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OBJECTIVES:Available data regarding whether appendicectomy performed after the onset of ulcerative colitis can modulate its clinical course are currently limited. This study aimed at addressing this issue.METHODS:In this study, we report a prospective case series of 30 adult patients (median age 35 years, range 17–70 years; male/female: 11/19) with ulcerative proctitis (median duration of symptoms 5 years, range 8 months to 30 years; median Simple Clinical Colitis Activity Index score 9, range 7–12), who underwent appendicectomy in the absence of any history suggestive of previous appendicitis. Patients were subsequently followed up clinically with the assessment of the Simple Clinical Colitis Activity Index for a median of 14 months (range 9–32 months).RESULTS:After appendicectomy, the clinical activity index improved significantly to a median score of 2 (range 0–12) (P<0.0005). The improvement in the clinical activity index occurred in 27 of 30 (90%) patients, whereas the index remained unchanged in the remaining 3 of 30 (10%) patients. Furthermore, 12 of 30 (40%) patients experienced a complete resolution of symptoms (clinical activity index score of 0) by 12 months, such that all pharmacological treatments could be withdrawn, and have remained in remission off all previous treatments for a median 9 months (range 6–25 months). The time required for a complete resolution of symptoms post appendicectomy ranged from 1 to 12 months (median 3 months) (Kaplan–Meier analysis). None of the clinical or histological factors analyzed were significantly associated with post-appendicectomy outcome.CONCLUSIONS:This case series, the largest reported so far, provides rationale for controlled trials to properly evaluate the possible role of appendicectomy in the treatment of ulcerative proctitis. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of this study was to investigate the separate effects of indigenous oropharyngeal- and colonic-type flora on small intestinal mucosal immunity and morphometry in small intestinal bacterial overgrowth (SIBO). METHODS: A duodenal aspirate and random biopsies of underlying mucosa were obtained from 52 adult subjects (age range. 18-90 yr: median. 60 yr) without disorders that may otherwise disturb small intestinal histology or mucosal immunity. Villus height, crypt depth, villus/crypt ratios, counts of intraepithelial lymphocytes (IELs) and lamina propria total mononuclear cells, IgA, IgM, and IgG plasma cells, mast cells, and B and T lymphocytes were determined in relation to the presence or absence of SIBO and the nature of the overgrowth flora in all subjects. CD4+ve and CDS+ve T-cell counts were determined in 24 subjects. RESULTS: SIBO was present in 26 of 52 (50%) subjects. Overgrowth flora included colonic-type bacteria in 20 subjects and oropharyngeal-type flora alone in 6 subjects. Lamina propria IgA plasma cell counts were significantly increased in subjects with SIBO, irrespective of whether the overgrowth flora comprised oropharyngeal-type flora alone or included colonic-type bacteria. Neither villus height, crypt depth, villus/crypt ratios, nor total or other mononuclear cell counts in lamina propria differed significantly between subjects with and without SIBO, irrespective of the nature of the overgrowth flora. IEL counts were significantly higher than in culture-negative subjects only when the over-growth flora included colonic-type bacteria. Even then, IEL counts were within a range currently considered normal. A significant, inverse correlation between advancing age and IEL counts became apparent after adjusting for the effect of SIBO of colonic-type flora. CONCLUSIONS: SIBO of oropharyngeal- and colonic-type flora are associated with differing disturbances of local duodenal mucosa. Nonetheless, these would not be readily apparent during routine histological assessment. Old age independently influences duodenal IEL counts. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The aims of this study were 1) to document the sensitivity, specificity, and predictive values of the rice breath hydrogen test for small intestinal bacterial over-growth; 2) to determine the possible influence of concurrent gastric bacterial overgrowth and gastroduodenal pH on the efficacy of this test; and 3) to investigate whether reliability is limited by an inability of small intestinal luminal flora to ferment rice or its product of hydrolysis, maltose. METHODS: Twenty adult subjects were investigated with microbiological culture of proximal small intestinal aspirate and a 3-g/kg rice breath hydrogen test. Gastroduodenal pH, the presence or absence of gastric bacterial overgrowth, and the in vitro capability of small intestinal luminal flora to ferment rice and maltose, its product of hydrolysis, were determined. RESULTS: Sensitivity of the rice breath hydrogen test for small intestinal bacterial overgrowth was 33% and remained low even when subjects with small intestinal overgrowth with oropharyngeal-type (38%) and colonic-type flora (20%) and those with concurrent small intestinal and gastric bacterial overgrowth (40%) were considered separately. Sensitivity remained suboptimal despite favorable gastroduodenal luminal pH and documented ability of bacterial isolates to ferment rice and maltose in vitro. Specificity of the rice breath hydrogen test for small intestinal bacterial over-growth was 91%. Positive predictive value, negative predictive value, and predictive accuracy were 75%, 63%, and 65%, respectively. CONCLUSIONS: Clinical value of the rice breath hydrogen test for detecting small intestinal bacterial overgrowth is limited. The rice breath hydrogen test is not a suitable alternative to small intestinal intubation and culture of secretions for the detection of small intestinal bacterial overgrowth. [ABSTRACT FROM AUTHOR]

