When Is Intestinal Gas
Dangerous?
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Chronic IBS-Like Symptoms
Pain/Discomfort
Gas
Urgency
Constipation
Diarrhea
Loose stools
Bloating
• Frequent cause of primary care visits
• May be primary reason for visit or
co-morbid with other condition
• Range of severity
• From mild to severe
• Moderate-Severe cases affect QOL,
high health care costs
• Often refractory/challenging
• Poor response to conventional
therapies
• May need referral to GI
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Common Causes of IBS-Like Symptoms
1. Irritable Bowel Syndrome
2. Small Intestinal Bacterial
Overgrowth (SIBO)
3. Fructose Malabsorption
4. Lactose Intolerance
5. Inflammatory Bowel Disease
6. Celiac Disease
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Problem: Accurate Diagnosis
1.
2.
3.
4.
5.
6.
IBS
SIBO
Fructose Mal.
Lactose Intol.
IBD
Celiac Disease
Cannot make a
symptom-based
diagnosis for 5/6
Cannot make a
correct diagnosis of
IBS without first
ruling out 5/6
Outcomes Depend on Accurate Diagnosis
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When is Intestinal Gas Dangerous?
The Seemingly Least
Important Symptom is in Fact
the Most Important Clue
• Intestinal gas production is
caused primarily by bacterial
fermentation
• The site of gas production is
critical
• Small Intestine = SIBO
• Large Intestine = carbohydrate
malabsorption
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Definition of SIBO
• Small Intestinal Bacterial
Overgrowth (SIBO) is a disorder
of either excessive growth or
alteration of the types of bacteria
present in the small intestine.
• SIBO is one of the most common
gastrointestinal diseases,
affecting approximately 30
million Americans
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Managing SIBO is Mandatory
“It is mandatory to consider SIBO in all cases of complex nonspecific dyspeptic complaints (bloating, abdominal discomfort,
diarrhea, abdominal pain), in motility disorders, anatomical
abnormalities of the small bowel and in all malassimilation
syndromes (malabsorption, maldigestion).”
Bures J, et al. Small intestinal bacterial overgrowth syndrome. World J Gastroenterology 2010
June 28; 16(24): 2978-2990
Why?
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SIBO Causes Enterocyte/Microvilli Damage
“Biopsies of the small bowel in
bacterial overgrowth can mimic
those of celiac disease, making
the diagnosis more challenging.”
• Blunting of microvilli
• Enterocyte damage
Toskes P, Giannella R, Jervis H, Rout W, Takeuchi A (1975). "Small intestinal mucosal
injury in the experimental blind loop syndrome. Light- and electron-microscopic and
histochemical studies". Gastroenterology 68 (5 Pt 1): 1193–203. PMID 1126607
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Wide Ranging Clinical Ramifications of
Undiagnosed/Untreated SIBO
GI Symptoms
•
•
•
•
•
•
Diarrhea
Loose stools
Urgency
Gas Production
Pain/Discomfort
Constipation
Carbohydrate
Malabsorption
• Fructose
• Lactose
SIBO
• Bacterial Macro
& Micro Nutrient
Consumption
• Bacterial
Metabolic
Byproducts
• Bacterial
Endotoxins
• Inflammatory
Response
Gut Damage
• Enterocyte
damage
• Villous atrophy
Malnutrition
• Macronutrients
– Carbs, Lipids,
Proteins
• Fat soluble vitamins
– Vitamin A, D, E
• B Vitamins, Iron
– B-12, thiamine
• Minerals
– Calcium,
magnesium
Leaky Gut
Extra-Intestinal
Symptoms
& Disease
Bacterial
Translocation
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•
•
•
•
•
•
•
•
•
Osteoporosis
Rosacea
Anemia
Polyneuropathy
Fatigue
Brain fog
Malaise
Weight loss
Etc.
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Rosacea: SIBO-Related Bacterial
Translocation?
Small intestinal bacterial overgrowth in
rosacea: clinical effectiveness of its eradication.
Parodi A1, Paolino S, Greco A, Drago F, Mansi C, Rebora A, Parodi A, Savarino V. Clinical Gastroenterology &
Hepatology. 2008 Jul;6(7):759-64. doi: 10.1016/j.cgh.2008.02.054. Epub 2008 May 5.
• The prevalence of SIBO was higher in patients than controls (52/113 vs
3/60, P < .001).
• 10 day treatment with Rifaxamin – non-absorbable antibiotic
• After eradication, cutaneous lesions cleared in 20 of 28 and greatly
improved in 6 of 28 patients, whereas patients treated with placebo
remained unchanged (18/20) or worsened (2/20)
• Eradication of SIBO induced an almost complete regression of cutaneous
lesions and maintained this excellent result for at least 9 months
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SIBO Associated Conditions
•
•
•
•
•
•
•
Achlorhydria
Celiac disease
Crohn’s
Diabetes
Fibromyalgia
Gastroparesis
IBS
Mild
• Immunodeficiency
syndromes
• Liver cirrhosis
• Chronic pancreatitis
• Restless legs syndrome
• Rosacea
• Scleroderma
• Short bowel syndrome
Range of Symptom Severity
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Severe
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Carbohydrate Malabsorption
• Fructose Malabsorption
– Poor absorption of fructose containing foods
• Colonic bacteria consume unabsorbed fructose 
leads to H2 production, bloating, gas & various GI
symptoms
• Lactose Intolerance
– Poor absorption of lactose due to lactase
deficiency
• Colonic bacteria consume unabsorbed lactose 
leads to H2 production, bloating, gas & various GI
symptoms
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Breath H2 Testing is Best Method to Diagnose
SIBO & Carbohydrate Malabsorption
• 40+ year history with lactose intolerance
• 25+ years with fructose malabsorption
• Used in virtually all research to diagnose SIBO and
carbohydrate malabsorption
• Non-invasive
• Highly accurate
• Covered by virtually all insurance
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HydroStat Gives Critical Diagnostic
Information
Assess target organ of
bacterial metabolic activity
Small Intestine:
• SIBO
Large Intestine:
• Fructose Malabsorption
• Lactose Intolerance
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HydroStat Improves
Diagnostic Ability
1. SIBO
2. Fructose
Malabsorption
3. Lactose
Intolerance
HydroStat accurately
diagnoses 3 of 6
common causes of IBSlike symptoms leading to
targeted treatment and
significantly improved
outcomes
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Diagnostic Workup for Moderate
to Severe IBS-Like Symptoms
History
• IBD (0.5%)
• Celiac (0.75%)
• Colorectal
Cancer
• Travel Abroad
Blood Tests
• CBC
• Celiac Panel
• Thyroid Panel
Alarm
Signals
• Rectal Bleeding
• Nocturnal
Diarrhea
• Weight Loss
• >50 Years Old
Stool
Studies
• Occult Blood
• Parasites
• Pathogens
+
HydroStat
• SIBO
• Fructose
Malabsorption
• Lactose
Intolerance
=
>70%
Treatment
Success
Targeted Diagnostics  Targeted Therapy  Better Outcomes
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