am 11.20 oxentenko

GI Disorders in Women: GI Disorders in Women: Clinical PearlsClinical Pearls

Amy S. Oxentenko, MD, FACP, FACGAmy S. Oxentenko, MD, FACP, FACGDivision of Gastroenterology and HepatologyDivision of Gastroenterology and Hepatology

Mayo Clinic, Rochester, MNMayo Clinic, Rochester, MNMarch, 2012March, 2012

Disclosure of Financial RelationshipsDisclosure of Financial Relationships

Amy S. Oxentenko, MD, FACP, FACGAmy S. Oxentenko, MD, FACP, FACG

Has no relationships with any entity Has no relationships with any entity producing, marketing, re-selling, or producing, marketing, re-selling, or

distributing health care goods or services distributing health care goods or services consumed by, or used on, patients.consumed by, or used on, patients.

Case #1Case #1

A 32 y/o female presents for evaluation of “diarrhea” and A 32 y/o female presents for evaluation of “diarrhea” and abdominal pain that she has had for 5 years. She gets lower abdominal pain that she has had for 5 years. She gets lower abdominal pain and bloating 1-2 times per week. On those abdominal pain and bloating 1-2 times per week. On those days, she reports 3-5 loose stools, predominantly in the days, she reports 3-5 loose stools, predominantly in the morning or after meals. Stools are non-bloody, non-greasy morning or after meals. Stools are non-bloody, non-greasy and never nocturnal. Stooling brings relief of her pain. She and never nocturnal. Stooling brings relief of her pain. She denies weight loss. PMH is unremarkable. She takes no denies weight loss. PMH is unremarkable. She takes no meds. She has no family hx of GI problems. Exam is normal.meds. She has no family hx of GI problems. Exam is normal.

Which of the following is the next best step?Which of the following is the next best step?

A.A. No further tests; reassuranceNo further tests; reassuranceB.B. CBC & IgA tissue transglutaminaseCBC & IgA tissue transglutaminaseC.C. Stool culturesStool culturesD.D. EGD w/ small bowel biopsiesEGD w/ small bowel biopsiesE.E. Colonoscopy w/ random biopsiesColonoscopy w/ random biopsies

A 32 y/o female presents for evaluation of A 32 y/o female presents for evaluation of “diarrhea”“diarrhea” and and abdominal painabdominal pain that she has had for that she has had for 5 years5 years. She gets lower . She gets lower abdominal pain and bloating 1-2 times per week. On those abdominal pain and bloating 1-2 times per week. On those days, she reports 3-5 loose stools, predominantly in the days, she reports 3-5 loose stools, predominantly in the morning or after mealsmorning or after meals. Stools are . Stools are non-bloody, non-greasynon-bloody, non-greasy and and never nocturnalnever nocturnal. . Stooling brings reliefStooling brings relief of her pain. She of her pain. She denies weight lossdenies weight loss. PMH is unremarkable. She takes no . PMH is unremarkable. She takes no meds. She has no family hx of GI problems. Exam is normal.meds. She has no family hx of GI problems. Exam is normal.


A.A. No further tests; reassuranceNo further tests; reassuranceB.B. CBC & IgA tissue transglutaminaseCBC & IgA tissue transglutaminaseC.C. Stool culturesStool culturesD.D. EGD w/ small bowel biopsiesEGD w/ small bowel biopsiesE.E. Colonoscopy w/ random biopsiesColonoscopy w/ random biopsies

Be Comfortable Diagnosing IBSBe Comfortable Diagnosing IBS

Spiller RC, et al. Am J Gastroenterol 2010:105;775-75.Brandt LJ, et al. Am J Gastroenterol 2009;104:S1-35.

Hard and lumpyHard and lumpy

Loose or wateryLoose or watery

Irritable Bowel SyndromeIrritable Bowel Syndrome

Clinical PearlClinical PearlDiarrhea-predominant irritable bowel Diarrhea-predominant irritable bowel syndrome is a diagnosis that can be syndrome is a diagnosis that can be made with little exclusionary testing made with little exclusionary testing

required, other than a CBC and IgA tTG, required, other than a CBC and IgA tTG, in the absence of alarm symptoms.in the absence of alarm symptoms.

