Breath test for bacteria in the small intestine. Bacterial overgrowth syndrome (SIBR) in the small intestine. Key aspects of patient management

bacterial overgrowth syndrome- a symptom complex that occurs if the concentration of microorganisms in the small intestine exceeds 10 5 cells / ml in the aspirated contents.

The main manifestations of the syndrome of excessive bacterial growth are: nausea, rumbling in the abdomen, diarrhea, malabsorption syndrome, weight loss. To diagnose the syndrome, aspiration of the small intestine contents for culture is performed; breath tests are performed. Treatment of patients with excess bacterial syndrome is carried out with antibacterial drugs.

  • Epidemiology of bacterial overgrowth syndrome

    At risk for the occurrence of bacterial growth syndrome are newborns, young children and the elderly (especially those with malnutrition).

    In the US, approximately 20-43% of diabetic patients develop bacterial overgrowth syndrome.

    Bacterial overgrowth syndrome is responsible for 50% of neonatal chronic diarrhoea.

  • Etiology of bacterial overgrowth syndrome

    Risk factors for bacterial overgrowth syndrome include:

    • Anatomical changes in the small intestine that delay the passage of contents through the digestive tract. These changes occur in patients with the following diseases:
      • intestinal strictures,
      • intestinal lymphomas,
    • The absence of an ileocecal valve and the length of the small intestine remaining after resection is less than 0.6 m in children and less than 1.5 m in adults:
    • Disturbances of peristalsis of the digestive tract:
      • diabetic neuropathy,
      • Amyloidosis,
      • scleroderma,
      • Hypothyroidism.
    • Hyposecretion of hydrochloric acid (the main etiological factor in the development of bacterial overgrowth syndrome in elderly patients).
    • Immune system disorders:
      • Taking immunosuppressants,
      • IgA deficiency,
      • Hypogammaglobulinemia.
    • The use of proton pump inhibitors, for example, omeprazole, ranitidine (due to inhibition of hydrochloric acid secretion).
  • Clinic of bacterial overgrowth syndrome
    • Main clinical manifestations of bacterial overgrowth syndrome

      The main manifestations of bacterial overgrowth syndrome are:

      • Nausea.
      • Pain and rumbling in the abdomen.
      • Bloating.
      • Diarrhea, steatorrhea.
      • In most cases, body weight is reduced.
      • Growth retardation occurs in children with bacterial overgrowth syndrome.
      • In some cases, bacterial overgrowth syndrome may be asymptomatic. At the same time, patients have only a decrease in body weight.
    • Complications of bacterial overgrowth syndrome

      The syndrome of excessive bacterial growth with a long course leads to malnutrition, deficiency of vitamins (in particular vitamin B 12) and microelements (in particular iron).

      If vitamin B12 deficiency occurs, macrocytic anemia develops; with the appearance of hypoferremia - microcytic anemia.

  • Diagnosis of bacterial overgrowth syndrome
    • Diagnostic methods
      • Non-invasive diagnostic methods
    • Diagnostic algorithm

      The gold standard for diagnosing bacterial overgrowth syndrome is the culture of the contents of the small intestine and the detection of an increased concentration of bacteria in it (more than 10 5 cells / ml).

      Breath tests are diagnostically informative and easier to perform from a technical point of view. Three tests are recommended: hydrogen, xylose, and bile acid, but xylose is the most specific.

      It is possible to determine the levels of 4-hydroxyphenylacetonic acid in urine tests of adult patients with bacterial overgrowth syndrome. It must be remembered that in 2% of cases it is possible to obtain false-positive results.

  • Treatment of bacterial overgrowth syndrome

    Treatment of patients with bacterial overgrowth syndrome is usually carried out with rifaximin (Alpha Normix) at a dose of 1200 mg per day. This dose provides a 60% decontamination rate.

    For the treatment of bacterial overgrowth syndrome, the following are also prescribed:

    • tetracycline (Tetracycline hydrochloride) - orally for adults, 500 mg 4 times a day; children under 8 years of age are not recommended.
    • gentamicin inside 50 mg / kg / day 4-6r / day (no more than 360 mg / day).
    • amoxicillin / clavulanic acid (Augmentin) - inside for adults. 250-500 mg 2 times a day; children - 40 mg / kg / day 2r / day.
    • clindamycin (Dalacin, Clindamycin) - inside for adults, 300 mg 3 times a day; IV 600-2700 mg/day 2 times a day; children - inside 30 mg / kg / day 2r / day; IV at 40 mg/kg/day 2-4r/day.
    • Amoxicillin/clavulanic acid is prescribed for patients with diabetes mellitus.
    • Clindamycin and metronidazole are recommended for elderly patients.
    • Gentamicin significantly improves the condition of children under the age of one year with bacterial overgrowth syndrome.
    • The patient should be monitored for several months after antibiotic therapy is completed.
    • It is necessary to treat the disease that led to the occurrence of bacterial overgrowth syndrome.
  • Prediction and prevention of bacterial overgrowth syndrome

    Prevention of bacterial overgrowth syndrome is reduced to the prevention of the disease that led to its development.

    If the cause that led to the occurrence of bacterial overgrowth syndrome is not eliminated, then it can recur.

Inevitably, EPI is accompanied by impaired digestion and absorption of nutrients, which can lead to the development of malabsorption. It is believed that adequate therapy with enzyme preparations should compensate for the deficiency of endogenous enzymes and restore normal digestion. However, in practice, it is far from always possible to easily cope with EPI. The main reason for this, as a rule, is associated with an insufficient dose of enzyme agents or the choice of an ineffective drug. There is a second, very serious reason for the persistent course of EPI and the low, at first glance, the effectiveness of enzyme therapy. This is associated with the development of small bowel bacterial overgrowth syndrome (SIBO), known in the English literature as "bacterial overgrowth". SIBO is little known to a wide range of doctors and is not taken into account in treatment tactics. Therefore, the purpose of this article was to familiarize internists and gastroenterologists with modern approaches to the correction of SIBO in CP. Normal microflora of the gastrointestinal tract

From modern positions, the normal human microflora (normoflora, microbiota) is considered as a set of many microbiocenoses occupying numerous ecological niches (biotopes) on the skin and mucous membranes of all body cavities open to the external environment. The total number of bacteria in an adult is 1015 cells, which is more than 10 times higher than the number of own cells of the macroorganism. The currently existing regulatory document "Russian industry standard for dysbacteriosis" offers the following definition of normal flora: it is "a qualitative and quantitative ratio of various populations of microbes of individual organs and systems that maintain the biochemical, metabolic and immunological balance of the macroorganism necessary to maintain human health." From this definition it follows that the normoflora of each biotope performs numerous functions not only to maintain its functioning, but also the homeostasis of the body as a whole.

The species and quantitative composition of the microflora of each biotope of the gastrointestinal tract (GIT) is quite constant due to the influence of numerous protective factors both from the host organism and the microbiota itself:

genetic predisposition

Acidic gastric environment

Normal motor-evacuation function of the gastrointestinal tract

Anatomical sphincters of the gastrointestinal tract

Constant level of intraluminal pH in different biotopes

The state of the immune system of the mucous membranes

Bactericidal substances produced by mucous membranes (lysozyme, lactoferrin, etc.)

Phagocytic activity of mucosal macrophages

Secretory IgA

Bacterial colicins and microcins (endogenous peptide antibiotics of microbial origin)

Only in the human gastrointestinal tract there are more than 400 species of bacteria - representatives of 17 different families. The human digestive tract is inhabited by bacteria unevenly.

