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Small intestinal bacterial overgrowth in patients with irritable bowel syndrome
Open accessAbstract
Background: Small intestinal bacterial overgrowth (SIBO) has been proposed to be common in irritable bowel syndrome (IBS), with altered small-bowel motility as a possible predisposing factor. Aim: To assess the prevalence of SIBO, by culture of small-bowel aspirate, and its correlation to symptoms and motility in IBS. Methods: 162 patients with IBS who underwent small-bowel manometry and culture of jejunal aspirate were included. Cultures from 26 healthy subjects served as controls. Two definitions of altered flora were used: the standard definition of SIBO (⩾10 5 colonic bacteria/ml), and mildly increased counts of small-bowel bacteria (⩾95th centile in controls). Results: SIBO (as per standard definition) was found in 4% of both patients and controls. Signs of enteric dysmotility were seen in 86% of patients with SIBO and in 39% of patients without SIBO (p = 0.02). Patients with SIBO had fewer phase III activities (activity fronts) than patients without SIBO (p = 0.08), but otherwise no differences in motility parameters were seen. Mildly increased bacterial counts (⩾5×10 3 /ml) were more common in patients with IBS than in controls (43% vs 12%; p = 0.002), but this was unrelated to small intestinal motility. No correlation between bacterial alterations and symptom pattern was observed. Conclusions: The data do not support an important role for SIBO according to commonly used clinical definitions, in IBS. However, mildly increased counts of small-bowel bacteria seem to be more common in IBS, and needs further investigation. Motility alterations could not reliably predict altered small-bowel bacterial flora.
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“Studies using small intestinal aspiration, considered the gold standard for diagnosing small intestinal bacterial overgrowth, have not demonstrated an increased prevalence of the condition in suspected IBS, 143 and the lactulose breath test correlates poorly with small intestinal aspiration.144”
From British Society of Gastroenterology guidelines on the management of irritable bowel syndrome (2021) · cites this paper as [143]
In the citing paper
“Preliminary studies suggest that more IBS patients have SIBO when a lower cut-off of >103 cfu/ml is used but well-designed studies are needed.82 85”
From Intestinal microbiota in functional bowel disorders: a Rome foundation report (2013) · cites this paper as [82]
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“However, when a lower cutoff concentration of ≥104 cfu/ml was used, significant differences were observed, suggesting increased numbers of bacteria in the small intestine of patients with IBS.”
From Intestinal microbiota and immune function in the pathogenesis of irritable bowel syndrome (2013) · cites this paper as [141]
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“Using this definition, a study of bacterial cultures of aspirates from patients with IBS compared with cultures from healthy volunteers showed no statistically significant differences in the incidence of SIBO (141).”
From Intestinal microbiota and immune function in the pathogenesis of irritable bowel syndrome (2013) · cites this paper as [141]
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Ghoshal, U. C., Shukla, R., Ghoshal, U., Gwee, K., Ng, S. C., & Quigley, E. M. M. (2012) · International Journal of Inflammation · doi:10.1155/2012/151085 · Cited by 144
“Qualitative or quantitative changes in the microbiota of small intestine may lead to the clinical features of SIBO [56, 57].”