Case #2Case #2

A 38 y/o female presents to the ER with recurrent abdominal pain, A 38 y/o female presents to the ER with recurrent abdominal pain, nausea and bilious vomiting. Six months ago, she had a Roux-en-Y nausea and bilious vomiting. Six months ago, she had a Roux-en-Y gastric bypass for obesity. She has had 3 episodes in 1 month. gastric bypass for obesity. She has had 3 episodes in 1 month. Pain is crampy, periumbilical, and crescendos over 1-2 hours and Pain is crampy, periumbilical, and crescendos over 1-2 hours and is relieved after vomiting undigested food and bilious fluid. During is relieved after vomiting undigested food and bilious fluid. During the last 2 episodes, ER eval with labs (CBC, liver biochemistries), the last 2 episodes, ER eval with labs (CBC, liver biochemistries), abdominal radiographs and RUQ ultrasounds were normal. She abdominal radiographs and RUQ ultrasounds were normal. She takes a MVI w/ iron, thiamine, calcium, vitamin D and B12, but no takes a MVI w/ iron, thiamine, calcium, vitamin D and B12, but no other meds. No other PMH. Her gallbladder was not removed w/ other meds. No other PMH. Her gallbladder was not removed w/ the laparoscopic bypass. the laparoscopic bypass.

Which of the following is the most likely cause of symptoms?Which of the following is the most likely cause of symptoms?

A.A. OvereatingOvereatingB.B. Biliary colic Biliary colic C.C. Internal herniaInternal herniaD.D. Stenosis of the gastric pouchStenosis of the gastric pouchE.E. Medication side effectMedication side effect

A 38 y/o female presents to the ER with recurrent A 38 y/o female presents to the ER with recurrent abdominal pain, abdominal pain, nausea and bilious vomitingnausea and bilious vomiting. Six months ago, she had a . Six months ago, she had a Roux-en-YRoux-en-Y gastric bypass for obesity. She has had 3 episodes in 1 month. gastric bypass for obesity. She has had 3 episodes in 1 month. Pain is crampy, Pain is crampy, periumbilical, and crescendosperiumbilical, and crescendos over 1-2 hours and over 1-2 hours and is is relieved after vomitingrelieved after vomiting undigested food and bilious fluid. During undigested food and bilious fluid. During the last 2 episodes, ER eval with labs (CBC, liver biochemistries), the last 2 episodes, ER eval with labs (CBC, liver biochemistries), abdominal radiographs and RUQ ultrasounds were normal. She abdominal radiographs and RUQ ultrasounds were normal. She takes a MVI w/ iron, thiamine, calcium, vitamin D and B12, but no takes a MVI w/ iron, thiamine, calcium, vitamin D and B12, but no other meds. No other PMH. Her gallbladder was not removed w/ other meds. No other PMH. Her gallbladder was not removed w/ the the laparoscopic bypasslaparoscopic bypass. .

Which of the following is the most likely cause of symptoms?Which of the following is the most likely cause of symptoms?

A.A. OvereatingOvereatingB.B. Biliary colic Biliary colic C.C. Internal herniaInternal herniaD.D. Stenosis of the gastric pouchStenosis of the gastric pouchE.E. Medication side effectMedication side effect

Roux limbBilio-pancreatic

limb

Commonchannel

Gastric remnant

Gastric pouch

Roux-en-YBypass

Short Roux limbLong common channel

Long Roux limbShort common channel

***Greater malabsorption

***Lesser malabsorption

Early Emergent ComplicationsEarly Emergent Complications• Anastomotic leaksAnastomotic leaks

– Early complicationEarly complication– Only feature may be Only feature may be

unexplained tachycardiaunexplained tachycardia

Early Emergent ComplicationsEarly Emergent Complications• Anastomotic leaksAnastomotic leaks

– Early complicationEarly complication– Only feature may be unexplained Only feature may be unexplained

tachycardiatachycardia• Internal herniasInternal hernias

– Occurs early or lateOccurs early or late– Nausea, vomiting (? bilious)Nausea, vomiting (? bilious)– Increased w/ laparoscopy; only Increased w/ laparoscopy; only

occurs with bypassoccurs with bypass• Both need surgery!!!Both need surgery!!!

Klein S, et al. Gastroenterology 2002;123:882-932.

