Q. What is small intestinal bacterial overgrowth (SIBO) ?
The small bowel, also known as the small intestine, is the section of the gastrointestinal tract that connects the stomach with the colon. The main purpose of the small intestine is to digest and absorb food into the body. The small intestine is approximately 21 feet in length and begins in the duodenum (into which food from the stomach empties), followed by the jejunum, and then the ileum (which empties the food that has not been digested into the large intestine or colon).
The entire gastrointestinal tract, including the small intestine, normally contains bacteria. The number of bacteria is greatest in the colon and much lower in the small intestine. Moreover, the types of bacteria within the small intestine are different than the types of bacteria within the colon.
Small intestinal bacterial overgrowth (SIBO) refers to a condition in which abnormally large numbers of bacteria are present in the small intestine and the types of bacteria in the small intestine resemble more the bacteria of the colon than the small intestine
Small intestinal bacterial overgrowth (SIBO) is also known as small bowel bacterial overgrowth (SBBO).
Q. What causes small intestinal bacterial overgrowth ?
The gastrointestinal tract is a continuous muscular tube through which digesting food is transported on its way to the colon. The coordinated activity of the muscles of the stomach and small intestine propels the food from the stomach, through the small intestine, and into the colon. Even when there is no food in the small intestine, muscular activity sweeps through the small intestine from the stomach to the colon.
The muscular activity that sweeps through the small intestine is important for the digestion of food, but it also is important because it sweeps bacteria out of the small intestine and thereby limits the numbers of bacteria in the small intestine. Anything that interferes with the progression of normal muscular activity through the small intestine can result in SIBO.
Simply stated, any condition that interferes with muscular activity in the small intestine allows the bacteria to stay longer and multiply in the small intestine. The lack of muscular activity also may allow bacteria to spread backwards from the colon and into the small intestine.
forms of inflammatory bowel disease (IBD)
There are two major forms of inflammatory bowel disease (IBD); Crohn's disease and ulcerative colitis.
1. Crohn's disease : -
Crohn's disease appears to be increasing in frequency. It is more common in Caucasians compared to individuals of African of Asian descent. It appears to be most common in some individuals of Jewish descent. Crohn's disease can become evident at any age. However, there appear to be two peaks at which patients develop significant symptoms, in the mid-20s and after 50 years of age.
The cause of Crohn's disease is unknown. An infection may be involved.
There appears to be a genetic susceptibility and environmental factors may be involved. Patients who smoke tend to have more active Crohn's disease.
Crohn's disease affect the gastrointestinal tract from the mouth to the anus. It occurs most commonly in the lower part of the small intestine (the terminal ileum), and the colon. It is characterized by inflammation of the bowel wall, which becomes chronic to the extent that fibrosis or scarring occurs.
This scarring can cause narrowing (strictures) in the small bowel. During acute phases of inflammation, patients may develop fistulae (abnormal connections between the bowel, other parts of the bowel or other organs such as the bladder, uterus, or skin). Disease activity is very variable; patients may have acute intermittent exacerbations or have low-grade active disease for several years.
Diarrhea is the most common complaint. Stools can be very loose or partly formed, with or without blood. Patients may have abdominal pain which is due to inflammation, cramping, infection or even obstruction. On account of significant diarrhea, patients may have weight loss and dehydration. Onset in childhood may cause growth retardation. Some patients may present with obscure fevers. Fistulae to the skin around the anal area will result in leakage. Fistulae to the vagina can result in stool discharge from the vagina. Fistulae in to the urinary tract can cause urinary tract infections.
Patients may also complain of some of the systemic effects of Crohn's disease which include arthritis, inflammation in the eye, skin changes, hepatitis, and gall stones.
Crohn's disease is diagnosed by obtaining biopsies of the affected intestine. Other helpful methods include barium studies which may show inflammation of the terminal ileum or colon. Blood tests are done to look for B12 deficiency (B12 is absorbed by the terminal ileum), and to assess systemic inflammation (white blood count and sedimentation rate) as signs of disease activity.
Occasionally, extensive imaging of the abdomen is required such as ultrasound or CAT scan to look for abscesses or other significant infections or other perforations.
The treatment of Crohn's disease depends on the symptoms, and the site and activity of disease. Patients with Crohn's disease are advised to stop smoking and may need to modify their diet (i.e. avoiding lactose containing foods which may exacerbate bloating and diarrhea). Vitamin supplements may be necessary.