As can be seen from the table, the highest density of microbial contamination in the colon is about 400 different species. The total biomass of colonic microbial cells is approximately 1.5 kg, which corresponds to 1011–1012 CFU/g of content and is about 1/3 of the dry weight of feces. It is the large intestine, due to such a high contamination, that bears the greatest functional load compared to other biotopes. The content of bacteria in the upper intestine varies in a narrow range of 103–104 CFU/ml of intestinal contents.

Bacteroids, eubacteria, bifidobacteria, peptostreptococci, ruminococci, clostridia, and lactobacilli are the bulk of bacteria in the large and lower sections of the small intestine, and bacteroids, lactobacilli, and cocci in the upper sections of the small intestine (Table 1). Despite the relatively small number of microorganisms in the proximal small intestine, their functions are very important for the vital activity of this biotope, in particular, for maintaining the luminal pH and the immune status of the mucosa. The normal microflora of the gastrointestinal tract as a whole performs metabolic, protective, antimutagenic and anticarcinogenic functions. Metabolic and anticarcinogenic functions fall mainly on the flora of the colon, and the microflora of all biotopes participates in the implementation of antitoxic, protective and immune functions, in maintaining colonization resistance and microbial antagonism in relation to pathogens and opportunistic pathogens. This applies equally to the upper sections of the small intestine. Colonization resistance is understood as a set of mechanisms that ensure the constancy of the species and quantitative composition of microbial populations in a particular biotope, preventing the reproduction of opportunistic and pathogenic flora and its translocation into uncharacteristic biotopes and into the internal environment of the body. A manifestation of such a translocation of the microflora can be SIBO in the small intestine with an increase in the microbial contamination of the latter by more than 104 CFU/ml of intestinal contents.

Syndrome of excessive bacterial growth (syndrome of excessive contamination - bacterial overgrowth)

As mentioned above, the normal content of bacteria in the upper intestines fluctuates in a narrow range of 103-104 CFU / ml of intestinal contents, and this value is a kind of constant for the small intestine. The species composition of the microbiota is also quite constant: bacteroids, lactobacilli, cocci.

Summarizing the existing definitions, from our point of view, we can give the following definition of SIBO syndrome: bacterial overgrowth syndrome is the contamination of the proximal parts of the small intestine over 104 m.k. (CFU) / ml of intestinal contents due to opportunistic microflora coming from the upper gastrointestinal tract (or upper respiratory tract) or due to retrograde translocation of opportunistic representatives of the colon microbiota.

It should be emphasized that the concept of SIBO in the international literature refers to the overgrowth of flora only in the small intestine, but not in the large intestine.

There are several main mechanisms leading to SIBO. The first mechanism is due to hypo- or achlorhydria of any origin. A decrease in the protective acid barrier allows microbes from the oral cavity and upper respiratory tract to colonize the stomach and then the small intestine. This process may be based on various reasons, but most often this pathway of microbial contamination of the small intestine occurs after gastrectomy or gastrectomy, with long-term use of gastric secretion inhibitors, with autoimmune gastritis, with autoimmune diseases such as pernicious anemia and scleroderma.

The second mechanism for the development of SIBO is due to a violation of the so-called "intestinal clearance", i.e. a violation of the ability of the small intestine to eliminate pathogens or opportunistic microorganisms that have fallen into it. Impaired clearance occurs with a decrease in the activity of protective mechanisms that maintain the constancy of the microbiota of the small intestine: inhibition of motor activity, a decrease in the synthesis of bactericidal substances and secretory IgA, a decrease in the phagocytic function of macrophages of the small intestine mucosa, etc.

The third mechanism is associated with retrograde translocation of microflora from the large intestine to the small intestine due to insufficiency of the ileocecal valve during inflammation or motor disorders of the large intestine. Almost any gastroenterological disease can lead to the development of SIBO.

Methods for assessing SIBO

Diagnosis of SIBO is very difficult, because methods of sampling the contents of the small intestine are too laborious. For this purpose, a simple and convenient method has been developed to determine the concentration of hydrogen in the exhaled air after a carbohydrate load with glucose or lactose (hydrogen breath test). In the presence of SIBO, the level of hydrogen in the exhaled air is high due to the formation of microbial metabolites in the small intestine. The same method can be used to monitor the results of treatment with various drugs that inhibit the growth of excess flora in the small intestine. The method is cheap, easy to perform, however, unfortunately, it is not widely used in Russia.

Chronic pancreatitis and SIBO

According to J.E. Dominguez-Munoz, SIBO occurs in 40% of patients with CP and is one of the most common causes leading to insufficient effectiveness of enzyme replacement therapy.

Thus, HP is accompanied by:

Violation of the processes of digestion and absorption

Development of bacterial overgrowth in the small intestine

Violation of the motor function of the gastrointestinal tract

The initial violation of cavitary digestion in CP through the interaction of complex mechanisms is aggravated by a violation of membrane digestion, and all participating mechanisms operate on the principle of a vicious circle.

Treatment of bacterial overgrowth syndrome

It should be borne in mind that SIBO is not an independent pathology, but only a secondary syndrome that accompanies many pathological conditions. If, as a rule, there are no clearly defined clinical symptoms in violations of the colon microbiota, then with SIBO, flatulence, stool disorders, and sometimes severe diarrhea usually occur. At the same time, all of these symptoms are not specific, and it is not possible to associate them unambiguously with SIBO. In the context of this article, flatulence, diarrhea, stetorrhea can equally be a consequence of both EPI and SIBO.

In any case, microbial disorders in both the large and small intestines are always secondary, therefore, in order to correct them, it is necessary first of all to eliminate the negative factors causing them (for example, medicinal or environmental influences) or to treat the underlying disease. It is important to emphasize that the correction of SIBO is not an end in itself and is carried out:

If it is impossible to eliminate its cause

Under the action of a permanent aggressive factor (for example, chemotherapy)

As an additional measure, with insufficient effectiveness of the treatment of the underlying disease that caused these disorders.

An ideal illustration of these provisions is SIBO developing against the background of EPI. Ideally, when an adequate dose of enzyme preparations is prescribed, digestion is restored and additional correction of SIBO is not required. However, SIBO is one of the most common reasons leading to insufficient effectiveness of enzyme replacement therapy. In one of the studies, the effect of Creon therapy on SIBO (according to the hydrogen breath test) was evaluated in 15 patients with EPI in CP. These patients within 2 months. conducted therapy with Creon 100-150 thousand IU per day. In the majority (65% - 10 patients), according to the repeated hydrogen test, SIBO was eliminated, in 53% (8 patients) flatulence disappeared, in 73% (11 patients) there was an improvement in well-being, but dyspeptic symptoms persisted.

Based on the foregoing, the administration of adequate doses of effective enzyme agents (Creon 25,000–40,000 IU with each meal) should be the first line therapy for pancreatic diseases with EPI with or without SIBO. With its insufficient effectiveness, the appointment of drugs to eliminate microbial growth in the small intestine is indicated. Therapeutic tactics for microbial disorders depends on the degree of their severity, the presence of clinical manifestations, and the translocation of bacteria to other biotopes. In some cases, in the presence of SIBO, it becomes necessary to conduct "selective microbial decontamination of the intestine." This concept implies carrying out intestinal sanitation (decontamination) with drugs that selectively suppress the growth of foreign flora and do not affect the normoflora. For the purpose of decontamination, several groups of agents are used:

Antibacterial drugs

Non-pathogenic fungi

Spore-forming preparations based on representatives of transient flora

microbial metabolites.

