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Small intestinal bacterial overgrowth

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of small intestinal bacterial overgrowth are prepared by our editorial team based on guidelines from the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN 2023), the American College of Gastroenterology (ACG 2020), the British Society of Gastroenterology (BSG 2018), and the North American Consensus (NAC 2017).
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Diagnostic investigations

Breath testing, indications: as per ACG 2020 guidelines, consider obtaining glucose hydrogen or lactulose hydrogen breath testing for the diagnosis of SIBO in patients with:
irritable bowel disease
suspected motility disorders
abdominal pain, gas, bloating, and/or diarrhea with previous luminal abdominal surgery.
C
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  • Breath testing (preparation)

  • Breath testing (technical considerations)

  • Breath testing (interpretation)

Diagnostic procedures

Duodenal aspiration and culture: as per ACG 2020 guidelines, use a colony count of ≥ 10³ CFU/mL as most suggestive of SIBO when obtaining duodenal culture.
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Medical management

Antibiotics: as per ACG 2020 guidelines, consider administering antibiotics in symptomatic patients with SIBO to eradicate overgrowth and resolve symptoms.
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  • Probiotics

Therapeutic procedures

Fecal microbiota transplantation: as per ACG 2020 guidelines, insufficient evidence to recommend fecal microbiota transplantation for the treatment of patients with SIBO.
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Preventative measures

Prevention of recurrence
As per ACG 2020 guidelines:
Determine and treat the underlying cause of SIBO as the primary mode of prevention of recurrences.
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Focus on prevention of SIBO to avoid the need for repeated courses of antibiotics.
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Follow-up and surveillance

Retesting: as per ACG 2020 guidelines, consider obtaining retesting after treatment in patients with abnormal breath test, as it may correlate with symptom improvement and may be confirmed by normalization of hydrogen or methane levels.
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