Diagnosi della SIBO

1. Diagnosi della SIBO Francesco Azzolini Gastroenterologia ed Endoscopia digestiva ASMN RE

2. Diagnosi della SIBO • Traditionally, the direct aspiration and culture of jejunal fluid, with results expressed as CFU/mL of jejunal fluid, although invasive, has been regarded by many investigators as the gold standard for the diagnosis SIBO Quigley The enteric flora in intestinal failure. Blackwell Publishing; 2008. p. 167–83.

3. Diagnosi della SIBO • Although widely quoted and applied, the basis for the classic criteria for the definition of SIBO based on aspirate and culture (105 CFU/mL of bacteria in the proximal small bowel) is uncertain. Khoshini R, Dai SC, Lezcano S, et al. Dig Dis Sci 2008;53:1443–54.

4. Diagnosi della SIBO • There were 50 papers that used culture to define SIBO. • In most studies, culture was just assumed to be the historic gold standard to be weighed against another test. • Only three studies tried to validate culture against controls. • Much heterogeneity was seen in sampling. Small bowel fluid aspirates were obtained via endoscopy in 18 papers, by direct sampling through nasal or oral cavity insertion of a tube in 30 others, and by unknown technique(s) in two studies. • The location and amount of small bowel fluid recovered were highly variable or not mentioned. Khoshini R, Dai SC, Lezcano S, et al. Dig Dis Sci 2008;53:1443–54.

5. Diversity in defining SIBO, with 22 studies using [105 cfu/ml(colony forming unit/milliliters) as positive results. Three investigators used [104 cfu/ml, seven used [106 cfu/ml, one used [107 cfu/ml, and 14 used variable definitions. • Studies conducted in patient with “stagnant loops”,an extreme form of SIBO,not IBS patients • Poor reproducibility of culture of jejunal contents was found to be less than 38%, compared with 92% for a breath test.57 Quigley The enteric flora in intestinal failure. Blackwell Publishing; 2008. p. 167–83.

8. Diagnosi della SIBO nel 2011

9. BREATH TEST AL LATTULOSIO

10. OVERGROWTH BATTERICO lattulosio

11. BREATH TEST AL LATTULOSIO

12. BREATH TEST AL GLUCOSIO

13. BREATH TEST AL LATTULOSIO • Pochi pazienti • Criterio di positività a 180’ • Non viene dettagliato cosa succede al gruppo positivi (solo 14!!!) a 90’, i veri positivi. • Corretta identificazione scintigrafica del cieco??? Yu, Gut 2011;60:334-340

14. BREATH TEST AL GLUCOSIO Cause dei risultati falsi negativi • assenza di batteri che producono H2 • Incremento non diagnostico nella produzione di H2 • rapido assorbimento del glucosio nella parte prossimale dell’intestino tenue • effetto pulizia di una concomitante diarrea Cause di risultati falsi positivi • Contaminazione batterica orale

15. BREATH TEST AL GLUCOSIO

16. BREATH TEST AL GLUCOSIO

17. Diagnosi della SIBO • No adequately validated diagnostic test for SIBO despites decades of recognizing it as a clinical entity. • The most provocative finding was the lack of evidence to verify culture as the representative gold standard test for SIBO.

18. Diagnosi della SIBO • Breath testing was the most common indirect method for evaluating SIBO. • However, with culture being a poor gold standard, breath testing could not be adequately evaluated.

19. Perché fare diagnosi di SIBO? • Condizione molto frequente • Test non invasivi • Terapia con scarsi effetti collaterali • Benefici della trattamento per molti pazienti