Other Common ComplicationsOther Common Complications• Marginal ulcerationMarginal ulceration

– May cause bleeding or stricture at May cause bleeding or stricture at G-J siteG-J site

– May create stomal stenosisMay create stomal stenosis– ? NSAIDs, ? smoking? NSAIDs, ? smoking

• BleedingBleeding– Can occur at any anastomotic siteCan occur at any anastomotic site– Think of remnant stomach and Think of remnant stomach and

duodenumduodenum– After routine EGD, may need GI After routine EGD, may need GI

expertise to evaluateexpertise to evaluate

Other Common ComplicationsOther Common Complications• Biliary stone diseaseBiliary stone disease

– ERCP scope 124 cm; cannot ERCP scope 124 cm; cannot reach papilla in RYGB ptsreach papilla in RYGB pts

• Typical Roux limb 100-150 cmTypical Roux limb 100-150 cm– Approach dependent on clinical Approach dependent on clinical

acuity and local expertiseacuity and local expertise• Nutritional deficienciesNutritional deficiencies

– Iron, B12, Ca++, vitamin DIron, B12, Ca++, vitamin D– Folate (give if childbearing)Folate (give if childbearing)– Thiamine (esp 1Thiamine (esp 1stst 6 months) 6 months)

papillapapilla

Clinical PearlClinical Pearl

There are many potential structural, There are many potential structural, absorptive and nutritional absorptive and nutritional

complications of bariatric surgery; complications of bariatric surgery; knowledge of the post-bariatric knowledge of the post-bariatric

anatomy is essential in being able anatomy is essential in being able to effectively manage these to effectively manage these

patients.patients.

Case #3Case #3

34 y/o female referred for “IBS” who is 16 weeks 34 y/o female referred for “IBS” who is 16 weeks pregnant. She had diarrhea in teens which resolved in pregnant. She had diarrhea in teens which resolved in her 20’s and recurred early in pregnancy. Has 4-6 BM her 20’s and recurred early in pregnancy. Has 4-6 BM daily with nocturnal stools. No abdominal pain. Takes daily with nocturnal stools. No abdominal pain. Takes a prenatal MVI, iron and levo-thyroxine. Her pre-a prenatal MVI, iron and levo-thyroxine. Her pre-pregnancy BMI = 17, with 5 lb weight gain thus far. pregnancy BMI = 17, with 5 lb weight gain thus far. Conceived her baby with IVF. Her TSH is normal.Conceived her baby with IVF. Her TSH is normal.


A.A. Tissue transglutaminase IgATissue transglutaminase IgAB.B. ColonoscopyColonoscopyC.C. Begin scheduled loperamideBegin scheduled loperamideD.D. Stool bacterial culturesStool bacterial culturesE.E. Begin nortriptylineBegin nortriptyline

34 y/o female referred for “IBS” who is 16 weeks 34 y/o female referred for “IBS” who is 16 weeks pregnant. She had pregnant. She had diarrhea in teensdiarrhea in teens which resolved in which resolved in her 20’s and her 20’s and recurred early in pregnancyrecurred early in pregnancy. Has . Has 4-6 BM 4-6 BM dailydaily with with nocturnal stoolsnocturnal stools. . No abdominal painNo abdominal pain. Takes . Takes a prenatal MVI, a prenatal MVI, iron and levo-thyroxineiron and levo-thyroxine. Her pre-. Her pre-pregnancy pregnancy BMI = 17BMI = 17, with , with 5 lb weight gain5 lb weight gain thus far. thus far. Conceived her baby with Conceived her baby with IVFIVF. Her TSH is normal.. Her TSH is normal.


A.A. Tissue transglutaminase IgATissue transglutaminase IgAB.B. ColonoscopyColonoscopyC.C. Begin scheduled loperamideBegin scheduled loperamideD.D. Stool bacterial culturesStool bacterial culturesE.E. Begin nortriptylineBegin nortriptyline

General GastrointestinalShort statureShort stature Diarrhea, steatorrheaDiarrhea, steatorrhea

Weight loss*Weight loss* Flatulence, distensionFlatulence, distension

Failure to thriveFailure to thrive Abdominal discomfortAbdominal discomfort

LethargyLethargy Anorexia, nausea, vomitingAnorexia, nausea, vomiting

Delayed pubertyDelayed puberty Constipation**Constipation**

EdemaEdema Angular cheilosis, glossitisAngular cheilosis, glossitis

* 10%+ obese** 20% constipated

General and GI Manifestations General and GI Manifestations of Celiac Diseaseof Celiac Disease

Rubio-Tapia A, Murray JA. Rubio-Tapia A, Murray JA. Curr Opin Gastroenterol 2010; 26:116-22.Curr Opin Gastroenterol 2010; 26:116-22.

