Treatment of SBBO depends fundamentally on the patient's general characteristics, especially on the presence of those clinical conditions listed in Table 13.3. Obviously, when possible, one should treat the predisposing conditions, improving factors to control bacterial flora.
In patients with clinical conditions associated with SBBO in whom treatment of the underlying disease does not always produce satisfactory results, such as in intestinal pseudo-obstruction syndrome and ileocecal valve resection, use of antibiotics is indicated.
0 20 40 60 80 100 120 140 160 180 200
0 20 40 60 80 100 120 140 160 180 200
Figure 13.3 Median of the concentration of hydrogen in the expired air in the children living in a slum (n = 50) and controls (n = 50) after the administration of 10 g of lactulose and 50 g of glucose on different days.
Boissieu et al41 observed the disappearance of symptoms attributed to SBBO, such as chronic abdominal pain and chronic diarrhea, after antibiotic therapy.
Lichtman6 reviewed the literature in 2000 on the use of antibiotics in the treatment of SBBO. Most reports dealt with small groups of patients, with different underlying diseases predisposing towards SBBO; there were no controlled studies or series with a sufficient number of patients. Therefore, based on his own experience and in view of the scanty evidence from the literature, this author recommended the use of antibiotics effective against bacteroids, such as metronida-zole, chloramphenicol and tetracycline. In children, an initial course of metronidazole for 2-4 weeks is considered the first choice.
In our practice, we normally prescribe courses of metronidazole and trimethoprim-sulfamethoxazole.
In the case of SBBO associated with severe acute diarrhea and with persistent diarrhea, a doubleblind placebo-controlled study was carried out by our group to assess the effect of oral polymyxin for 7 days on the clinical course and on the proximal small-intestine fluid culture in 25 hospitalized infants.32 Both groups were on the same basic and dietary treatments; pre-treatment rates of SBBO were 61.5% in the polymyxin group and 71.4% in the placebo group. Both groups had a satisfactory clinical course. SBBO, however, persisted after treatment in a high proportion of patients: 76.9% of those given polymyxin and 57.1% on the placebo (NS). However, in the group treated with polymyxin a reduced need for other antibiotics for suspected systemic infections was found (p = 0.08).
Recently, growing attention has been given to the possible use of probiotics in a variety of gastrointestinal disorders, including SBBO, and some preliminary evidence of possible efficacy is beginning to emerge. In fact, the risk of bacterial translocation in experimental short-bowel syndrome, a condition characterized by frequent episodes of SBBO, has been found to be reduced by the administration of Bifidobacterium lactis in rats.62 Furthermore, two strains of lactobacilli (Lactobacillus casei and L. acidophilus strains cerela) have been found useful in the treatment of SBBO-related chronic diarrhea.63
When SBBO is associated with environmental enteropathy, there is no evidence that antibiotics can help control it; in addition, the chronic nature of the process with possible recurrences clearly discourages this type of treatment. However, environmental enteropathy shows spontaneous
regression once appropriate environmental conditions are restored. It is obvious, therefore, that the mainstay for the approach to this socially relevant problem has to be through creating suitable living conditions for such a wide proportion of the world's children.
Universidade Federal de São Paulo, 2000.
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40. Davidson GP, Robb TA, Kirubakaran CP. Bacterial contamination of the small intestine as an important cause of chronic diarrhea and abdominal pain: 57
Cristia YG, Arbelo TF, Vivanca MVP et al. Estudos de la microflora intestinal in niños com diarreia aguda y persistent. GEN 1994; 48: 236-244. Coello-Ramirez P, Lifschitz F. Enteric microflora and carbohydrate intolerance in infants with diarrhea. Pediatrics 1972; 49: 233-242.
Sprinz H, Sribhibhadh R, Gangarosa et al. Biopsy of small bowel of Thai people. Am J Clin Pathol 1962; 38: 43-51.
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Pereira SP, Khin-Maung U, Bolin TD et al. A pattern of breath hydrogen excretion suggesting small bowel bacterial overgrowth in Burmese village children. J Pediatr Gastroenterol Nutr 1991; 13: 32-38. Reis JC, Morais MB, Fagundes-Neto U. Teste do H2 no ar expirado na avaliação de absorção de lactose e sobrecrescimento bacteriano no intestino delgado de escolares. Arq Gastroenterol 1999; 36: 169-176. Alves GMS, Morais MB, Fagundes-Neto U. Estado nutricional e teste do hidrogénio no ar expirado com lactose e lactulose em crianças indígenas terenas. J Pediatr (Rio de J) 2002; 78: 113-119. Reis JC. Utilização da glicose e lactulose no diagnóstico de sobrecrescimento bacteriano no intestino delgado por meio do teste do hidrogénio no ar expirado. Thesis, Universidade Federal de São Paulo, 2002. Eizaguirre I, Urkia NG, Asensio AB et al. Probiotic supplementation reduces the risk of bacterial translocation in experimental short bowel syndrome. J Pediatr Surg 2002; 37: 699-702. Gaon D, Garmendia C, Murrielo NO et al. Effect of Lactobacillus strains (L. casei and L. acidophillus strains cerela) on bacterial overgrowth-related chronic diarrhea. Med (Buenos Aires) 2002; 62: 159-163.
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