What are the procedures for testing and treating Small Intestine Bacterial Overgrowth (SIBO) in Calgary?

Testing and Treatment for Small Intestinal Bacterial Overgrowth (SIBO) in Calgary

For SIBO diagnosis in Calgary, breath testing combining hydrogen and methane measurement is recommended over empirical treatment, with rifaximin 550 mg twice daily for 1-2 weeks being the most effective treatment option. 1

Diagnostic Methods for SIBO

Recommended Testing Approach

• Breath Testing (First-Line):

  • Combined hydrogen and methane breath testing is more accurate than hydrogen testing alone 1, 2
  • Either glucose or lactulose can be used as substrates, with glucose providing greater accuracy 3
  • False negatives can occur in non-hydrogen producers (3-25% of individuals) 2

• Small Bowel Aspirate (Gold Standard):

  • Qualitative assessment via upper GI endoscopy when breath testing is unavailable 1
  • Procedure for small bowel aspirate during endoscopy:
    • Avoid aspirating on intubation
    • Flush 100 mL of sterile saline into the duodenum
    • Flush channel with 10 mL of air
    • Turn down suction
    • Leave fluid for a few seconds
    • Aspirate ≥10 mL into a sterile trap
    • Send to microbiology (positive aspirates will grow colonic bacteria) 1

• Important Considerations:

  • Proper test preparation and standardization are crucial for maximizing diagnostic accuracy 3
  • A negative breath test does not exclude SIBO 2
  • Agreement with local microbiology services should be established before undertaking qualitative assessment 1

Treatment Options for SIBO

First-Line Treatment

• Rifaximin:
  • Dosage: 550 mg twice daily for 1-2 weeks 1
  • Effectiveness: 60-80% in patients with proven SIBO 1
  • Preferred as it's not absorbed from the GI tract, reducing systemic resistance risk 1, 2

Alternative Antibiotics

• Equally effective options include:
  • Doxycycline
  • Ciprofloxacin
  • Amoxicillin-clavulanic acid
  • Cefoxitin 1
• Metronidazole is less effective 1

Treatment Approaches Based on SIBO Pattern

• For patients with reversible cause (e.g., immunosuppression during chemotherapy):
  • Usually one course of antibiotics is sufficient 1
• For recurrent SIBO:
  • Options include low-dose long-term antibiotics, cyclical antibiotics, or recurrent short courses 1

Management of Complications and Special Considerations

Pancreatic Enzyme Replacement Therapy (PERT)

• If PERT is not tolerated, this often indicates underlying SIBO 1
• Once SIBO is eradicated, PERT is typically better tolerated 1

Dietary and Lifestyle Modifications

• Low-FODMAP diet and avoiding gas-producing foods 2
• Eating slowly, chewing food thoroughly 2
• Smaller, more frequent meals 2
• Separating liquids from solids (drink 15 minutes before or 30 minutes after meals) 2

Monitoring and Preventing Recurrence

• Monitor nutritional status, including micronutrient deficiencies (iron, B12, fat-soluble vitamins) 2
• Avoid medications that worsen gastric motility (anticholinergics, opioids, long-term PPIs) 2
• Consider prokinetics to improve intestinal motility and prevent recurrence 2

Common Pitfalls and Caveats

• Lack of response to empirical antibiotics may be due to:
  • Resistant organisms
  • SIBO not being present
  • Other disorders causing similar symptoms 1
• Testing rather than empirical treatment should be used whenever possible to help establish the cause for symptoms and support antibiotic stewardship 1
• SIBO can significantly impact quality of life and requires accurate diagnosis and individualized treatment 4