Extraintestinal Manifestations: Extraintestinal Manifestations: Celiac DiseaseCeliac Disease

Category ExamplesHematologicHematologic Anemia (iron*, B12, folate); functional asplenia (HJ-bodies)Anemia (iron*, B12, folate); functional asplenia (HJ-bodies)MusculoskeletalMusculoskeletal Osteopenia/osteoporosis; osteomalacia; arthropathyOsteopenia/osteoporosis; osteomalacia; arthropathyNeurologicNeurologic Seizures; peripheral neuropathy; ataxiaSeizures; peripheral neuropathy; ataxiaReproductiveReproductive Infertility; recurrent miscarriagesInfertility; recurrent miscarriagesSkinSkin Dermatitis herpetiformisDermatitis herpetiformisOtherOther Enamel defects; abnormal liver biochemistries; vitamin-Enamel defects; abnormal liver biochemistries; vitamin-

deficient states, cardiomyopathy, depression/mooddeficient states, cardiomyopathy, depression/mood•*Prevalence of CD in pts with IDA:*Prevalence of CD in pts with IDA:

•3-9% (no GI sxs) 3-9% (no GI sxs) •10-15% (GI sxs)10-15% (GI sxs)

Rubio-Tapia A, Murray JA. Curr Opin Gastroenterol 2010; 26:116-22.Rubio-Tapia A, Murray JA. Curr Opin Gastroenterol 2010; 26:116-22.

How to Diagnose Celiac DiseaseHow to Diagnose Celiac Disease• TTG IgATTG IgA single best screening test single best screening test

– IgA levels not warranted for allIgA levels not warranted for all• Small bowel biopsiesSmall bowel biopsies in: in:

– All with positive serologiesAll with positive serologies– Negative serology but clinical suspicionNegative serology but clinical suspicion– Iron deficiency anemiaIron deficiency anemia– Other unexplained extraintestinal featuresOther unexplained extraintestinal features

• Treatment:Treatment: Lifelong, strict gluten-free diet Lifelong, strict gluten-free diet– Wheat, barley, rye (oats for 1st year)Wheat, barley, rye (oats for 1st year)

Celiac Follow-UpCeliac Follow-Up• Baseline:Baseline:

– Dietician, DEXA (latter for adults only)Dietician, DEXA (latter for adults only)– CBC, folate, ferritin, B12, Ca++, zinc, copper, vit D, INR, retinol, albumin, CBC, folate, ferritin, B12, Ca++, zinc, copper, vit D, INR, retinol, albumin,

ALT, alk phosALT, alk phos

• Follow-up visit 3-6 months:Follow-up visit 3-6 months: – Assess clinical sxs, serologiesAssess clinical sxs, serologies

• Annual visits thereafter:Annual visits thereafter:– Assess clinical sxs, serologies, dieticianAssess clinical sxs, serologies, dietician– Follow-up abnormal labs; DEXA if first abnormalFollow-up abnormal labs; DEXA if first abnormal

• Repeat biopsies ONLY for those:Repeat biopsies ONLY for those:– Asymptomatic presentationsAsymptomatic presentations– Persistent or recurrent sxsPersistent or recurrent sxs

Leffler D. JAMA 2011;306:1582-92.

Clinical PearlClinical PearlCeliac disease now commonly Celiac disease now commonly

presents with “atypical” or presents with “atypical” or extraintestinal features; heightened extraintestinal features; heightened

awareness of these features is key to awareness of these features is key to thinking of the diagnosis.thinking of the diagnosis.

Case #4Case #4

28 y/o female presents with constipation for 5 years. 28 y/o female presents with constipation for 5 years. Reports one BM every 5-7 days. She has to strain and Reports one BM every 5-7 days. She has to strain and has a sense of incomplete evacuation. She has had to has a sense of incomplete evacuation. She has had to digitalize on occasion to evacuate a stool. No blood. digitalize on occasion to evacuate a stool. No blood. Had a significant tear with her vaginal delivery 6 years Had a significant tear with her vaginal delivery 6 years ago, requiring forceps delivery. No FHx colon cancer. ago, requiring forceps delivery. No FHx colon cancer. Weight stable. Exam normal with the exception of Weight stable. Exam normal with the exception of paradoxical contraction of the external anal sphincter.paradoxical contraction of the external anal sphincter.