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“IBS has been suggested to be associated with small intestinal bacterial overgrowth (SIBO), defined as a bacterial density (colonic bacteria) of ≥10(5) colony-forming units (cfu) per mL of intestinal fluid,(29) measured by the “gold standard” jejunal culture method.(30,31) SIBO is, however, often diagnosed through cult…”
MethodSelf-citationNew treatments and therapeutic targets for IBS and other functional bowel disorders
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Self-citationClinical predictors of small intestinal bacterial overgrowth by duodenal aspirate culture
Choung, R. S., Ruff, K. C., Malhotra, A., Herrick, L. M., Locke, G. R., Harmsen, W. S., Zinsmeister, A. R., Talley, N. J., & Saito, Y. A. (2011) · Alimentary Pharmacology & Therapeutics · doi:10.1111/j.1365-2036.2011.04625.x · Cited by 135
Bushyhead, D. W., & Quigley, E. M. M. (2022) · Gastroenterology · doi:10.1053/j.gastro.2022.04.002 · Cited by 149
Diagnosis and management of IBS
Khan, S., & Chang, L. (2010) · Nature Reviews Gastroenterology &Hepatology · doi:10.1038/nrgastro.2010.137 · Cited by 147
Diagnosis and Management of Small Intestinal Bacterial Overgrowth
Bohm, M. E., Siwiec, R. M., & Wo, J. M. (2013) · Nutrition in Clinical Practice · doi:10.1177/0884533613485882 · Cited by 123
Low, K., Hwang, L., Hua, J., Zhu, A., Morales, W., & Pimentel, M. (2010) · Journal of Clinical Gastroenterology · doi:10.1097/mcg.0b013e3181c64c90 · Cited by 125
“More recently, IBS has been linked to an excess amount of bacteria in the small intestine; this is known as small intestinal bacterial overgrowth (SIBO).(4) Subjects with SIBO have similar symptoms to IBS, such as bloating, abdominal pain, and altered bowel habits.”
BackgroundKerckhoffs, A. P. M., Amor, K. B., Samsom, M., van der Rest, M. E., de Vogel, J., Knol, J., & Akkermans, L. M. A. (2010) · Journal of Medical Microbiology · doi:10.1099/jmm.0.022848-0 · Cited by 124
Intestinal Microbiota and its Role in Irritable Bowel Syndrome (IBS)
Öhman, L., & Simrén, M. (2013) · Current Gastroenterology Reports · doi:10.1007/s11894-013-0323-7 · Cited by 126
“culture of jejunal aspirate, we were unable to find an increased prevalence of SIBO in IBS, even though a mild increase of small intestinal bacteria was more commonly found in patients with IBS than in healthy controls [62].”
BackgroundSelf-citationChen, B., Kim, J. J.-W., Zhang, Y., Du, L., & Dai, N. (2018) · Journal of Gastroenterology · doi:10.1007/s00535-018-1476-9 · Cited by 117
“The reported prevalence of SIBO in the IBS population is highly variable, ranging from 4 to 84%, which may be related to the testing methods performed to diagnose SIBO [7, 11].”
Intestinal microbiota and immune function in the pathogenesis of irritable bowel syndrome
Ringel, Y., & Maharshak, N. (2013) · American Journal of Physiology-Gastrointestinal and Liver Physiology · doi:10.1152/ajpgi.00207.2012 · Cited by 115
“(14) Using this definition, a study of bacterial cultures of aspirates from patients with IBS compared with cultures from healthy volunteers showed no statistically significant differences in the incidence of SIBO.”
ResultInfluentialmanabe, N., wong, B. S., camilleri, M., burton, D., mckinzie, S., & zinsmeister, A. R. (2010) · Neurogastroenterology & Motility · doi:10.1111/j.1365-2982.2009.01442.x · Cited by 142
Rubio‐Tapia, A., Barton, S. H., Rosenblatt, J. E., & Murray, J. A. (2009) · Journal of Clinical Gastroenterology · doi:10.1097/mcg.0b013e3181557e67 · Cited by 115
“This test-to-test and center-to-center variability may explain the contradictory results obtained after comparing breath testing with other diagnostic test (specifically with quantitative culture of intestinal aspirate) or even among researchers using the same breath test for assessment of the frequency of SIBO in a p…”
Grover, M., Kanazawa, M., Palsson, O. S., Chitkara, D. K., Gangarosa, L. M., Drossman, D. A., & Whitehead, W. E. (2008) · Neurogastroenterology & Motility · doi:10.1111/j.1365-2982.2008.01142.x · Cited by 111
Association between Gut Dysbiosis and the Occurrence of SIBO, LIBO, SIFO and IMO
Banaszak, M., Górna, I., Woźniak, D., Przysławski, J., & Drzymała-Czyż, S. (2023) · Microorganisms · doi:10.3390/microorganisms11030573 · Cited by 113
A role for corticotropin-releasing factor in functional gastrointestinal disorders
Taché, Y., Kiank, C., & Stengel, A. (2009) · Current Gastroenterology Reports · doi:10.1007/s11894-009-0040-4 · Cited by 109
“For instance, CRF preferentially activates the ERK pathways in the limbic structures involved in memory, environmental information processing, and behavioral response to stress [ 24 ].”