Antibiotics

The optimal antibacterial drug for decontamination of the small intestine and elimination of SIBO should meet the following requirements:

Have minimal absorption from the gut

Create a high concentration in the intestinal cavity

Possess selectivity (should suppress foreign flora and not affect the normoflora

Have a broad spectrum of antimicrobial activity, including aerobes and anaerobes

Have a minimum of side effects and be safe

Have proven clinical efficacy

One of the newest in Russia and the most interesting drug from all three points of view is a derivative of rifamycin - the drug rifaximin (Alfa-normix). It is not absorbable<1%) при приеме внутрь антибиотик, достигающий высоких концентраций в слизистой оболочке ЖКТ.

The drug does not act outside the gastrointestinal tract, i.e. is a locally acting intestinal antiseptic. Rifaximin is well tolerated, has a minimum of side effects and does not cause bacterial resistance. The drug has a wide spectrum of antibacterial action against gram-positive (Enterococcus spp, M. tuberculosis, Streptococcus pyogenes, Streptococcus faecalis, Streptococcus pneumoniae, Staphylococcus epidermidis, Staphylococcus aureus) and gram-negative (Escherichia coli, Shigella spp, Salmonella spp, Yersinia enterocolica, Proteus spp, Vibrio cholerae) aerobic bacteria and Gram-positive (Clostridium perfrigens, Clostridium difficile, Peptococcus spp, Peptostreptococcus spp) and Gram-negative (Bacteroides spp, Bacteroides fragilis, Helicobacter pylori) anaerobes. This spectrum of action determines the therapeutic potential of the drug. Thus, rifaximin satisfies all the basic requirements for an ideal antibacterial drug. It has been successfully used in acute intestinal infections, for the sanitation of the colon with "dysbacteriosis", for the correction of SIBO, with antibiotic-associated intestinal lesions and with hepatic encephalopathy. For SIBO proven by the hydrogen breath test, rifaximin is used 400 mg 3 times a day for 7 days. At the same time, the level of exhaled hydrogen decreases by 3–5 times already by the third day of treatment, which indicates a rapid sanitation of the small intestine.

For a long time, various antibiotics (tetracyclines, lincomycin, ampicillin, etc.) have been used to treat SIBO in various pathologies, which do not have selectivity, do not affect the anaerobic flora, are rapidly absorbed from the gastrointestinal tract and have a wide range of side effects (including antibiotics). associated diarrhea) and suppress normal flora. To demonstrate the effectiveness of rifaximin, a double-blind study was conducted confirming the priority of rifaximin over tetracycline in SIBO. In this study, SIBO in two groups of patients was assessed by a hydrogen breath test and the peak of hydrogen excretion in exhaled air and the total hydrogen concentration after a glucose load before and 3 days after the end of the antibiotic course were determined. It was shown that at equal initial levels of hydrogen, its peak after glucose loading, as well as the total concentration in exhaled air after treatment, was significantly lower in patients treated with rifaximin compared with the group treated with chlortetracycline.

Other effective antibacterial agents include oxyquinolone derivatives, low-absorbable nitrofuran derivatives (nifuroxazide) and nitroimidazoles (metronidazole, tinidazole). Although the last group is absorbed from the large intestine, nevertheless, its use is effective, mainly in case of contamination with anaerobic microorganisms. The duration of the decontamination course for SIBO is 12–14 days.

Non-pathogenic fungi

In case of intolerance to antibacterial drugs, it is possible and effective to prescribe drugs based on non-pathogenic yeast fungi of the genus S. boulardii. At the same time, S. boulardii does not inhibit the growth of obligate microorganisms in the intestinal cavity and is resistant to the action of hydrochloric acid. With daily intake, they are found in all parts of the gastrointestinal tract, including the small intestine. These yeasts are a transient flora for humans, therefore, 2–5 days after the end of the drug intake, they are completely eliminated from the body without side effects. The drug is not absorbed from the lumen of the gastrointestinal tract and is a locally acting intestinal antiseptic. The antimicrobial activity of S. boulardii was established in vitro and in vivo against pathogens of intestinal infections (Cl. difficile, Salmonella, Shigella, Yersinnia), protozoa (Giardia and a number of) opportunistic microorganisms (pathogenic cocci, fungi, Klebsiela, etc.) that can lead to the development of SIBO.

Spore-forming non-pathogenic antibacterial agents can also be used in SIBO as an alternative to antibiotics in case of intolerance. This group includes drugs based on the hay bacillus Bacillus subtilis and a similar microorganism B. cereus. Spore microorganisms are a transient flora for humans, therefore, they are quickly eliminated from the intestine after stopping the intake. The mechanism of action of these drugs is due to the formation of acid metabolites in the process of life and a decrease in pH throughout the intestine, thereby inhibiting the growth of opportunistic flora. In addition, these drugs synthesize a number of digestive enzymes, partially compensating for the decrease in the intestine's own enzyme activity when damaged by bacteria and their toxins. The course of treatment for SIBO is 10–14 days. A longer course is undesirable, because. B. cereus are capable of producing enterotoxins that cause diarrhea.

Microbial metabolites

An additional agent that restores the microflora of the predominantly small intestine is the microbial metabolite hilak forte. The main biologically active components that make up hilak forte are short-chain fatty acids (SCFA) and lactic acid, obtained from saccharolytic and proteolytic representatives of the normal intestinal microflora. The concentration of biologically active substances in one drop of the drug corresponds to the action of the corresponding metabolites from 1010 bacteria. The mechanism of action of hilak forte on the normalization of the composition and functions of the microbiota and on the restoration of intestinal activity is mediated by its constituent components. SCFA contained in the preparation provide mucous membranes with additional energy, promote the regeneration of damaged epithelial cells of the intestinal wall, and improve mucosal trophism. The influence of acid metabolites (SCFA, lactic acid) ensures the regulation of intraluminal pH, which leads to inhibition of the growth of pathogens and opportunistic pathogens throughout the intestine.

Thus, the tactics of treating CP with SIBO should be built as follows:

Adequate enzyme therapy (Creon 75,000 IU or more per day)

Decontamination of the small intestine: antibiotic therapy (rifaximin)

Microbial metabolites

Normalization of colonic microbiocenosis with pro- and prebiotics (if necessary)

Elimination of motor disorders - duodenal hypertension, accelerated propulsion (if necessary).

Intestinal bacterial overgrowth syndrome (SIBO) is a pathological condition caused by colonization of the small intestine with fecal microflora. SIBO accompanies diarrhea and malabsorption of fats and vitamins.

It is a consequence of pathological disorders in the intestines and is caused by the introduction of undigested food residues into the large intestine, contributing to the formation of additional colonies of putrefactive and yeast bacteria that disrupt the digestive tract. Toxic substances of Escherichia coli, entering the bloodstream, cause intoxication, leading to inflammatory changes in the alimentary tract.

Epidemiology

Causes of SIBO

When a baby is born, his intestines are sterile. Over the next weeks, the digestive tract is colonized by streptococci, lactobacilli and enterococci. Further, the number of coli bacteria in the small intestine decreases sharply, and multiplying in the large intestine, they become the norm.

In the pathological condition of SIBO, cecoileal reflux occurs, leading to increased gas formation and additional stimulation of the peristalsis of the small and large intestines.

Risk factors

The causes leading to the appearance of the syndrome of excessive bacterial growth in the intestine are: morphological or destructive features in the small intestine, contributing to the partial inhibition of the movement of food through the digestive system. Pathological conditions lead to this: prolonged stress, enteropathies of various etiologies, persistent inflammatory bowel diseases, cholangitis, and the like.

