Treatment

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

Time (min)

0 20 40 60 80 100 120 140 160 180 200

Time (min)

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

REFERENCES

  1. Ellis H, Smith ADM. The blind loop syndrome. Monogr Surg Sci 1977; 4: 193-197.
  2. Gorbach SL, Tabaqchali S. Bacteria, bile and small bowel. Gut 1969; 10: 963-972.
  3. Ament MF, Shimoda SS, Sanders DP. Phatogenesis of steatorrhea in three cases of small intestinal stasis syndrome. Gastroenterology 1972; 63: 728.
  4. Gracey M. The contaminated small bowel symdrome: pathogenesis, diagnosis, and treatment. Am J Clin Nutr 1979; 32: 234-243.
  5. Fagundes Neto U. Enteropatia Ambiental uma Conseqüência do Fracasso das Políticas de Saúde Pública. Rio de Janeiro: Livraria e Editora Revinter Ltda; 1996.
  6. Lichtman SN. Bacterial overgrowth. In Walker WA, Durie PT, Hamilton JR et al. Pediatric Gastrointestinal Disease, 3rd edn. Ontario: BC Decker, 2000: 569-581.
  7. Araya M, Figueroa G. Flora residente intestinal. Funciones fisiológicas y alterações. Rev Chil Pediatr 1985; 56: 490-496.
  8. Morais TB, Morais MB, Sigulem DM. Bacterial contamination of the lacteal contents of feeding bottles in metropolitan. Bull World Health Organ 1998; 76: 173-181.
  9. Dixon JM. The fate of bacteria in the small intestine. J Path Bact 1960; 79: 131-139.
  10. Ament EM, Vargas J. Diagnóstico e tratamento da síndrome da pseudo-obstrução intestinal crónica na criança. In Fagundes Neto U, Wehba J, Pena FJ, eds. Gastrenterologia Pediátrica, 2nd edn. Rio de Janeiro: MEDSI, 1991: 349-368.
  11. King CE, Tokes PP. Small intestine bacterial overgrowth. Gastroenterology 1979; 76: 1035-1055.
  12. Simon GL, Gorbach SL. Intestinal flora in health and disease. Gastroenterology 1984; 86: 174-193.
  13. Kocoshis AS, Scheletewitz K, Lovelace G, Laine AR. Duodenal bile acids among children: keto derivatives and aerobic small bowel bacterial overgrowth. J Pediatr Gastroenterol Nutr 1987; 6: 686-696.
  14. Dickman MD, Chappelka AR, Schaelder RW. The microbial ecology of the upper small bowel. AJG 1976; 65: 57-62.
  15. Thadepalli H, Ann Lou SM, Bach VT et al. Microflora of the human small intestine. A J Surge 1979; 138: 845-850.
  16. Fagundes Neto U, Reis MHL, Webha J et al. Small bowel bacterial flora in normal and in children with acute diarrhea. Arq Gastroenterol São Paulo 1980; 17: 103-108.
  17. Drasar BS, Shiner M. Studies on the intestinal flora: part II. Bacterial flora of the small intestine in patients with gastrointestinal disorders. Gut 1969; 10: 812-819.

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.

  1. Isaacs PET, Kim YS. The contaminated small bowel syndrome. Am J Med 1979; 67: 1049-1057.
  2. Davidson GP, Butler RN. Breath analysis. In Walker WA, Durie PD, Hamilton JR et al., eds. Pediatric Gastrointestinal Disease, 3rd edn. Ontario: BC Decker, 2000: 1529-1537.
  3. Kirsch M. Bacterial overgrowth. Am J Clin Nutr 1990; 85: 231-237.
  4. Suarez L, Perdomo M, Escobar H. Microflora bacteriana y ecosistema intestinal isiopatologia del intestino delgado contaminado. Diarréia aguda. Meio ambiente en Espana. GEN 1994; 48: 61-64.
  5. 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.
  6. 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: 1328-1331.
  7. Attar A, Flourié B, Rambaud JC et al. Antibiotic efficacy in small intestinal bacterial overgrowth-related chronic diarrhea: a crossover, randomized trial. Gastroenterology 1999; 117: 794-797.
  8. Bardhan PK, Feger A, Kogon M et al. Urinary choloyl-PABA excretion in diagnosing small intestinal bacterial overgrowth. Dig Dis Sci 2000; 45: 474-479.
  9. King CE, Toskes PP. Comparison of the 1-Gram [14C] xylose, 10-Gram lactulose-H2, and 80-Gram glucose-H2 breath test in patients with small intestine bacterial overgrowth. Gastroenterology 1986; 91: 1447-1451.
  10. Khin-Maung U, Tin-Ay, Ku-Tin M et al. In vitro hydrogen production by enteric bacteria cultured from children with small bowel bacterial overgrowth. J Pediatr Gastroenterol Nutr 1992; 14: 192-197.
  11. Rumessen JJ, Gudmand-Hoyer E, Bachmann E, Justesen T. Diagnosis of bacterial overgrowth of small intestine: comparison of the 14C D-xylose breath test and jejunal cultures in 60 patients. Scand J Gastroenterol 1985; 20: 1267-1275.
  12. Farfán GF, Augusto CY, Raúl RL, Tello RC. Sobrepoblacion bacteriana del intestino delgado y diarrea cronica: estudo clínico y bacteriológico de 40 casos. Diagnostico 1991; 28: 41-47.
  13. Challacombe DN, Richardson MJ, Andersoon CM. Bacterial microflora of the upper gastrointestinal tract in infants without diarrhoea. Arch Dis Child 1974; 49: 264-269.
  14. Cruz AS, Fagundes Neto U. Influência da Escherichia coli enteropatogênica clássica sobre a proliferação bacteriana no intestino delgado na diarréia aguda e persistente do lactente. Rev Ass Med Brasil 1996; 42: 89-94.
  15. Tahan S. O efeito de um antimicrobiano na microbiota 49 duodenal e na evolução clínica de lactentes hospitalizados por diarréia aguda e persistente: um ensaio clínico duplo-cego randomizado. Thesis, 50

Universidade Federal de São Paulo, 2000.

