Small bowel bacterial overgrowth in patients with alcoholic cirrhosis

Abstract

A total of 89 patients with alcoholic cirrhosis and 40 healthy subjects were included in a study to assess the prevalence of intestinal bacterial overgrowth and to analyze its relationship with the severity of liver dysfunction, presence of ascites, and development of spontaneous bacterial peritonitis (SBP). Bacterial overgrowth was measured by means of a breath test after ingestion of glucose. Intestinal bacterial overgrowth was documented in 27 (30.3%) of the 89 patients with alcoholic cirrhosis and in none of the healthy subjects. The prevalence of intestinal bacterial overgrowth was significantly higher in cirrhotics with ascites (37.1%) than in those with no evidence of ascites (5.3%) and among patients with Pugh-Child class C (48.3%) than in patients with class A (13.1%) or B (27%). Twelve (17.1%) of the 70 patients with ascites developed an episode of SBP. The prevalence of spontaneous bacterial peritonitis was significantly higher in patients who had intestinal bacterial overgrowth (30.7%) than in patients who did not (9.09%). We conclude that intestinal bacterial overgrowth occurs in approximately one third of patients with cirrhosis secondary to alcohol, particularly in patients with ascites and advanced liver dysfunction. Moreover, bacterial overgrowth may be a condition favoring infection of the ascitic fluid.

A Positive Breath Hydrogen Test Does Not Predict the Occurrence of a Spontaneous Bacterial Peritonitis in Cirrhotic Patients with Ascites

“…Moreover, these figures are in agreement with previous published results using our criteria which have shown that the 50 g D -glucose BH 2 T has a sensitivity range of 67–93% and a specificity range of 78–100% for the diagnosis of SIBO [26,27,28]. An elevated fasting BH 2 T concentration is considered by some teams associated with SIBO [3, 5, 6]. Fasting BH 2 concentrations depend on the amount of carbohydrates, glycoproteins and at a lesser degree proteins delivered to the colonic flora under fasting conditions: this amount may be increased in patients with cirrhosis because of delayed intestinal transit, protein-losing enteropathy or hemorrhage, conditions associated with malabsorption other than SIBO (e.g.…”

“…Reasons for the high prevalence of SIBO in patients with cirrhosis include spontaneous or drug-induced hypochlorhydria [5], spontaneous or drug-induced intestinal dysmotility [2] and severity of cirrhosis [4, 6]. More recently, Morencos et al [6] have shown that SIBO diagnosed by BH 2 T occurred in cirrhotics particularly when ascites was present (37% in patients with ascites vs. 5% in patients without ascites).…”

“…More recently, Morencos et al [6] have shown that SIBO diagnosed by BH 2 T occurred in cirrhotics particularly when ascites was present (37% in patients with ascites vs. 5% in patients without ascites). To increase the probability of a positive BH 2 T, we include in our study cirrhotic patients with ascites.…”

“…Several conditions have been demonstrated to favor SIBO in cirrhotic patients, in particular spontaneous or drug-induced gastric hypochlorhydria [5] and motor abnormalities of the small intestine [2, 3]. Furthermore, the risk of SIBO is positively correlated with the severity of liver dysfunction, assessed by the Child-Pugh score [4] and one study has shown that SIBO diagnosed by a positive BH 2 T is more frequent in cirrhotics with ascites compared to those without (respectively 37 vs. 5%) [6], suggesting that ascites by increasing intestinal stasis predispose to SIBO.…”

“…The increased rate of SIBO in cirrhotic patients in particular with ascites as assessed by a positive BH 2 T raises the hypothesis that SIBO might be a factor increasing the risk of bacterial translocation and of SBP. This hypothesis is strengthened by (i) data in experimental cirrhosis, where bacterial translocation found only when ascites is present, is associated with SIBO and SBP [12,13,14,15]; (ii) the frequent culture of bacteria from enteric origin in SBP; (iii) the therapeutic effect of selective intestinal decontamination with antibiotics which strongly reduces the risk of recurrence of SBP [16], and (iv) the fact that SIBO assessed by a positive BH 2 T is associated with a history [3] or concomitant episode of SBP [6]. To determine whether a positive BH 2 T was associated in time with an increased risk of SBP in cirrhotic patients with ascites, we conducted a prospective observational study with a long-term follow-up of cirrhotics in monitoring regularly BH 2 T and the occurrence of SBP.…”