What is the most likely diagnosis?What is the most likely diagnosis?A.A. Irritable bowel syndromeIrritable bowel syndromeB.B. Slow-transit constipationSlow-transit constipationC.C. Rectal prolapseRectal prolapseD.D. Hirschsprung’sHirschsprung’sE.E. Pelvic floor dysfunctionPelvic floor dysfunction

28 y/o female presents with 28 y/o female presents with constipation for 5 yearsconstipation for 5 years. . Reports one BM every 5-7 days. She has to Reports one BM every 5-7 days. She has to strainstrain and and has a sense of has a sense of incomplete evacuationincomplete evacuation. She has had to . She has had to digitalizedigitalize on occasion to evacuate a stool. No blood. on occasion to evacuate a stool. No blood. Had a Had a significant tearsignificant tear with her vaginal delivery 6 years with her vaginal delivery 6 years ago, requiring ago, requiring forceps deliveryforceps delivery. No FHx colon cancer. . No FHx colon cancer. Weight stable. Exam normal with the exception of Weight stable. Exam normal with the exception of paradoxical contractionparadoxical contraction of the external anal sphincter. of the external anal sphincter.

What is the most likely diagnosis?What is the most likely diagnosis?A.A. Irritable bowel syndromeIrritable bowel syndromeB.B. Slow-transit constipationSlow-transit constipationC.C. Rectal prolapseRectal prolapseD.D. Hirschsprung’sHirschsprung’sE.E. Pelvic floor dysfunctionPelvic floor dysfunction

How to Define Constipation?How to Define Constipation?

• In the past:In the past:– < 3 stools per week< 3 stools per week

• More recent:More recent:– Effort to defecateEffort to defecate– Consistency and formConsistency and form

• Bristol stool form scaleBristol stool form scale• Correlates w/ transit Correlates w/ transit

timestimes

Brandt LJ, et al. Am J Gastroenterol 2005;100:S5-21.Brandt LJ, et al. Am J Gastroenterol 2005;100:S5-21.

3 Subtypes of Primary 3 Subtypes of Primary ConstipationConstipation

• Slow-transit constipationSlow-transit constipation– Prolonged transit due to myopathy or neuropathyProlonged transit due to myopathy or neuropathy

• Pelvic floor dysfunctionPelvic floor dysfunction– Also referred to as dyssynergic defecationAlso referred to as dyssynergic defecation– Impaired abdominal, rectoanal and pelvic floor Impaired abdominal, rectoanal and pelvic floor

muscle coordinationmuscle coordination• Constipation-predominant IBSConstipation-predominant IBS

– Pain or discomfort a predominant symptom; transit Pain or discomfort a predominant symptom; transit and pelvic function normaland pelvic function normal

Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.

• Age > 50 yearsAge > 50 years• Short duration symptoms (< 6 months)Short duration symptoms (< 6 months)• Family hx colorectal cancerFamily hx colorectal cancer• Blood in stoolsBlood in stools• Weight lossWeight loss

*** These patients need an evaluation *** These patients need an evaluation which includes colonoscopy ***which includes colonoscopy ***

Alarm Features for Alarm Features for Constipation?Constipation?

Work-Up for ConstipationWork-Up for Constipation• CBC, calcium, TSH, fasting glucoseCBC, calcium, TSH, fasting glucose

• If If ≥ 50 or alarm features ≥ 50 or alarm features colonoscopy colonoscopy

• If features of pelvic floor dysfunction If features of pelvic floor dysfunction a)a) Anorectal manometry/balloon expulsionAnorectal manometry/balloon expulsionb)b) Colonic transit study Colonic transit study

• 1) radio-opaque markers, or1) radio-opaque markers, or• 2) scintigraphy, or2) scintigraphy, or• 3) pH capsule3) pH capsule

Clinical Features of Clinical Features of Pelvic Floor DysfunctionPelvic Floor Dysfunction

• Risk factors: childbirth, abuse, chronic Risk factors: childbirth, abuse, chronic constipation, other pelvic traumaconstipation, other pelvic trauma

• Excessive straining, toilet rocking or Excessive straining, toilet rocking or repositioningrepositioning

• Sense of incomplete evacuationSense of incomplete evacuation• Sense of anorectal blockage* Sense of anorectal blockage* • Digitation for stool evacuation*Digitation for stool evacuation*


Examination Features of Examination Features of Pelvic Floor DysfunctionPelvic Floor Dysfunction