2. Ulcerative Colitis : -
Just like some people get arthritis which is an inflammation of the joints, it is also possible to get inflammation of the colon. Inflammation of the colon (large intestine) is called colitis. Germs can cause colitis. Poor blood supply can cause colitis. Some medications can cause colitis. However, in most cases, the cause of colitis is not known.
When no other cause can be found for the inflammation, it falls into either one of two categories, ulcerative colitis or Crohn's colitis (Crohn's disease of the colon). Diet and psychological factors do not cause ulcerative colitis or Crohn's colitis. No germs have been found to cause these conditions. Colitis is not infectious; it cannot be passed from one person to another like the flu or a common cold.
Ulcerative colitis causes inflammation only in the mucosal (superficial) lining of the colon. It does not affect the small intestine or the stomach. Ulcerative colitis generally starts in the rectum and spreads from the rectum toward the first part of the colon in a steady progression.
Crohn's colitis involves the entire thickness of the wall of the colon, and can also involve other parts of the intestines such as the small intestine. Since Crohn's disease can involve the entire thickness of the intestine, sometimes long ulcers are seen in the colon lining. These ulcers look as if someone had pulled a grass rake across the lining of the colon. They are called rake ulcers or bear claw ulcers. Crohn's disease can be patchy. It can be present in one part of the colon, absent in another, and then present in the next part.
Crohn's disease involves the small intestine, but ulcerative colitis does not. The last one to two feet of the small intestine are called the ileum. If ulcers and extensive inflammation are seen in the ileum the colitis may be due to Crohn's disease.
The colitis associated with Crohn's disease is often associated with anal problems such as fissures, fistulas, abscesses and skin tags; whereas, ulcerative colitis never causes anal problems.
Ulcerative colitis can be cured by removing the entire colon if necessary. Crohn's disease can never be completely cured. If areas of the small intestine or colon which are involved with the Crohn's disease are removed, the surgery will generally relieve the person's symptoms for a while, sometimes for many years. However, at some point in the future, symptoms may recur.
Whether colitis is due to ulcerative colitis or Crohn's disease is generally not important unless surgery is required. If surgery is required, then ulcerative colitis is treated differently than Crohn's colitis. If surgery is not required, ulcerative colitis is generally treated with medications in the same manner as is Crohn's colitis.
Causes
The abnormally large numbers of bacteria in the small intestine compete for nutrients with the person who has the condition. As a result, the person with the condition may not absorb enough nutrients.
In addition, the breakdown of nutrients by the bacteria in the small intestines can damage the cells lining the intestinal wall.
Diseases that slow small bowel movement, such as diabetes and scleroderma
Small bowel diverticulosis -- small protruding sacs of the inner lining of the intestine; although these sacs can happen anywhere along the intestinal tract, they are more common in the large bowel than the small bowel.
Complications of diseases or surgery that create blind pouches or obstructions in the small bowel, such as Crohn's disease, Billroth II gastrectomy, and small bowel diverticulosis
Diseases such as chronic pancreatitis, cirrhosis of the liver, alcoholism, and end-stage renal disease Immunodeficiency, such as AIDS.
Diagnosis
Anemia is probably one of the most common findings. Blood tests are available (antigliadin and antiendomysial antibodies). The antiendomysial antibody test is the most specific. The ideal way to confirm celiac disease is to perform an upper endoscopy and to inspect and take samples from (biopsy) the small intestine. On inspection the lining of the small intestine appears atrophic and has a "cracked earth" appearance. The degree of microscopic damage varies from mild inflammation to complete blunting or atrophy of the finger like projections called villi.
Treatment
The treatment of celiac sprue is to remove all gluten from the diet. Even small amounts of gluten can prevent a clinical response. It is important for the patient to become very familiar with gluten free products. Information is available in celiac disease support groups as well as a web page for celiac disease. Some patients may not respond to a gluten free diet and need other treatment, such as steroids. Failure to respond to a gluten free diet and/or steroids should always raise the suspicion of another diagnosis.
Patients on gluten free diets should have supplements of vitamins, particularly vitamin D, folic acid, and iron. These may need to be given by injection if they cannot be absorbed in the oral form.
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