Among the factors causing pathological changes in the balance of the microflora of the small intestine include:

  • impaired functioning of the ileocecal valve;
  • surgical interventions - the formation of a blind loop, cholecystectomy, resection of the small intestine, etc.;
  • diseases of the digestive system, which are based on intestinal motility disorders (chronic constipation, gastrostasis, duodenostasis);
  • conditions caused by pathological changes in abdominal digestion and absorption (maldigestion and malabsorption);
  • pathological changes in the pancreas associated with secretory insufficiency;
  • pathological conditions of the biliary tract;
  • constant nutritional imbalance, intestinal inflammation, diverticula, short bowel syndrome;
  • immunosuppressive pathologies in AIDS and chemotherapy, antibiotics;
  • tumors of the intestine and surrounding lymph nodes
  • Crohn's disease.
  • celiac disease
  • hypogammaglobulinemia

Pathogenesis

The pathogenesis of SIBO consists of the following elements:

  • Poor absorption of lipids, proteins, polysaccharides, vitamins leads to inhibition of the functions of enterocytes and bacterial changes in the nutrient medium to a state of toxic and non-absorbable.
  • Anaerobic flora leads to a pathological change in bile acids and excludes them from the digestion process. Altered acids and carbohydrate fragments provoke loose stools.
  • Anaerobic microorganisms absorb vitamin B12, which leads to the formation of macrocytic anemia.

Symptoms of SIBO

Symptoms of SIBO are as follows: attacks of nausea, phenomena of increased gas formation, diarrhea, malabsorption syndrome, persistent weight loss. SIBO helps to diagnose such specific studies as: aspiration of the contents of the small intestine for culture and breath tests.

Symptoms are divided into two groups:

  1. Abdominal caused by pathological processes in the abdominal cavity, quite frequent bloating and rumbling in the abdomen, sometimes nausea that occurs some time after eating. Chair instability.
  2. Are common, which are based on a lack of fat-soluble vitamins, cyanocobalamin and folic acid, iron, leading to decreased performance, fatigue, impotence, lethargy, dizziness, and weight loss. Vitamin deficiency states are characterized by dry skin, blurred vision at dusk; increased anxiety, mood swings, nervousness.

Complications and consequences

Diagnosis of SIBO

Careful history taking ensures accurate diagnosis. The patient is asked in detail about the presence of functional diseases of the gastrointestinal tract, accompanied by pain of varying intensity in the abdomen, flatulence, diarrhea.

Diagnosis - SIBO requires the use of laboratory tests and various methods of examination (non-invasive, invasive).

It is obligatory to sow the aspiration masses of the small intestine in order to determine the type of pathological microflora. A typical diagnostic test is a breath test.

In the coprogram with SIBO, undigested food remains, the formation of an excessive amount of fat are determined. Conducted intestinoscopy and biopsy of the walls of the small intestine.

Breath test for bacterial overgrowth syndrome

Glucose test. It is based on the identification of hydrogen in the air exhaled by the patient using a special device. It is carried out on an empty stomach. The patient takes a deep breath, holds his breath for 10-15 seconds. Then slowly exhale into the testing device. The laboratory assistant writes down the readings of the device. Then the patient drinks a solution with the addition of glucose. With an interval of 30 minutes, the specialist takes measurements three times on exhalation. A noticeable increase in hydrogen levels indicates problems in the small intestine.

xylose test(xylose is a carbohydrate that is absorbed only in the small intestine). With this test, altered CO2 is detected, the formation of which is associated with impaired metabolic reactions of the patient's body caused by SIBO.

Analyzes

When making a diagnosis of bacterial overgrowth syndrome, laboratory tests are recommended: complete blood count - determination of anemia (low hemoglobin, pathologically altered red blood cells, low color index), the presence of inflammation (leukocytosis, elevated ESR);

Biochemical blood test (increased ALT, AST, positive result of C-reactive protein).

Urinalysis (presence of a large amount of mucus, bacteria).

Coprological examination of feces (detect undigested food residues, increased acidity of feces and high fat content)

Bacteriological culture (detection of the rapid growth of colonies of pathological microorganisms).

Instrumental diagnostics

Intestinoscopy is an endoscopic method. A conductor with an optical device is inserted into the patient's small intestine to aspirate its contents, followed by inoculation of the aspirate on a nutrient medium.

A biopsy of the small intestine is an instrumental capture of the tissue of the small intestine for the purpose of microscopic examination. In the symptom complex of excessive bacterial growth, pathologically altered atrophic villi in the small intestine are determined.

An x-ray is performed to identify the main cause of the SIBO that caused it (diverticulum, streak of the small intestine, etc.).

Differential Diagnosis

SIBO should be differentiated from celiac disease and exocrine pancreatic insufficiency. Pathological changes are very similar: partial villous atrophy, crypt hyperplasia, accumulations of lymphocytes in the own layer of the epithelium are characteristic of these diseases. Clarification of the differential diagnosis requires specific studies.

SIBO treatment

Therapy should be of a complex etiopathogenetic nature. It is necessary to eliminate the pathology that caused the occurrence of SIBO.

Patients are treated with antibacterial drugs, vitamins, pro- and prebiotics, absorbents.

The decision to choose an antibiotic is based on the results of a bacteriological analysis of aspirate of the small intestine and tests for the sensitivity of the pathological flora to drugs. Therapy of patients with SIBO is carried out with broad-spectrum antibiotics rifaximin in a daily dose of 1200 mg.

Adults actively use tetracycline antibiotics, for example, tetracycline hydrochloride- 0.5 g 4 rubles / day. Contraindicated in children under 8 years of age. Side effects are expressed in the form of increased intracranial pressure, dizziness, weakness, allergic manifestations, photosensitivity.

Amoxicillin. Adults - inside 0.25-0.5 g 2 rubles / day; children - 40 mg / kg / day 2r / day. Possible manifestations of adverse reactions - itching, redness of the skin, Quincke's edema, anaphylactic shock.

For successful treatment of bacterial overgrowth syndrome in the intestine, it is necessary to create unique conditions that have a beneficial effect on the restoration of normal microflora and colonization of the intestine with bifidus and lactobacilli. Medicines that have these properties are called pre- and probiotics.

"Colibacterin". It contains live cultures of the E. coli M-17 strain with antagonism to pathogenic and opportunistic microflora. Usually take 6 to 10 doses in one or two doses (take the drug 40 minutes before meals) for a month.

"Bificol". It combines simultaneously cultivated bacteria E.coli M-17 and bifidobacteria. The daily rate is from 6 to 10 doses.

vitamins

Patients who have problems with weight loss or a lack of certain vitamins and minerals are prescribed vitamin preparations, which include vitamin B12, ascorbic acid, fat-soluble vitamins, calcium and magnesium (Undevit, Supradin, Multi-tabs immuno plus, Vitrum, Revit) .

Physiotherapy treatment

As a physiotherapeutic treatment for SIBO, warm mineral bicarbonate-chloride and sodium-calcium waters are taken orally. They inhibit intense motility and thereby reduce the frequency of defecation. In the digestive tract, mineral water restores and corrects various types of metabolism. Reception may be recommended - Borjomi, Narzan, Slavyanovskaya, etc.

Alternative treatment

curd whey. It is made from kefir, which is placed in hot water, where it goes through the process of separation into curd and whey. The serum is carefully drained and used for the effective treatment of dysbacteriosis.

Kefir enema. Kefir (80 g) is heated and administered to the baby before bedtime.

blueberry jelly for the treatment of SIBO, prepare according to the recipe: mix a tablespoon of blueberries with a tablespoon of starch and a small amount of water. Add another glass of water in a thin stream and, with constant stirring, bring the mixture to a boil. It is recommended to drink jelly warm.

SIBO is defined as an overgrowth of bacteria in the small intestine. This syndrome is still a little studied disease. In English, it sounds like SIBO.

