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Small intestinal bacterial overgrowth

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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Guidelines

1.Diagnostic investigations

Breath testing, indications, ACG: 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)

2.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.
B

3.Medical management

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

More topics in this section

  • Probiotics

4.Therapeutic procedures

Fecal microbiota transplantation: insufficient evidence to recommend fecal microbiota transplantation for the treatment of patients with SIBO.
I

5.Preventative measures

Prevention of recurrence
Determine and treat the underlying cause of SIBO as the primary mode of prevention of recurrences.
B
Focus on prevention of SIBO to avoid the need for repeated courses of antibiotics.
B

6.Follow-up and surveillance

Retesting: 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.
C