BackgroundSystematic review of animal models of post-infectious/post-inflammatory irritable bowel syndrome
Qin, H., Wu, J. C. Y., Tong, X.-D., Sung, J. J. �., Xu, H., & Bian, Z. (2010) · Journal of Gastroenterology · doi:10.1007/s00535-010-0321-6 · Cited by 111
“This characteristic matches the phenomenon where IBS patients have bacterial overgrowth in the small intestine [ 64 , 65].”
BackgroundProton Pump Inhibitor Therapy Use Does Not Predispose to Small Intestinal Bacterial Overgrowth
Ratuapli, S. K., Ellington, T. G., O'Neill, M. T., Umar, S. B., Harris, L. A., Foxx–Orenstein, A. E., Burdick, G. E., DiBaise, J. K., Lacy, B. E., & Crowell, M. D. (2012) · The American Journal of Gastroenterology · doi:10.1038/ajg.2012.4 · Cited by 108
Small Intestinal Bacterial Overgrowth
Quigley, E. M. M., & Abu-Shanab, A. (2010) · Infectious Disease Clinics of North America · doi:10.1016/j.idc.2010.07.007 · Cited by 108
Lappinga, P. J., Abraham, S. C., Murray, J. A., Vetter, E. A., Patel, R., & Wu, T. T. (2010) · Archives of Pathology & Laboratory Medicine · doi:10.5858/134.2.264 · Cited by 106
Small Intestinal Bacterial Overgrowth
Adike, A., & DiBaise, J. K. (2017) · Gastroenterology Clinics of North America · doi:10.1016/j.gtc.2017.09.008 · Cited by 106
Giamarellos‐Bourboulis, E. J., Tang, J., Pyleris, E., Pistiki, A. C., Barbatzas, C., Brown, J. S., Lee, C. C., Harkins, T. T., Kim, G. H., Weitsman, S. R., et al. (2015) · Scandinavian Journal of Gastroenterology · doi:10.3109/00365521.2015.1027261 · Cited by 108
“The support for this concept has been based on breath test studies [6,7,25–28], small bowel culture studies [8,9], and the success of antibiotic treatments in improving IBS symptoms [6,29,30].”
BackgroundKiank, C., Taché, Y., & Larauche, M. H. (2009) · Brain Behavior and Immunity · doi:10.1016/j.bbi.2009.08.006 · Cited by 107
Small Intestinal Bacterial Overgrowth and Other Intestinal Disorders
Ghoshal, U. C., & Ghoshal, U. (2017) · Gastroenterology Clinics of North America · doi:10.1016/j.gtc.2016.09.008 · Cited by 102
Ghoshal, U. C., Srivastava, D., Ghoshal, U., & Misra, A. (2014) · European Journal of Gastroenterology & Hepatology · doi:10.1097/meg.0000000000000122 · Cited by 100
Majewski, M. S., & McCallum, R. W. (2007) · PubMed · Cited by 101
Irritable bowel syndrome in Asia: Pathogenesis, natural history, epidemiology, and management
Gwee, K., Ghoshal, U., & Chen, M.-H. (2018) · Journal of Gastroenterology and Hepatology · doi:10.1111/jgh.13987 · Cited by 103
Lovell, R. M., & Ford, A. C. (2012) · American Journal of Gastroenterology · doi:10.1038/ajg.2012.336 · Cited by 95
Spiegel, B. M. R., Chey, W. D., & Chang, L. (2008) · The American Journal of Gastroenterology · doi:10.1111/j.1572-0241.2008.01992.x · Cited by 95
“More recently, Posserud and colleagues found no difference in jejunal aspirate yield between IBS and control patients when adopting the 105 colony forming units (CFU) threshold, but did find that mildly increased bacterial counts (using a lower 103 CFU cut off) were more common in IBS than controls (10).”