• Abnormal perineal descentAbnormal perineal descent• Abnormal resting and squeeze toneAbnormal resting and squeeze tone• Paradoxical contraction of Paradoxical contraction of

puborectalis or external anal puborectalis or external anal sphinctersphincter


Normal RestNormal Rest Normal defecationNormal defecation

Those with pelvic floor dysfunction have paradoxical Those with pelvic floor dysfunction have paradoxical contraction of puborectalis and external sphinctercontraction of puborectalis and external sphincter

Pelvic Floor DysfunctionPelvic Floor Dysfunction

Management of Pelvic Floor Management of Pelvic Floor DysfunctionDysfunction

• Refer for biofeedback programRefer for biofeedback program• Significantly improves (for at least 1 year):Significantly improves (for at least 1 year):

• Spontaneous BMsSpontaneous BMs• DyssynergiaDyssynergia• Balloon expulsion timeBalloon expulsion time• Colonic transit timeColonic transit time

• If there is concomitant prolapse, fix pelvic If there is concomitant prolapse, fix pelvic floor dysfunction firstfloor dysfunction first

Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.Rao SSC, et al. Am J Gastroenterol 2010;105:890-6.Rao SSC, et al. Am J Gastroenterol 2010;105:890-6.


Constipation associated with a sense of Constipation associated with a sense of anorectal blockage, the need for digitation anorectal blockage, the need for digitation

to evacuate stool, and paradoxical to evacuate stool, and paradoxical contraction of the puborectalis is contraction of the puborectalis is

suggestive of pelvic floor dysfunction; suggestive of pelvic floor dysfunction; anorectal manometry is indicated.anorectal manometry is indicated.

Case #5Case #5

A 58 year old female presents for an evaluation of diarrhea that A 58 year old female presents for an evaluation of diarrhea that has been present for 4 months. She has crampy pain, bloating has been present for 4 months. She has crampy pain, bloating and weight loss of 10 pounds. She denies any blood in her and weight loss of 10 pounds. She denies any blood in her stool, but notes it to be foul smelling and greasy appearing. No stool, but notes it to be foul smelling and greasy appearing. No recent medication changes. No travel. She does have a history recent medication changes. No travel. She does have a history of prior cervical cancer 4 years ago, s/p resection, of prior cervical cancer 4 years ago, s/p resection, chemotherapy and radiation. Labs reveal a hemoglobin of 10.4 chemotherapy and radiation. Labs reveal a hemoglobin of 10.4 g/dL, MCV of 102 fL and albumin of 3.1 g/dL. She states that g/dL, MCV of 102 fL and albumin of 3.1 g/dL. She states that dairy avoidance has somewhat, but not fully, helped. TTG IgA is dairy avoidance has somewhat, but not fully, helped. TTG IgA is normal. Colonoscopy with ileal inspection is normal. normal. Colonoscopy with ileal inspection is normal.


A.A. CT of the pancreasCT of the pancreasB.B. Lactose breath testLactose breath testC.C. PET scan PET scan D.D. Lactulose breath testLactulose breath testE.E. Flex sig w/ biopsiesFlex sig w/ biopsies

A 58 year old female presents for an evaluation of A 58 year old female presents for an evaluation of diarrheadiarrhea that that has been present for 4 months. She has has been present for 4 months. She has crampy pain, bloating crampy pain, bloating and weight loss of 10 poundsand weight loss of 10 pounds. She denies any blood in her . She denies any blood in her stool, but notes it to be foul smelling and stool, but notes it to be foul smelling and greasygreasy appearing. No appearing. No recent medication changes. No travel. She does have a history recent medication changes. No travel. She does have a history of prior of prior cervical cancercervical cancer 4 years ago, s/p resection, 4 years ago, s/p resection, chemotherapy and chemotherapy and radiationradiation. Labs reveal a . Labs reveal a hemoglobin of 10.4hemoglobin of 10.4 g/dL, g/dL, MCV of 102 fLMCV of 102 fL and and albumin of 3.1 g/dLalbumin of 3.1 g/dL. She states that . She states that dairy avoidance has somewhat, but not fully, helped. TTG IgA is dairy avoidance has somewhat, but not fully, helped. TTG IgA is normal. Colonoscopy with ileal inspection is normal. normal. Colonoscopy with ileal inspection is normal.


