Asha Misra

Tropical sprue is associated with contamination of small bowel with aerobic bacteria and reversible prolongation of orocecal transit time.

Background:  In tropical sprue (TS), response to antibiotics may suggest a role for bacterial contamination of the small bowel, which is known in diseases with prolonged orocecal transit time (OCTT).

Frequency of Small Intestinal Bacterial Overgrowth in Patients with Irritable Bowel Syndrome and Chronic Non-Specific Diarrhea

Introduction Small intestinal bacterial overgrowth (SIBO) occurs in varying frequency in irritable bowel syndrome (IBS). We studied the frequency of SIBO in IBS and chronic non-specific diarrhea (CNSD). Methods 129 patients with IBS (Mannings criteria), 73 with CNSD (≥ 4 weeks diarrhea with two of these tests normal [urine D-xylose, fecal fat and duodenal biopsy]) and 51 healthy controls (HC) were evaluated for SIBO using glucose hydrogen breath test (GHBT). Diarrhea-predominant IBS (D-IBS) was grouped into CNSD. Rise in breath hydrogen 12 ppm above basal following 100 g glucose was diagnostic of SIBO. Results Of 129 patients with IBS, 7 were constipation (C-IBS), and 122 were of indeterminate type (I-IBS). Patients with IBS were younger than HC and CNSD (IBS vs. HC: 36.6 yr ± 11.4 vs. 44.1 yr ± 13.6, p = 0.001; IBS vs. CNSD: 36.6 yr ± 11.4 vs. 42 yr ± 14.5, p = 0.003). Patients with CNSD were comparable to HC in age (42 yr ± 14.5 vs. 44.1 yr ± 13.6, p = ns). Patients with IBS were more often male than HC [108/129 (83.7%) vs. 34/51 (66.7%) p = 0.02]; gender of CNSD and HC was comparable [male 39/73 (53.4%) vs. 34/51 (66.7%) p = ns]. SIBO was commoner in CNSD than HC [16 (21.9%) vs. 1 (2%), p = 0.003], but was comparable in IBS and HC [11 (8.5%) vs. 1 (2%), p = 0.18]. Patients with CNSD more often had SIBO than IBS [16 (21.9%) vs. 11 (8.5%), p = 0.007]. Conclusions SIBO was more common in CNSD including D-IBS than other types of IBS and HC.

Lactose intolerance in patients with irritable bowel syndrome from northern India: A case–control study

Background and Aim:  Symptoms of irritable bowel syndrome (IBS) and lactose intolerance (LI) overlap. Data on the frequency of LI in patients with IBS from India are scanty. The aim of this study was to evaluate: (i) the frequency of LI in patients with IBS and its various subtypes as compared with healthy subjects (HS) from northern India; (ii) the relationship between self‐reported milk intolerance and laboratory evidence of LI; and (iii) the role of small intestinal bacterial overgrowth in LI in patients with IBS.

Strongyloides stercoralis infestation associated with septicemia due to intestinal transmural migration of bacteria

Abstract  Strongyloides stercoralis infestation is common in the tropics and is usually asymptomatic. Patients with immunocompromised states may develop hyperinfection and fulminant disease. It has been suggested that bacteria accompany S. stercoralis during its passage across the bowel wall, resulting in systemic sepsis. Herein is a report on a 30‐year‐old man with S. stercoralis infestation and small bowel bacterial overgrowth presenting as malabsorption syndrome. He developed extensive duodenojejunal ulceration, septicemia and fatal hypokalemia. Blood and jejunal fluid grew Escherichia coli with the same antibiotic sensitivity patterns. This supports the hypothesis of migration of bacteria from the intestinal lumen as a cause of septicemia in patients with fulminant S. stercoralis infestation .

Malabsorption syndrome with and without small intestinal bacterial overgrowth: A study on upper-gut aspirate using 1H NMR spectroscopy

Biochemicals in the upper‐gut aspirate in 31 patients with malabsorption syndrome (MAS) with and without small intestinal bacterial overgrowth (SIBO), and 10 disease‐free controls were analyzed using high‐resolution 1H‐NMR spectroscopy, and were correlated with the degree of SIBO and severity of MAS. Compared to controls, the patients had higher quantities (μmol/L: median [range]) of total bile acids/cholesterol (2000 [0–12000] vs. 300 [0–600]), lactate (700 [0–5200] vs. nil [0–30]), acetate (200 [0–6500] vs. 20 [0–200]), and formate (80 [0–900] vs. nil [0–50]) (P < 0.01, Mann‐Whitney U‐test). However, amino acids and glucose were comparable in both. Quantities (μmol/L: median [range]) of acetate (1330 [220–6500] vs. 100 [0–1430]), lactate (1430 [670–3300] vs. 300 [0–5200]), formate (360 [0–600] vs. 25 [0–800]), and unconjugated bile acids (500 [40–600] vs. 10 [0–300]) were higher in MAS patients with SIBO than those without SIBO (P < 0.01, Mann‐Whitney U‐test, for all). In patients with MAS the quantity of acetate positively correlated with the degree of SIBO, and unconjugated bile acids correlated with the degree of steatorrhoea (Spearmans rank correlation coefficient, two‐tailed, P < 0.05: 0.46 and 0.52, respectively). This study demonstrates the bacterial production of metabolites and deconjugation of bile acids in patients with MAS. Magn Reson Med, 2006.