BackgroundSystematic review and meta‐analysis: Small intestinal bacterial overgrowth in chronic pancreatitis
Capurso, G., Signoretti, M., Archibugi, L., Stigliano, S., & Fave, G. D. (2016) · United European Gastroenterology Journal · doi:10.1177/2050640616630117 · Cited by 93
“Furthermore, all the included studies employed BTs as diagnostic procedure for SIBO and none of them jejunal aspirate and culture, which is often considered the gold standard for the diagnosis.(25) However, jejunal aspirate and culture might not diagnose SIBO occurring in the distal part of the small intestine.”
Evaluating Breath Methane as a Diagnostic Test for Constipation-Predominant IBS
Hwang, L. J., Low, K., Khoshini, R., MELMED, G. Y., Sahakian, A. B., Makhani, M. D., Pokkunuri, V. B., & Pimentel, M. (2009) · Digestive Diseases and Sciences · doi:10.1007/s10620-009-0778-4 · Cited by 90
Ghoshal, U. C., Sachdeva, S., Ghoshal, U., Misra, A., Puri, A. S., Pratap, N., Shah, A., Rahman, M. M., Gwee, K. A., Tan, V. P. Y., et al. (2022) · Indian Journal of Gastroenterology · doi:10.1007/s12664-022-01292-x · Cited by 90
“12% in controls when a lower threshold of ≥10(3) CFU/ mL was used [15].”
MethodPimentel, M., Morales, W., Pokkunuri, V. B., Brikos, C., Kim, S. M., Kim, S., Τriantafyllou, Κ., Weitsman, S. R., Marsh, Z. A., Marsh, E., et al. (2014) · Digestive Diseases and Sciences · doi:10.1007/s10620-014-3435-5 · Cited by 88
“culture-based studies have confirmed an excess of coliform bacteria in the small intestine of IBS compared to healthy controls [21] and to subjects with other foregut disease [22].”
BackgroundHydrogen Breath Tests in Gastrointestinal Diseases
Rana, S. V., & Malik, A. (2014) · Indian Journal of Clinical Biochemistry · doi:10.1007/s12291-014-0426-4 · Cited by 89
“Symptoms of IBS generally resemble SIBO [29].”
Scarpellini, E., Giorgio, V., Gabrielli, M., Lauritano, E. C., Pantanella, A., Fundaro, C., & Gasbarrini, A. (2009) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2009.03.033 · Cited by 89
Metadata
- Authors
- Posserud, I., Stotzer, P.-O., Björnsson, E. S., Abrahamsson, H., & Simrén, M.
- Affiliations
- Sahlgrenska University Hospital (SE)
- ORCID
- Simrén, Magnus
- Venue
- Gut
- Publisher
- BMJ
- Published
- 2006-12-05
- Volume
- 56
- Issue
- 6
- Pages
- 802-808
- ISSN
- 0017-5749 (ISSN-L)
- 1468-3288
- PMC
- PMC1954873
- OpenAlex
- W2120896017
- Cited by
- 499
- References
- 53
- Citations by year
- 2026: 8 · 2025: 13 · 2024: 7 · 2023: 15 · 2022: 10 · 2021: 18 · 2020: 22 · 2019: 17 · 2018: 22 · 2017: 29 · 2016: 26 · 2015: 34 · 2014: 35 · 2013: 31 · 2012: 31
- FWCI
- 28.64
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Gut (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- HighWire Press Open Archive (submittedVersion)
- Funders
- Medical Research Council
- Topics
- Health Sciences › Medicine › Gastroenterology › Gastrointestinal motility and disorders
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Gut microbiota and health
- Health Sciences › Medicine › Gastroenterology › Microscopic Colitis
- Keywords
- small intestinal bacterial overgrowth, irritable bowel syndrome, small intestine motility, SIBO prevalence
- MeSH terms
- Adult, Aged, Anti-Bacterial Agents, Bacteria, Bacterial Infections, Breath Tests, Constipation, Diarrhea, Female, Gastrointestinal Motility, Humans, Intestine, Small, Jejunum, Male, Manometry, Middle Aged, Treatment Outcome, Irritable Bowel Syndrome
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