Initially, SIBO (bacterial overgrowth syndrome) was thought to occur in only a small number of patients, but it is now clear that the disorder is more common. However, patients with bacterial overgrowth syndrome experience a variety of symptoms: chronic diarrhea, weight loss, and malabsorption, although minor symptoms occur.

Bacterial Overgrowth Syndrome: Symptoms and Treatment

Patients with SIBO may also suffer from malnutrition and osteoporosis. A common misconception has been that SIBO only affects a limited number of patients who have anatomical abnormalities of the upper gastrointestinal tract or mobility disorders.

However, thanks to new diagnostic tests, it has become known that this is a more common disease, because the general symptoms of diarrhea and weight loss can be the cause of various disorders.

Therefore, the very first step in dealing with stomach problems is to determine if the cause of the symptom is an overgrowth of bacteria in the stomach.


What is SIBR?

This abbreviation stands for bacterial overgrowth in the small intestine.. Those. this condition is due too many microbes in the small intestine.

Everyone knows that bacteria are normal in a healthy digestive tract. All bacteria vary in type and concentration depending on their location in the digestive system.

Some bacteria, such as probiotics, are very beneficial for our body. However, other types of bacteria that are beneficial in one place can be very harmful in another.

So SIBO occurs when too much colon bacteria enters the small intestine.

SIBO is defined as a bacterial population in the small intestine that exceeds 105 - 106 microorganisms per ml.

Usually, there should be less than 103 microorganisms/ml in the upper small intestine, and most of them are gram-negative microorganisms.

In addition to the absolute number of microorganisms, the type of microbial flora present also plays an important role in the manifestation of signs and symptoms of overgrowth.

For example, the predominance of bacteria that metabolize bile salts into insoluble compounds leads to malabsorption or diarrhea.

Microorganisms that mainly convert carbohydrates into short chain fatty acids and gases cause bloating without diarrhea.

Gram-negative bacteria, such as the Klebsiella species, produce toxins that damage the mucosa and interfere with absorption.

SIBO and the small intestine

The bacteria that cause SIBO are usually found in the large intestine. A rarer situation occurs when they are found elsewhere in the body other than the small intestine, albeit at low concentrations.

The small intestine is the largest part of the digestive tract. In this area, food mixes with digestive juices and essential minerals and vitamins are absorbed into the bloodstream.

The small intestine should normally have fewer bacteria than the large intestine (about 103 - 104 per ml of liquid compared to more than 109 per ml).

These gut bacteria are needed to fight "bad" bacteria, maintain healthy immune function, improve nutrient absorption, and promote vitamin K production.

It is well known that problems like SIBO occur when bacteria in the large and small intestines mix or get out of balance. But why this happens is a more difficult question.

It is known that SIBO develops when the normal homeostatic mechanisms that control intestinal bacterial populations are disrupted. The two processes that most commonly predispose to bacterial growth are decreased gastric acid secretion and dysmotility of the small intestine.

What causes SIBO?

Despite its prevalence, the causes of bacterial overgrowth syndrome are not yet well understood.

Studies show that this syndrome occurs in a large number of people, but the symptoms vary greatly from one person to another.

SIBO is known to start for many reasons, from general aging to small bowel defects, diabetes, and pancreatitis. With regular antibiotic use, the balance of digestive bacteria is also disturbed, which causes this condition.

Some physical obstructions in the gut, like surgical scars or Crohn's disease, also contribute to it.

However, the most important factor for its development is the regular consumption of foods filled with simple sugars, refined carbohydrates, yeast, or alcohol.

Is it worth it to be afraid?

When properly balanced, the bacteria in the colon help digest foods and the body absorbs essential nutrients. However, when bacteria invade and take over the small intestine, it can lead to poor absorption of nutrients and even damage to the lining of the stomach.

With SIBO, food passes through the small intestine and excess bacteria interfere with healthy digestion and absorption. Bacteria actually consume certain foods and nutrients, resulting in unpleasant symptoms, including pain.

Is there any reason to be concerned if SIBO is suspected? The longer you live without treatment, the worse the impact will be.

An overgrowth of bacteria can lead to nutrient malabsorption, leading to digestive ailments such as gas, bloating, and even leaky gut syndrome.

Iron, calcium and other vitamins are necessary for every organism. Vitamin malabsorption leads to malnutrition, general weakness, mental stress, and even long-term nerve damage.

Since SIBO can damage the intestinal mucosa, sometimes small food particles move into the bloodstream and other parts of the body, thereby triggering an immune response in the body, which also leads to the development of food allergies.

Many people, often hearing about bacteria, are immediately afraid of getting infected from other patients. But, fortunately, this is not a contagious disease. And the fact that it is so common is most likely due to the fact that people lead a similar lifestyle and few people eat right.

Are there other health problems?

There is evidence that SIBO is associated with various other conditions, including irritable bowel syndrome, inflammatory bowel disease, rosacea, and others.

For unknown reasons, it is a common symptom in people with hypothyroidism, non-alcoholic fatty liver disease, and cirrhosis.

It is no coincidence that its main symptoms are the same for leaky gut syndrome. In fact, the same symptoms have been found in more than 80% of patients with leaky gut syndrome, leading some scientists to suggest that this is the underlying cause of the latter disorder.

It is not yet known what percentage of the general population suffers from bacterial overgrowth, but in some studies, scientists refer to the fact that their number is as high as 20%.

This disease should not be underestimated, as people rarely seek medical attention for such symptoms.

If SIBO is not treated in time, it can lead to other complications over time.

Growth of bacteria in the small intestine can lead to malnutrition, which prevents many nutrients, proteins, carbohydrates, and fats from being absorbed properly. Later, there is a deficiency of iron, vitamin B12, calcium, and even a deficiency of fat-soluble vitamins: A, D, E and vitamin K.

Nutrient deficiencies lead to general weakness, fatigue, confusion, and damage to the central nervous system.

Vitamin B12 deficiency is the most common. Vegetarians and vegans are more susceptible to it, as well as people with insufficient stomach acid production or taking medications that suppress stomach acid.

Signs of SIBO

The main symptoms include:

    Chronic gassiness;

    Bloating (especially a few hours after eating);

    Signs of a vitamin or mineral deficiency;

    constipation or diarrhea;

  • Frequent abdominal pain;

    Fatigue;

    convulsions;

    Sudden food intolerances (gluten, lactose or fructose);

    Leaky intestine;

  • Chronic diseases (diabetes, autoimmune diseases);

    Skin rashes (rosacea, acne, eczema, rash);

    Depression;

  • Malnutrition and unexplained weight loss (in very extreme cases).

Main Risk Factors

There are many conditions that promote the growth of bacteria in the small intestine. These include general aging, chronic pancreatitis, diabetes, diverticulosis, structural defects in the small intestine, wounds, fistulas, intestinal lymphoma, and scleroderma.

Stomach acid inhibits the growth of ingested bacteria, thereby limiting the number of bacteria in the upper small intestine. Reduced gastric acid production is a significant risk factor for SIBO and may develop after Helicobacter pylori colonization or as a consequence of aging.

Use of certain medications(immunosuppressants, proton pump inhibitors), immune system disorders, recent surgery and celiac disease, Also associated with an increased risk of developing SIBO.

Celiac disease is especially dangerous because it disrupts intestinal motility, leading to improper functioning of the small intestine.

Another cause of SIBO is blind loop syndrome.. This happens when the small intestine actually forms a loop, forcing food to bypass part of the digestive tract. Food moves more slowly, causing it to become a breeding ground for bacteria to grow.