Objective: Some rodent strains with experimental small intestinal bacterial overgrowth (SIBO) unrelated to jejunoileal bypass are susceptible to hepatic damage, possibly because of increased small intestinal permeability to proinflammatory bacterial polymers. However, data on the prevalence of hepatic damage in human subjects with SIBO in this setting are lacking. This study addressed this issue. Methods: Seventy adult subjects were investigated for possible SIBO and hepatic damage with bacteriological analysis of small intestinal aspirates and measurement of serum concentrations of alkaline phosphatase, gamma-glutamyl transpeptidase, aspartate aminotransferase, and alanine aminotransferase. Nutritional indices (serum albumin and anthropometry) and the urinary lactulose/mannitol ratio, an index of small intestinal permeability, were measured in all subjects with SIBO and liver damage. Results: SIBO was present in 40 of 70 subjects (57.1%). Overgrowth flora included salivary-type bacteria alone in 11 subjects and colonic-type bacteria in 29 subjects (facultative anaerobes [En-terobacteriaceae] alone in 21 subjects and both facultative and obligate anaerobes [Enterobacteriaceae and Bacteroides spp] in eight subjects). Biochemical evidence of liver damage was found in zero of 30 subjects without SIBO, zero of 11 subjects with SIBO with salivary-type bacteria alone, zero of 21 subjects with SIBO with facultative but not obligate anaerobic colonic-type bacteria, and in one of eight subjects (12.5%) with SIBO with obligate anaerobic colonic-type bacteria, in whom serum alkaline phosphatase and gamma-glutamyl transpeptidase levels were elevated. Nutritional indices were normal in this patient. Small intestinal permeability was increased and, along with liver enzyme abnormalities, normalized after eradication of SIBO. Small intestinal permeability was also increased in three of six patients (50.0%) with SIBO with obligate anaerobic colonic-type bacteria who had no... [ABSTRACT FROM AUTHOR]

Objective: Elevated antigliadin antibody levels in small intestinal luminal secretions of subjects with normal or only mildly abnormal small intestinal histology are considered indicative of "latent" or "potential" celiac disease. The purpose of this study was to determine whether small intestinal bacterial overgrowth (SIBO) might provide an alternative explanation for positive luminal antigliadin antibodies in such subjects. Methods: Twenty-six adult subjects without predisposition to disturbed mucosal immunity were investigated with culture of small intestinal luminal secretions. Luminal total IgA and IgA-antigliadin antibody concentrations were measured by radial immunodiffusion and indirect enzyme immunoassay, respectively. Local mucosal counts of IgA-plasma cells were determined by immunohistochemistry. Small intestinal histology and intraepithelial lymphocyte counts were assessed by light microscopy. Corresponding serum antigliadin antibody concentrations were determined. Results: SIBO was present in 17/26 (65.4%) subjects. No subject with SIBO had villous atrophy. Luminal total IgA concentrations (p < 0.0005), mucosal IgA-plasma cell counts (p < 0.01), and intraepithelial lymphocyte counts (p < 0.01) were significantly increased in subjects with SIBO. Luminal IgA-antigliadin antibodies were detected in 6/17 (35.3 %) subjects with SIBO and 0/9 (0%) subjects without SIBO. Luminal IgA-antigliadin antibody concentrations correlated significantly with luminal total IgA levels (p < 0.01) but not with serum values (p < 0.1). Serum IgG-antigliadin antibody concentrations were elevated in 2/6 (33.3%) subjects with SIBO and positive luminal antigliadin antibodies. Conclusions: SIBO may be an alternative explanation to "latent" or "potential" celiac disease for positive luminal antigliadin antibodies in subjects with either normal or only mildly abnormal small intestinal histology, even when serum... [ABSTRACT FROM AUTHOR]

