Pathophysiology

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In patients with SBBO, functional and/or morphological alterations can be observed, owing to the capacity of these bacteria to promote decon-jugation of bile salts, such as 7a-dehydroxylation, which transforms them into secondary bile salts. The deconjugation of bile salts causes a reduction in the capacity to form mixed micelle, which is important in the process of lipid digestion and absorption, because the concentration in the intestinal lumen does not achieve a critical micel-lar concentration. Therefore, lower solubility of fats in the diet causing steatorrhea is observed. On the other hand, the secondary bile acids (deoxy-cholic and lithocholic) have a large capacity to provoke lesions in the intestinal mucosa, causing partial villous atrophy that may be associated with the secretion of electrolytes and malabsorption of glucose.5,12,13

Patients with SBBO also present reduced absorption of carbohydrates from the diet by:

  • 1) Metabolism of carbohydrates by the SBBO bacteria, which generates short-chain fatty acids (acetic, propionic and butyric acids) and gases, such as hydrogen, which, after diffusion through the intestinal mucosa, pass through to the circulatory system and reach the lungs, where they are eliminated in respiration.
  • 2) Reduction in the activity of disaccharidases due to alterations in the ultrastructure of the small intestine.

Consequently, the unabsorbed carbohydrates remain in the intestinal lumen in their original form or in the form of short-chain fatty acids as a result of bacterial fermentation, generating osmotic pressure that promotes the secretion of water into the intestinal lumen.5,11

Evidence also exists of a reduction in protein digestion and absorption from the diet due to intraluminal protein catabolism as well as a reduction in the transport and uptake of amino acids by the intestinal mucosa.5,11

SBBO may also cause malabsorption of liposoluble vitamins A and D accompanied by steatorrhea. Reduction in the absorption of vitamin B12 may

Table 13.2 Probable effects of bacterial overgrowth

Intraluminal

Mucosal

Systemic

Bile salt deconjugation

Deficiency of disaccharidases

Absorption of bacterial toxins and antigens

Decrease of the biliary salt 'pool'

Enterocyte damage

Hepatic inflammation

Steatorrhea

Inflammation

Immune complex formation

Vitamin B12 malabsorption

Protein loss

Vasculitis

Production of short-chain fatty acids

Bleeding

Polyarthritis

occur, owing to the consumption of vitamins by bacteria present in the intestinal lumen, especially Bacteroides.5,11

Systemic effects of SBBO are associated with the absorption of antigens and bacterial products through the injured intestinal mucosa.6 Table 13.2 lists the effects of an overgrowth of bacteria on its host.

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