Metabolic disorders, including type 2 diabetes, also lead to or contribute to certain gastrointestinal disorders.

Body aging- a special risk factor for the development of SIBO. As we age, the digestive tract slows down.

Those who suffer from rosacea, acne and eczema are also at risk. As you can see, bacterial overgrowth in the thin is associated with a wide range of conditions.

How to diagnose SIBO?

Due to the complexity of this condition, no test is definitely suitable for diagnosing it. The small intestine makes access difficult, so standard stool samples are the best indicator of the health of the colon, but not the small intestine.

The standard test for determining SIBO is the hydrogen breath test. It measures the amount of hydrogen and methane gas produced by bacteria in the digestive system.

If you have SIBO, these gases at certain concentrations can be detected in the exhaled air a few hours after drinking a regular sugar solution.

A similar test with the use of lactulose. Bacteria can digest lactulose, and when they do, gas is created. If a lactulose breath test detects gas, then you most likely have an overgrowth of bacteria.

Breath tests are far from perfect because they allow interpretation. All doctors have different experience, they can diagnose the results as positive or negative, because the symptoms of SIBO often fall into the spectra of different diseases.

For this reason, it is usually best to take several tests at once to get a clearer picture of the internal bacterial level.

How to deal with SIBO?

If you have found an overgrowth of bacteria in the small intestine, then do not panic. It is possible to restore the balance of bacteria and relieve symptoms.

1) Stick to a diet

One of the main factors that provoke bacterial growth is malnutrition, filled with easily digestible foods. These include simple sugars, refined carbohydrates, and all types of alcohol.

The first point of the diet is to give up foods that feed these bacteria. The goal of the diet is to feed you but leave the bacteria hungry, usually by restricting carbohydrates and filling the stomach with insoluble fiber.

Foods to avoid:

    Fructose - some fruit juices, honey, processed grains, baked goods, corn and maple syrups, processed sugars.

    Lactose - regular dairy products and processed foods with milk and lactose additives, such as milk powder.

    Fructans - asparagus, onion, artichoke, wheat porridge, garlic, broccoli, kale.

    Galactans - legumes, cabbage, Brussels sprouts, soybeans.

    Polyols (carbohydrates with very large molecules) - sorbitol, isomalt, lactitol, maltitol. They are found in chewing gums, hard candies, and some medicines.

    Foods you can eat:

    Fibrous vegetables (greens, cucumbers, carrots, squash, tomatoes);

  • Fresh fruits;

    Tuna and salmon;

    Beef and lamb;

  • Raw hard cheeses;

    Almond or coconut milk;

    Fresh berries (blueberries, strawberries, currants);

    Nut oils.

Due to the high fiber content, fresh fruits will not ferment in the stomach. before digestion begins.

Don't Overeat, because excessive food limits the production of acid in the stomach, and therefore creates a suitable environment for the reproduction of bacteria in the small intestine.

It's also wise to eat smaller meals more often throughout the day rather than three large meals. This will help the digestive system process each meal more efficiently. After this two-week meal, the diet changes a bit to rebalance the bacteria in the entire digestive tract and prevent toxins from entering the bloodstream.

All grains, processed sugars, high starch foods, processed foods, and non-organic meat dairy products should still be avoided.

Gradually introduce foods rich in probiotics, but not store-bought yogurt, but homemade, cultivated vegetables, natto, kombucha, and fermented foods such as sauerkraut.

2) Dietary supplements

SIBO often leads to nutritional deficiencies because gut bacteria digest a large percentage of your food.

Take a daily multivitamin with vitamins B12, D, K, zinc and iron until the state is back under control.

High vitamin levels also help fight or reduce the chances of developing SIBO.

3) Antibiotics

Antibiotics are often the cause of SIBO, but they also help to restore the normal level of bacteria. Antibiotics kill unwanted bacteria, thereby reducing their numbers in the small intestine.

However, antibiotics kill bacteria indiscriminately, so the number of beneficial bacteria will also decrease, resulting in a high recurrence rate.

4) Probiotics

Doctors often prescribe probiotics along with antibiotics and in combination with the diet. to reduce the recurrence rate.

5) Herbal remedies

Many plants have natural antibacterial properties, such as mugwort extract, argan oil, Indian barberry root extract, and lemon balm oil. They will help cut down on small bacterial growth.

Some essential oils can also improve the symptoms of SIBO and even eradicate the condition permanently.

Peppermint essential oil reduces painful symptoms of the gastrointestinal tract, such as constipation and diarrhea, as well as clove oil, tarragon and frankincense essential oil.

One of the best ways to improve your entire digestive system is to adopt a healthy lifestyle. Stress control, regular exercise, and meditation may reduce the risk of SIBO.published.

P.S. And remember, just by changing your consumption, we are changing the world together! © econet


For citation: Belousova E.A. Syndrome of excessive bacterial growth of the small intestine in chronic pancreatitis // BC. 2009. No. 5. S. 317

Introduction Chronic pancreatitis (CP) is considered as a disease with a complex of severe symptoms, which are dominated by pain and excretory pancreatic insufficiency (EPI). The reasons for the development of these syndromes is chronic obstruction of the pancreatic ducts of varying severity, which impedes the flow of pancreatic juice into the duodenum. Inevitably, EPI is accompanied by impaired digestion and absorption of nutrients, which can lead to the development of malabsorption. It is believed that adequate therapy with enzyme preparations should compensate for the deficiency of endogenous enzymes and restore normal digestion. However, in practice, it is far from always possible to easily cope with EPI. The main reason for this, as a rule, is associated with an insufficient dose of enzyme agents or the choice of an ineffective drug. There is a second, very serious reason for the persistent course of EPI and the low, at first glance, the effectiveness of enzyme therapy. This is associated with the development of small bowel bacterial overgrowth syndrome (SIBO), known in the English literature as "bacterial overgrowth". SIBO is little known to a wide range of doctors and is not taken into account in treatment tactics. Therefore, the purpose of this article was to familiarize internists and gastroenterologists with modern approaches to the correction of SIBO in CP.