Partially responsive celiac disease resulting from small intestinal bacterial overgrowth and lactose intolerance

BackgroundCeliac disease is a common cause of chronic diarrhea and malabsorption syndrome all over the world. Though it was considered uncommon in India in past, it is being described frequently recently. Some patients with celiac disease do not improve despite gluten free diet (GFD). A study described 15 cases of celiac disease unresponsive to GFD in whom small intestinal bacterial overgrowth (SIBO) or lactose intolerance was the cause for unresponsiveness.Case presentationDuring a three-year period, 12 adult patients with celiac disease were seen in the Luminal Gastroenterology Clinic in a tertiary referral center in northern India. Two of these 12 patients (16.6%), who did not fully respond to GFD initially, are presented here. Unresponsiveness resulted from SIBO in one and lactose intolerance in the other. The former patient responded to antibiotics and the latter to lactose withdrawal in addition to standard GFD.ConclusionIn patients with celiac disease partially responsive or unresponsive to GFD, SIBO and lactose intolerance should be suspected; appropriate investigations and treatment for these may result in complete recovery.

Breath tests in the diagnosis of small intestinal bacterial overgrowth in patients with irritable bowel syndrome in comparison with quantitative upper gut aspirate culture.

Background Small intestinal bacterial overgrowth (SIBO) is reported in 4–78% patients with irritable bowel syndrome (IBS). This wide range of percentages might be because of the different techniques and criteria used to define the condition. We studied the utility of early (breath hydrogen increase 20 ppm above basal within 90 min) and double peaks on lactulose and glucose hydrogen breath tests (LHBT and GHBT, respectively) to diagnose SIBO (gold standard: upper gut aspirate culture). We also studied the clinical parameters that are associated with SIBO among them. Methods Overall, 80 patients with IBS (Rome 3) were evaluated for SIBO using aspirate culture, GHBT, and LHBT (with methane). Results A total of 15/80 (19%) patients had SIBO (≥105 CFU/ml) on culture compared with 0/10 historical controls; 4/15 (27%) with and none of 65 without SIBO had positive GHBT (sensitivity 27%, specificity 100%). None of 15 with and one of 65 without SIBO had double peaks on LHBT (sensitivity 0%, specificity 98%); 5/15 (33%) with and 23/65 (35%) without SIBO had an early peak on LHBT (sensitivity 33%, specificity 65%); and 2/15 (13.3%) with and 26/63 (41.3%) without SIBO had high methane on LHBT (sensitivity 13.3%, specificity 58.7%). Patients with SIBO on culture more often had diarrhea [6/15 (40%) vs. 8/65 (12.3%), P=0.011], higher weekly stool frequency [21 (3–28) vs. 14 (4–49), P=0.003], and looser forms [Bristol 5–6, 11/15 (73.3%) vs. 33/65 (50.8%), P=0.116]. Conclusion On the basis of culture, 19% patients with IBS had SIBO. The specificity of GHBT was 100%, but the sensitivity of this test and the diagnostic performances of LHBT and breath methane were all very poor. SIBO was more common in IBS patients with diarrhea than in patients with other bowel habits.

Patients With Irritable Bowel Syndrome Exhale More Hydrogen Than Healthy Subjects in Fasting State

BACKGROUND/AIMS Irritable bowel syndrome (IBS) is a common disorder with significant morbidity and impairment of quality of life. Most patients (26%-83%) with IBS from Asia reported bloating. Bloating may result from increased amount or distribution of gas in the gut or exaggerated perception of distension. To evaluate whether patients with IBS produce more hydrogen even in fasting state, we conducted a study with the following aims: (1) to estimate fasting breath hydrogen levels among patients with IBS as compared with healthy controls (HC) and (2) to study relationship between symptoms of IBS and stool frequency and fasting breath hydrogen levels. METHODS Eighty-one patients with IBS (Rome III criteria) and 123 HC were included. Hydrogen breath test was performed using a gas analyzer after an overnight (12 hours) fast. Both patients with IBS and HC had similar preparation before breath hydrogen estimation. RESULTS Of 93 patients with symptoms of functional gastrointestinal disorders, 81 (87.1%) met Rome III criteria and 12 (12.9%) were negative and hence, excluded from the study. Patients with IBS were comparable in age (35 +/- 11.8 years vs 37.5 +/- 13.1 years, p = NS) and gender (male 61/81 [75.3%] vs 77/123 [62.6%], p=0.67) with HC. Average fasting breath hydrogen was higher in patients with IBS as compared to HC (mean 10.1 +/- 6.5 ppm vs 5.5 +/- 6.2 ppm, p < 0.0001). Number of stools per week correlated with average fasting breath hydrogen excretion in patients with IBS (r = 0.26, p = 0.02). CONCLUSIONS Inspite of similar preparation for the test, fasting breath hydrogen was higher in patients with IBS as compared to HC. Number of stools per week correlated with fasting breath hydrogen levels among patients with IBS.

PNEUMATIC DILATION FOR ACHALASIA CARDIA: REDUCTION IN LOWER ESOPHAGEAL SPHINCTER PRESSURE IN ASSESSING RESPONSE AND FACTORS ASSOCIATED WITH RECURRENCE DURING LONG-TERM FOLLOW UP

Background:  Data on utility of post‐pneumatic dilation (PD) lower esophageal sphincter (LES) pressure measurement in evaluating short and long‐term efficacy of dilation, which tears the non‐relaxing LES in achalasia, are scanty.

Slow Transit Constipation Associated With Excess Methane Production and Its Improvement Following Rifaximin Therapy: A Case Report

Constipation, a common problem in gastroenterology practice, may result from slow colonic transit. Therapeutic options for slow transit constipations are limited. Excessive methane production by the methanogenic gut flora, which is more often found in patients with constipation, slows colonic transit. Thus, reduction in methane production with antibiotic treatment directed against methanogenic flora of the gut may accelerate colonic transit resulting in improvement in constipation. However, there is not much data to prove this hypothesis. We, therefore, report a patient with slow transit constipation associated with high methane production both in fasting state and after ingestion of glucose, whose constipation improved after treatment with non-absorbable antibiotic, rifaximin, which reduced breath methane values.