Original article—alimentary tract
Increased Incidence of Small Intestinal Bacterial Overgrowth During Proton Pump Inhibitor Therapy

https://doi.org/10.1016/j.cgh.2009.12.022Get rights and content

Background & Aims

Proton pump inhibitors (PPIs) can cause diarrhea, enteric infections, and alter the gastrointestinal bacterial population by suppressing the gastric acid barrier. Among patients that received long term PPI treatment, we evaluated the incidence of small intestinal bacterial overgrowth (SIBO; assessed by glucose hydrogen breath test [GHBT]), the risk factors for development of PPI-related SIBO and its clinical manifestations, and the eradication rate of SIBO after treatment with rifaximin.

Methods

GHBTs were given to 450 consecutive patients (200 with gastroesophageal reflux disease who received PPIs for a median of 36 months; 200 with irritable bowel syndrome [IBS], in absence of PPI treatment for at least 3 years; and 50 healthy control subjects that had not received PPI for at least 10 years). Each subject was given a symptoms questionnaire.

Results

SIBO was detected in 50% of patients using PPIs, 24.5% of patients with IBS, and 6% of healthy control subjects; there was a statistically significant difference between patients using PPIs and those with IBS or healthy control subjects (P < .001). The prevalence of SIBO increased after 1 year of treatment with PPI. The eradication rate of SIBO was 87% in the PPI group and 91% in the IBS group.

Conclusions

SIBO, assessed by GHBT, occurs significantly more frequently among long term PPI users than patients with IBS or control subjects. High dose therapy with rifaximin eradicated 87%–91% of cases of SIBO in patients who continued PPI therapy.

Section snippets

Patients

Between January 2006 and September 2008, 450 consecutive subjects were enrolled in 3 different groups. In group 1 were 200 patients affected by gastroesophageal reflux disease and using PPIs for at least 2 months. Group 2 had 200 patients with IBS (Rome III diagnostic criteria) in absence of PPI treatment for at least 3 years. The rationale for using IBS as “pathologic” control (PC) stands on the large prevalence of SIBO in IBS patients and the overlapping of symptoms between the 2 clinical

Demographics

Overall 450 subjects were evaluated in this study:

  • 200 patients with gastroesophageal reflux disease using PPIs (esoprazole 35%, lansoprazole 30%, omeprazole 15%, rabeprazole 10%, pantoprazole 10%): mean age 39 ± 19 years; 120 male, with a median duration of PPI treatment of 36 months (range, 2 months to 7 years), at standard dosage for at least 3 fourths of the considered time. At the observation time 68% of them were H. pylori negative.

  • 200 patients with IBS (40% diarrhea, 40% constipation, 20%

Discussion

The gold standard for the diagnosis of SIBO is yet to be defined, as direct tests of culture have substantial limitations for accessibility and performance difficulties.5 Hydrogen breath tests are indirect diagnostic methods based on the fact that detection of hydrogen in expired breath is considered a measure of the metabolic acivity of enteric bacteria because mammalian tissues do not generate hydrogen. They are noninvasive, easy to perform, sensitive enough, and highly specific for SIBO

Acknowledgments

This work was partially presented, as an oral comunication, at the Digestive Disease Week, AGA Institute, 2009, Chicago, Illinois.

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    Conflicts of interest The authors disclose no conflicts.

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