Chronic pancreatitis (CP) is considered as a disease with a complex of severe symptoms, among which pain and excretory pancreatic insufficiency (EPI) dominate. The reasons for the development of these syndromes is chronic obstruction of the pancreatic ducts of varying severity, which impedes the flow of pancreatic juice into the duodenum. Inevitably, EPI is accompanied by impaired digestion and absorption of nutrients, which can lead to the development of malabsorption. It is believed that adequate therapy with enzyme preparations should compensate for the deficiency of endogenous enzymes and restore normal digestion. However, in practice, it is far from always possible to easily cope with EPI. The main reason for this, as a rule, is associated with an insufficient dose of enzyme agents or the choice of an ineffective drug. There is a second, very serious reason for the persistent course of EPI and the low, at first glance, the effectiveness of enzyme therapy. This is associated with the development of small bowel bacterial overgrowth syndrome (SIBO), known in the English literature as "bacterial overgrowth". SIBO is little known to a wide range of doctors and is not taken into account in treatment tactics. Therefore, the purpose of this article was to familiarize internists and gastroenterologists with modern approaches to the correction of SIBO in CP.
Normal microflora
gastrointestinal tract
From modern positions, the normal human microflora (normoflora, microbiota) is considered as a set of many microbiocenoses occupying numerous ecological niches (biotopes) on the skin and mucous membranes of all body cavities open to the external environment. The total number of bacteria in an adult is 1015 cells, which is more than 10 times higher than the number of own cells of the macroorganism. The currently existing regulatory document "Russian industry standard for dysbacteriosis" offers the following definition of normoflora: it is "a qualitative and quantitative ratio of various populations of microbes of individual organs and systems that support biochemical, metabolic and immunological the balance of the macroorganism necessary to maintain human health. From this definition it follows that the normoflora of each biotope performs numerous functions not only to maintain its functioning, but also the homeostasis of the body as a whole.
The species and quantitative composition of the microflora of each biotope of the gastrointestinal tract (GIT) is quite constant due to the influence of numerous protective factors both from the host organism and the microbiota itself:
. genetic predisposition
. Acidic gastric environment
. Normal motor-evacuation function of the gastrointestinal tract
. Anatomical sphincters of the gastrointestinal tract
. Constant level of intraluminal pH in different biotopes
. The state of the immune system of the mucous membranes
. Bactericidal substances produced by mucous membranes (lysozyme, lactoferrin, etc.)
. Phagocytic activity of mucosal macrophages
. Secretory IgA
. Bacterial colicins and microcins (endogenous peptide antibiotics of microbial origin)
More than 400 species of bacteria live in the human gastrointestinal tract alone - representatives of 17 different families. The human digestive tract is unevenly populated with bacteria; the composition of the microflora of different biotopes is presented in Table 1.
As can be seen from the table, the highest density of microbial contamination in the colon is about 400 different species. The total biomass of colon microbial cells is approximately 1.5 kg, which corresponds to 1011-1012 CFU/g of content and is about 1/3 of the dry weight of faeces. It is the large intestine, due to such a high contamination, that bears the greatest functional load compared to other biotopes. The content of bacteria in the upper intestine varies in a narrow range of 103-104 CFU/ml of intestinal contents. The main mass of bacteria in the large and lower sections of the small intestine are bacteroids, eubacteria, bifidobacteria, peptostreptococci, ruminococci, clostridia and lactobacilli, and in the upper sections of the small intestine - bacteroids, lactobacilli and cocci (Table 1).
Despite the relatively small number of microorganisms in the proximal small intestine, their functions are very important for the vital activity of this biotope, in particular, for maintaining the luminal pH and the immune status of the mucosa. The normal microflora of the gastrointestinal tract as a whole performs metabolic, protective, antimutagenic and anticarcinogenic functions. Metabolic and anticarcinogenic functions fall mainly on the flora of the colon, and the microflora of all biotopes participates in the implementation of antitoxic, protective and immune functions, in maintaining colonization resistance and microbial antagonism in relation to pathogens and opportunistic pathogens. This applies equally to the upper sections of the small intestine.
Colonization resistance is understood as a set of mechanisms that ensure the constancy of the species and quantitative composition of microbial populations in a certain biotope, preventing the reproduction of opportunistic and pathogenic flora and its translocation into uncharacteristic biotopes and into the internal environment of the body. A manifestation of such a translocation of the microflora can be SIBO in the small intestine with an increase in the microbial contamination of the latter by more than 104 CFU / ml of intestinal contents.
Bacterial overgrowth syndrome
contamination - bacterial overgrowth)
As mentioned above, the normal content of bacteria in the upper intestines fluctuates in a narrow range of 103-104 CFU / ml of intestinal contents, and this value is a kind of constant for the small intestine. The species composition of the microbiota is also quite constant: bacteroids, lactobacilli, cocci.
Summarizing the existing definitions, from our point of view, we can give the following definition of SIBO syndrome: bacterial overgrowth syndrome is a seeding of the proximal parts of the small intestine over 104 mc. (CFU) / ml of intestinal contents due to opportunistic microflora coming from the upper gastrointestinal tract (or upper respiratory tract) or due to retrograde translocation of opportunistic representatives of the colon microbiota.
It should be emphasized that the concept of SIBO in the international literature refers to the overgrowth of flora only in the small intestine, but not in the large intestine.
There are several main mechanisms leading to SIBO. The first mechanism is due to hypo- or achlorhydria of any origin. A decrease in the protective acid barrier allows microbes from the oral cavity and upper respiratory tract to colonize the stomach and then the small intestine. This process may be based on various reasons, but most often this pathway of microbial contamination of the small intestine occurs after gastrectomy or gastrectomy, with long-term use of gastric secretion inhibitors, with autoimmune gastritis, with autoimmune diseases such as pernicious anemia and scleroderma.
The second mechanism for the development of SIBO is due to a violation of the so-called "intestinal clearance", i.e. a violation of the ability of the small intestine to eliminate pathogenic or opportunistic microorganisms that have entered it. Impaired clearance occurs with a decrease in the activity of protective mechanisms that maintain the constancy of the microbiota of the small intestine: inhibition of motor activity, a decrease in the synthesis of bactericidal substances and secretory IgA, a decrease in the phagocytic function of macrophages of the small intestine mucosa, etc.
The third mechanism is associated with retrograde translocation of microflora from the colon to the small intestine due to insufficiency of the ileocecal valve during inflammation or motor disorders of the colon. Almost any gastroenterological disease can lead to the development of SIBO (Table 2).
Methods for assessing SIBO
Diagnosis of SIBO is very difficult, because methods of sampling the contents of the small intestine are too laborious. For this purpose, a simple and convenient method has been developed to determine the concentration of hydrogen in the exhaled air after a carbohydrate load with glucose or lactose (hydrogen breath test). In the presence of SIBO, the level of hydrogen in the exhaled air is high due to the formation of microbial metabolites in the small intestine. The same method can be used to monitor the results of treatment with various drugs that inhibit the growth of excess flora in the small intestine. The method is cheap, easy to perform, however, unfortunately, it is not widely used in Russia.
Chronic pancreatitis and SIBO
According to J.E. Dominguez-Munoz, SIBO occurs in 40% of patients with CP and is one of the most common causes leading to insufficient effectiveness of enzyme replacement therapy. Numerous mechanisms leading to impaired digestion and SIBO in CP are presented in detail in Figure 1.
Thus, HP is accompanied by:
. violation of the processes of digestion and absorption
. bacterial overgrowth in the small intestine
. impaired motor function of the gastrointestinal tract
The initial violation of cavitary digestion in CP through the interaction of complex mechanisms is aggravated by a violation of membrane digestion, and all participating mechanisms operate on the principle of a vicious circle.
Treatment of overweight syndrome
bacterial growth
It should be borne in mind that SIBO is not an independent pathology, but only a secondary syndrome that accompanies many pathological conditions. If, as a rule, there are no clearly defined clinical symptoms in violations of the colon microbiota, then with SIBO, flatulence, stool disorders, and sometimes severe diarrhea usually occur. At the same time, all of these symptoms are not specific, and it is not possible to associate them unambiguously with SIBO. In the context of this article, flatulence, diarrhea, stetorrhea can equally be a consequence of both EPI and SIBO.
