Small Bowel Bacterial Overgrowth Syndrome - Risk Factors and Causes

Risk Factors and Causes

Certain patients are more predisposed to the development of bacterial overgrowth because of certain risk factors. These factors can be grouped into three categories: (1) disordered motility or movement of the small bowel or anatomical changes that lead to stasis, (2) disorders in the immune system and (3) conditions that cause more bacteria from the colon to enter the small bowel.

Problems with motility may either be diffuse, or localized to particular areas. Diseases like scleroderma and possibly celiac disease cause diffuse slowing of the bowel, leading to increased bacterial concentrations. More commonly, the small bowel may have anatomical problems, such as out-pouchings known as diverticula that can cause bacteria to accumulate. After surgery involving the stomach and duodenum (most commonly with Billroth II antrectomy), a blind loop may be formed, leading to stasis of flow of intestinal contents. This can cause overgrowth, and is termed blind loop syndrome.

Disorders of the immune system can cause bacterial overgrowth. Chronic pancreatitis, or inflammation of the pancreas can cause bacterial overgrowth through mechanisms linked to this. The use of immunosuppressant medications to treat other conditions can cause this, as evidenced from animal models. Other causes include inherited immunodeficiency conditions, such as combined variable immunodeficiency, IgA deficiency, and hypogammaglobulinemia.

Finally, abnormal connections between the bacteria-rich colon and the small bowel can increase the bacterial load in the small bowel. Patients with Crohn's disease or other diseases of the ileum may require surgery that removes the ileocecal valve connecting the small and large bowel; this leads to an increased reflux of bacteria into the small bowel. After bariatric surgery for obesity, connections between the stomach and the ileum can be formed, which may increase bacterial load in the small bowel. Some believe Proton pump inhibitor medications, that decrease acid in the stomach, cause bacterial overgrowth by a similar mechanism, as they prevent the anti-bacterial effects of acid in the stomach. There is evidence both supporting and disproving this theory, and the clinical significance of this in causing symptoms is unclear.

In recent years, several proposed links between SIBO and other disorders have been made. However, the usual methodology of these studies involves the use of breath testing as an indirect investigation for SIBO. Breath testing has been critizised by some authors for being an imperfect test for SIBO, with multiple known false positives.