowth also damages the intestinal mucosa. Fat malabsorption and mucosal damage can cause diarrhea.

Symptoms and Signs of Bacterial Overgrowth Syndrome

The most common symptom of SIBO is bloating. The other symptoms are abdominal discomfort, diarrhea, and excess flatulence. Some patients have significant diarrhea or steatorrhea. (See also the American Journal of Gastroenterology's guidelines for small intestinal bacterial overgrowth.)

Diagnosis of Bacterial Overgrowth Syndrome

  • Breath tests

  • Quantitative culture of intestinal aspirate

  • Imaging studies

Some clinicians advocate response to empiric antibiotic therapy as a diagnostic test. However, because bacterial overgrowth can mimic other malabsorptive disorders (eg, Crohn disease Crohn Disease Crohn disease is a chronic transmural inflammatory bowel disease that usually affects the distal ileum and colon but may occur in any part of the gastrointestinal tract. Symptoms include diarrhea... read more Crohn Disease ) and adverse effects of the antibiotics can worsen symptoms of diarrhea, establishing a definitive etiology is preferred.

(See also the American Journal of Gastroenterology's guidelines for small intestinal bacterial overgrowth.)

Breath testing, specifically with glucose hydrogen or lactulose hydrogen, is suggested in symptomatic patients for the diagnosis of small intestinal bacterial overgrowth (SIBO). Before breath testing, it is recommended that patients avoid use of antibiotics for 4 weeks and avoid promotility agents and laxatives for at least 1 week.

The standard for diagnosis of SIBO is quantitative culture of intestinal fluid aspirate showing a bacterial count > 103 colony-forming units/mL. This method, however, requires endoscopy.

If the anatomic alterations are not due to previous surgery, an upper gastrointestinal series with small-bowel follow-through should be done to identify predisposing anatomic lesions. Alternatively, CT enterography or magnetic resonance enterography can be done.

Treatment of Bacterial Overgrowth Syndrome

  • Oral antibiotics (various)

  • Dietary modification

Treatment of bacterial overgrowth syndrome is with 10 to 14 days of oral antibiotics that cover both aerobic and anaerobic enteric bacteria. Empiric regimens include use of one or two of the following:

  • Amoxicillin/clavulanic acid 500 mg 3 times a day

  • Cephalexin 250 mg 4 times a day

  • Trimethoprim/sulfamethoxazole 160/800 mg 2 times a day

  • Metronidazole 250 to 500 mg 3 or 4 times a day

  • Rifaximin 550 mg 3 times a day

  • Ciprofloxacin 500 mg 2 times a day

Antibiotic treatment can be cyclic, if symptoms tend to recur, and changed based on culture and sensitivity. Changing antibiotic treatment may be difficult, however, due to coexistence of multiple bacteria.

Because bacteria metabolize primarily carbohydrates in the intestinal lumen rather than fats, a diet high in fat and low in carbohydrates and fiber is beneficial.

Underlying conditions and nutritional deficiencies (eg, vitamin B12) should be corrected.

Key Points

  • Anatomic alterations in stomach or intestines or intestinal motility disorders lead to gastrointestinal stasis and thus bacterial overgrowth.

  • Bacteria deconjugate bile salts, causing fat malabsorption.

  • Diagnosis is made using a glucose-hydrogen or lactulose-hydrogen breath test or quantitative culture of intestinal aspirate.

  • Oral antibiotics are used, and a high-fat, low-carbohydrate diet is followed.

More Information

The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

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Small Intestinal Bacterial Overgrowth (SIBO)
Small intestinal bacterial overgrowth can lead to vitamin deficiencies, fat malabsorption, and undernutrition. This syndrome can be caused by anatomic alterations or intestinal motility disorders. Which of the following may cause bacterial overgrowth in older people? 
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