A.A. CT of the pancreasCT of the pancreasB.B. Lactose breath testLactose breath testC.C. PET scan PET scan D.D. Lactulose breath testLactulose breath testE.E. Flex sig w/ biopsiesFlex sig w/ biopsies

Causes of Bacterial OvergrowthCauses of Bacterial OvergrowthStructuralStructural Small bowel diverticula Small bowel diverticula

Small bowel strictures (radiation, IBD, NSAIDs)Small bowel strictures (radiation, IBD, NSAIDs)Enterocolonic fistulaEnterocolonic fistula

SurgicalSurgical Blind loops, afferent limbsBlind loops, afferent limbsIleocecal valve resectionIleocecal valve resection

DysmotilityDysmotility Chronic pseudoobstruction (Scleroderma)Chronic pseudoobstruction (Scleroderma)AmyloidosisAmyloidosisDiabetic neuropathyDiabetic neuropathy

Diminished Diminished AcidAcid

Achlorhydria/atrophyAchlorhydria/atrophyGastric resectionGastric resectionAcid suppressionAcid suppression

OtherOther Chronic liver or kidney diseaseChronic liver or kidney diseaseChronic pancreatitisChronic pancreatitisImmunodeficienciesImmunodeficienciesCeliac diseaseCeliac diseaseElderly (15% prevalence)Elderly (15% prevalence)Irritable bowel syndromeIrritable bowel syndrome

Diagnosis of SIBODiagnosis of SIBO• Small bowel culturesSmall bowel cultures

– Anaerobic & aerobic; > 10Anaerobic & aerobic; > 1055 organisms/mL organisms/mL– Jejunum; most taken from duodenumJejunum; most taken from duodenum

• Hydrogen breath testingHydrogen breath testing– Lactulose (rise by 20 ppm first 90 min)Lactulose (rise by 20 ppm first 90 min)– Glucose (rise by 12 ppm first 90 min)Glucose (rise by 12 ppm first 90 min)– 2nd criteria = double peak (small bowel, colon)2nd criteria = double peak (small bowel, colon)– False (+): rapid transit, recent foodFalse (+): rapid transit, recent food– False (-): methane producer (10%), antibioticsFalse (-): methane producer (10%), antibiotics

• Empiric Trial of AntibioticsEmpiric Trial of Antibiotics

©2011 MFMER | 3149421-45

Breath Testing SIBOBreath Testing SIBO

A) Lactulose breath test without SIBOB) Lactulose breath test w/ SIBOC) Lactulose breath test w/ SIBO & double-peak pattern

From Dukowicz AC, et al. Gastroenterol Hepatol 2007;3:118-119.

A B C

Treatment of SIBOTreatment of SIBO• Modify underlying risk factorModify underlying risk factor (minority) (minority)

– Diabetes, surgery, etc.Diabetes, surgery, etc.• Nutritional supportNutritional support

– Correct deficiencies (vit B12, vit D, Ca++)Correct deficiencies (vit B12, vit D, Ca++)– Lactose malabsorption (secondary)Lactose malabsorption (secondary)

• Antibiotic therapyAntibiotic therapy– Single 7-10 days (46-90% improve for months)Single 7-10 days (46-90% improve for months)– Recurrence 44% at 9 monthsRecurrence 44% at 9 months– Some may need repeat courses (1 week/month)Some may need repeat courses (1 week/month)

Treatment for Bacterial OvergrowthTreatment for Bacterial OvergrowthCiprofloxacinCiprofloxacin 250 mg BID250 mg BIDNorfloxacinNorfloxacin 800 mg QD800 mg QDMetronidazoleMetronidazole 250 mg TID250 mg TIDTrimethoprim-SMXTrimethoprim-SMX 1 DS BID1 DS BIDDoxycyclineDoxycycline 100 mg BID100 mg BIDTetracyclineTetracycline 250 mg QID250 mg QIDAmoxicillin-clavulanateAmoxicillin-clavulanate 500 mg TID500 mg TIDRifaximinRifaximin 800-1200 mg QD800-1200 mg QD

Quigley EMM, et al. Infect Dis Clin N Am 2010; 24: 943-59.


Small intestinal bacterial overgrowth Small intestinal bacterial overgrowth is typically diagnosed with small is typically diagnosed with small

bowel cultures or hydrogen breath bowel cultures or hydrogen breath testing; management includes testing; management includes

correcting nutritional abnormalities correcting nutritional abnormalities and antibiotic therapy.and antibiotic therapy.

©2011 MFMER | 3149421-48

Thank you!Thank you!

[email protected]@mayo.edu

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