In any case, microbial disorders in both the large and small intestines are always secondary, therefore, in order to correct them, it is necessary first of all to eliminate the negative factors that cause them (for example, medicinal or environmental influences) or to treat the underlying disease. It is important to emphasize that the correction of SIBO is not an end in itself and is carried out:
. if it is impossible to eliminate its cause
. under the action of a constant aggressive factor (for example, chemotherapy)
. as an additional measure, with insufficient effectiveness of the treatment of the underlying disease that caused these disorders.
An ideal illustration of these provisions is SIBO developing against the background of EPI. Ideally, when an adequate dose of enzyme preparations is prescribed, digestion is restored and additional correction of SIBO is not required. However, SIBO is one of the most common reasons leading to insufficient effectiveness of enzyme replacement therapy. In one of the studies, the effect of Creon therapy on SIBO (according to the hydrogen breath test) was evaluated in 15 patients with EPI in CP. These patients within 2 months. conducted therapy with Creon 100-150 thousand IU per day. In the majority (65% - 10 patients), according to the repeated hydrogen test, SIBO was eliminated, in 53% (8 patients) flatulence disappeared, in 73% (11 patients) there was an improvement in well-being, but dyspeptic symptoms persisted.
Based on the foregoing, the administration of adequate doses of effective enzyme agents (Creon 25,000-40,000 IU with each meal) should be the first line therapy for pancreatic diseases with EPI with or without SIBO. With its insufficient effectiveness, the appointment of drugs to eliminate microbial growth in the small intestine is indicated.
Therapeutic tactics for microbial disorders depends on the degree of their severity, the presence of clinical manifestations, and the translocation of bacteria to other biotopes. In some cases, in the presence of SIBO, it becomes necessary to conduct "selective microbial decontamination of the intestine." This concept implies the sanation of the intestine (decontamination) with drugs that selectively suppress the growth of foreign flora and do not affect the normoflora. For the purpose of decontamination, several groups of agents are used:
. antibacterial drugs
. non-pathogenic fungi
. spore-forming preparations based on representatives of transient flora
. microbial metabolites.
Antibiotics
The optimal antibacterial drug for decontamination of the small intestine and elimination of SIBO should meet the following requirements:
. have minimal absorption from the intestines
. create a high concentration in the intestinal cavity
. have selectivity (should suppress foreign flora and not affect the normoflora
. have a wide spectrum of antimicrobial activity, including aerobes and anaerobes
. have a minimum of side effects and be safe
. have proven clinical efficacy
One of the newest in Russia and the most interesting drug from all three points of view is a derivative of rifamycin - the drug rifaximin (Alfa-normix). It is not absorbable<1%) при приеме внутрь антибиотик, достигающий высоких концентраций в слизистой оболочке ЖКТ. Препарат не действует вне ЖКТ, т.е. является местнодействующим кишечным антисептиком. Рифа-кси-мин хорошо переносится, имеет минимум побочных эф-фек-тов и не вызывает бактериальной резистентности. Препарат имеет широкий спектр антибактериального действия против грамположительных (Enterococcus spp, M. tuberculosis, Streptococcus pyogenes, Streptococcus faecalis, Streptococcus pneumoniae, Staphylococcus epidermidis, Staphylococcus aureus) и грамотрицательных (Escheri-chia coli, Shigella spp, Salmonella spp, Yersinia enterocolica, Proteus spp, Vibrio cholerae) аэробных бактерий и грампо-ло-жительных (Clostridium perfrigens, Clostridium difficile, Peptococcus spp, Peptostreptococcus spp) и грамот-ри-цательных (Bacteroides spp, Bacteroides fragilis, Helico-bacter pylori) анаэробов . Такой спектр действия определяет те-ра-певтические возможности препарата. Таким образом, ри-фак-симин удовлетворяет всем основ-ным требованиям, предъявляемым к идеальному антибактериальному препарату. Он с успехом используется при острых кишечных инфекциях, для санации толстой кишки при «дисбактериозе», для коррекции СИБР, при антибиотико-ассо-ции-ро-ванных поражениях кишечника и при печеночной энцефалопатии. При СИБР, доказанном с помощью водородного дыхательного теста, рифаксимин применяется по 400 мг 3 раза в сутки в течение 7 дней. При этом уровень выдыхаемого водорода снижается в 3-5 раз уже к третьему дню лечения, что свидетельствует о быстрой санации тонкой кишки .
For a long time, various antibiotics (tetracyclines, lincomycin, ampicillin, etc.) have been used to treat SIBO in various pathologies, which do not have selectivity, do not affect the anaerobic flora, are rapidly absorbed from the gastrointestinal tract and have a wide range of side effects (including antibiotics). -associated diarrhea) and suppress normal flora. To demonstrate the effectiveness of rifaximin, a double-blind study was conducted confirming the priority of rifaximin over tetracycline in SIBO. In this study, SIBO in two groups of patients was assessed by a hydrogen breath test and the peak of hydrogen excretion in exhaled air and the total hydrogen concentration after a glucose load before and 3 days after the end of the antibiotic course were determined. It was shown that at equal initial levels of hydrogen, its peak after glucose loading, as well as the total concentration in exhaled air after treatment, was significantly lower in patients treated with rifaximin compared with the group treated with chlortetracycline.
Other effective antibacterial agents include oxyquinolone derivatives, low-absorbable nitrofuran derivatives (nifuroxazide) and nitroimidazoles (metronidazole, tinidazole). Although the last group is absorbed from the large intestine, nevertheless, its use is effective, mainly in case of contamination with anaerobic microorganisms. The duration of the decontamination course for SIBO is 12-14 days.
Non-pathogenic fungi
In case of intolerance to antibacterial drugs, it is possible and effective to prescribe drugs based on non-pathogenic yeast fungi of the genus S. boulardii. At the same time, S. boulardii does not inhibit the growth of obligate microorganisms in the intestinal cavity and is resistant to the action of hydrochloric acid. With daily intake, they are found in all parts of the gastrointestinal tract, including the small intestine. These yeasts are a transient flora for humans, therefore, 2-5 days after the end of the drug intake, they are completely eliminated from the body without side effects. The drug is not absorbed from the lumen of the gastrointestinal tract and is a locally acting intestinal antiseptic. The antimicrobial activity of S. boulardii was established in vitro and in vivo against pathogens of intestinal infections (Cl. difficile, Salmonella, Shigella, Yersinnia), protozoa (Giardia and a number of) opportunistic microorganisms (pathogenic cocci, fungi , Klebsiela, etc.), which can lead to the development of SIBO.
Spore-forming non-pathogenic antibacterial agents can also be used in SIBO as an alternative to antibiotics in case of intolerance. This group includes drugs based on the hay bacillus Bacillus subtilis and a similar microorganism B. cereus. Spore microorganisms are a transient flora for humans, therefore, they are quickly eliminated from the intestine after stopping the intake. The mechanism of action of these drugs is due to the formation of acid metabolites in the process of life and a decrease in pH throughout the intestine, due to which the growth of opportunistic flora is inhibited. In addition, these agents synthesize a number of digestive enzymes, partially compensating for the decrease in the intestine's own enzymatic activity when damaged by bacteria and their toxins. The course of treatment for SIBO is 10-14 days. A longer course is undesirable, because. B. cereus is capable of producing enterotoxins that cause diarrhea.
Microbial metabolites
An additional agent that restores the microflora of the predominantly small intestine is the microbial metabolite hilak forte. The main biologically active components that make up hilak forte are short-chain fatty acids (SCFA) and lactic acid, obtained from saccharolytic and proteolytic representatives of the normal intestinal microflora. The concentration of biologically active substances in one drop of the drug corresponds to the action of the corresponding metabolites from 1010 bacteria. The mechanism of action of hilak forte on the normalization of the composition and functions of the microbiota and on the restoration of intestinal activity is mediated by its constituent components. SCFA contained in the preparation provide mucous membranes with additional energy, promote the regeneration of damaged intestinal wall epithelial cells, and improve mucosal trophism. The influence of acid metabolites (SCFA, lactic acid) ensures the regulation of intraluminal pH, which leads to inhibition of the growth of pathogens and opportunistic pathogens throughout the intestine.
Thus, the tactics of treating CP with SIBO should be built as follows:
. adequate enzyme therapy (Creon 75,000 IU or more per day)
. decontamination of the small intestine: antibiotic therapy (rifaximin)
. microbial metabolites
. normalization of colon microbiocenosis with pro- and prebiotics (if necessary)
. elimination of motor disorders - duodenal hypertension, accelerated propulsion (if necessary).

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