33. Silva NS. Cultura de bactérias aeróbias e anaeróbias e teste do hidrogénio no ar expirado no diagnóstico de 51

sobrecrescimento bacteriano no intestino delgado. Thesis, Universidade Federal de São Paulo, 2001.

  1. Levitt MD, Bond JH. Volume, composition, and source 52 of intestinal gas. Gastroenterology 1970; 59: 921-929.
  2. Corazza G, Menozzi GM, Strocchi A et al. The diagnosis of small bowel bacterial overgrowth. Gastroenterology 53

36. Perman JA. Clinical application of breath hydrogen measurements. Can J Physiol Phamacol 1991; 69:

111-115. 54

  1. Kerlin P, Wong L. Breath hydrogen testing in bacterial overgrowth of the small intestine. Gastroenterology 1988; 95: 982-988.
  2. Riordan SM, Mciver CJ, Bolin TD, Duncombe VM. 55 Fasting breath hydrogen concentrations in gastric and small-intestinal bacterial overgrowth. Scand J

Gastroenterol 1995; 30: 252-257.

39. MacMahon M, Gibbons N, Mullins E et al. Are 56 hydrogen breath tests valid in the elderly? Gerontology

40. Davidson GP, Robb TA, Kirubakaran CP. Bacterial contamination of the small intestine as an important cause of chronic diarrhea and abdominal pain: 57

diagnosis by breath hydrogen test. Pediatrics 1984; 74: 229-235.

  1. Boissieu D, Chaussain M, Badoual J et al. Small-bowel bacterial overgrowth in children with chronic diarrhea, abdominal pain, or both. J Pediatr 1996; 128: 203-207.
  2. Marcelino RT. Teste do hidrogénio no ar expirado no diag- 58 nóstico do sobrecrescimento bacteriano do intestino delgado. Thesis, Universidade Federal de São Paulo, 1995.
  3. Guno MJV, Nolasco ET, Rogacion JM et al. Small bowel bacterial overgrowth in severely malnourished filipino 59 children using breath hydrogen tests. J Pediatr

Gastrentrol Nutr 2000; 31(Suppl 2): 240.

  1. World Health Organization. Persistent diarrhoea in children in developing countries. Report of a WHO 60
  2. Bull World Health Organ 1988; 66: 709-717.
  3. World Health Organization. Evalution of an algorithm for the treatment of persistent diarrhea: a multicentre study. Bull World Health Organ 1996; 74: 479-489. 61
  4. Fagundes Neto U, Toccalino H, Dujovney F. Stool bacterial aerobic overgrowth in the small intestine of children with acute diarrhoea. Acta Paediatr Scand

1976; 65: 609-615. 62

  1. Albert MJ, Bhat P, Rojand D et al. Jejunal microbial flora of Southern India infants in health and with acute gastroenteritis. J Med Microbiol 1978; 11: 43-44.
  2. Penny ME, Silva DGH, Mcneish AS. Bacterial 63 contamination of the small intestine of infants with enteropathogenic Escherichia coli and other enteric infections: a factor in the aetiology of persistent diarrhoea? Br Med J 1986; 292: 1223-1225.

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.

Klipstein FA. Recent advances in tropical malabsorption. Scand J Gastroenterol Suppl 1970; 6: 93-114.

Gerson CD, Kent TH, Saha JR et al. Recovery of small-intestinal structure and function after residence in the tropics. II. Studies in Indians and Pakistanis living in New York City. Ann Intern Med 1971; 75: 41-48. Fagundes-Neto U, Viaro T, Wehba J et al. Enteropatia tropical: na infância: uma síndrome decorrente da contaminação ambiental (enteropatia ambiental). J Pediatr (Rio de J) 1983; 54: 313-319. Fagundes-Neto U, Viaro T, Wehba J et al. Tropical enteropathy (environmental enteropathy) in early childhood: a syndrome caused by contaminated environment. J Trop Pediatr 1984; 30: 204-209. Fagundes Neto U, Martins MCV, Lima FMLS et al. Symptomatic environmental enteropathy in infancy: bacterial proliferation, functional and morphological alterations of the small bowel. Rev Hosp Säo Paulo Esc Paul Med 1992; 4: 64-70.

Gusmão RHP, Martins MCV, Gusmão SRB, Fagundes Neto U. Enteropatia ambiental: estudo ultra-estrutural da mucosa jejunal de criancas assintomaticas [Ambiental intestinal diseases: ultrastructure of the jejunum mucosa of asymptomatic children]. J Pediatr (Rio de J) 1993; 69: 21-26.

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.

Weight Loss Funnel

Weight Loss Funnel

Who Else Wants To Discover The 3 Most Effective Fat Burning Methods The Weight Loss Industry Does NOT Want You To Know About.

Get My Free Ebook


Post a comment