Objectives: 1) To determine the prevalence of small intestinal overgrowth with colonic-type bacteria in symptomatic elderly subjects, particularly those without important "clues" such as clinically apparent predisposition or vitamin B12 deficiency, and 2) to investigate defense mechanisms such as gastric acidity, small intestinal motility, and luminal IgA in this setting. Methods: Fifty-two symptomatic subjects without vitamin B12 deficiency or clinically apparent predisposition to bacterial overgrowth or disturbed mucosal immunity, including 22 subjects ≥ 75 yr old, underwent culture of small intestinal luminal secretions. Indicator paper was used to measure fasting gastric pH. The presence of bacteria of confirmed nonsalivary origin in small intestinal secretions served as an index of small intestinal dysmotility. Small intestinal luminal IgA concentrations were measured by radial immunodiffusion. Results: Small intestinal overgrowth with colonic-type flora was not present in any subject investigated for dyspepsia, irrespective of age. In subjects with chronic diarrhea, anorexia, or nausea, overgrowth with colonic-type flora (Enterobacteriaceae) was present in 0/12 (0%), 1/10 (10.0%), and 9/14 (64.3%) subjects aged < 50 yr, 50-74 yr, and ≥ 75 yr, respectively. Enterobacteriaceae were not concurrently recovered from saliva of any subject ≥ 75 yr old with small intestinal overgrowth with these bacteria. Fasting hypochlorhydria was present in only 1/9 (11.1%) such subjects. Luminal IgA concentrations were significantly greater in subjects ≥ 75 yr old with bacterial overgrowth than in culture-negative subjects (p ≤ 0.003). Conclusions: Small intestinal overgrowth with colonic-type bacteria should be considered in subjects ≥ 75 yr old with chronic diarrhea, anorexia, or nausea, even in the absence of clues such as clinically apparent predisposition or vitamin B12 deficiency. Small... [ABSTRACT FROM AUTHOR]

Objective: Small intestinal hypomotility is an important cause of small intestinal bacterial overgrowth, yet assessment of small intestinal motility in this setting is problematic. This study was performed to investigate the validity of a bacteriological method for detecting small intestinal hypomotility. Methods: Twenty-five subjects without previous gastric surgery were studied with (i) concurrent bacteriological analyses of fasting saliva and gastric and proximal small intestinal aspirates, (ii) measurement of gastric pH, and (iii) scintigraphic assessment of small intestinal transit rates of a liquid test meal. The reproducibility of bacteriological analyses of saliva and small intestinal secretions was determined in 12 subjects. Results: Serial bacteriological analyses of saliva and proximal small intestinal secretions yielded reproducible results over time periods of up to 1 month. Eleven subjects were deemed to harbor Enterobacteriaceae of nonsalivary origin in proximal small intestinal secretions. Orocaecal transit, but not gastric emptying, of a liquid test meal was significantly delayed in this group (p = 0.002 and p = 0.84, respectively), suggesting the presence of small intestinal hypomotility. Impaired gastric acidity unlikely confounded assessment of the origin of small intestinal Enterobacteriaceae in any instance. Conclusions: The presence of Enterobacteriaceae of nonsalivary origin in proximal small intestinal secretions may be taken to reflect the presence of small intestinal hypomotility. The presence of impaired gastric acidity does not confound this approach. Because small intestinal intubation and culture of aspirate are required anyway to accurately diagnose small intestinal bacterial overgrowth, the simple addition of concurrent bacteriological analysis of saliva may allow small intestinal hypomotility to be detected at the same time as the presence or absence of small intestinal bacterial overgrowth itself is established, thus... [ABSTRACT FROM AUTHOR]

Objectives: To i) document the sensitivity and specificity of a combined scintigraphic/lactulose breath hydrogen test for small intestinal bacterial overgrowth and ii) investigate the validity of currently accepted definitions of an abnormal lactulose breath hydrogen test based on "double peaks" in breath hydrogen concentrations. Methods: Twenty-eight subjects were investigated with culture of proximal small intestinal aspirate and a 10-g lactulose breath hydrogen test combined with scintigraphy. Gastroduodenal pH, the presence or absence of gastric bacterial overgrowth, and the in vitro capability of overgrowth flora to ferment lactulose were determined. Results: Sensitivity (16.7%) and specificity (70.0%) of the lactulose breath hydrogen test alone for small intestinal bacterial overgrowth were poor. Combination with scintigraphy resulted in 100% specificity, because double peaks in serial breath hydrogen concentrations may occur as a result of lactulose fermentation by cecal bacteria. Sensitivity increased to 38.9% with scintigraphy, because a single rise in breath hydrogen concentrations, commencing before the test meal reaches the cecum, may occur in this disorder. Sensitivity remained suboptimal irrespective of the definition of small intestinal bacterial overgrowth used, the nature of the overgrowth flora, favorable luminal pH, the presence of concurrent gastric bacterial overgrowth, or the in vitro ability of the overgrowth flora to ferment lactulose. Conclusions: Definitions of an abnormal lactulose breath hydrogen test based on the occurrence of double peaks in breath hydrogen concentrations are inappropriate. Not even the addition of scintigraphy renders this test a clinically useful alternative to culture of aspirate for diagnosing small intestinal bacterial overgrowth. [ABSTRACT FROM AUTHOR]

Objectives: To document the sensitivity of the 1-g 14C-D-xylose breath test for bacterial overgrowth and to investigate luminal and nonluminal factors that may influence breath 14CO2 levels and impact on the clinical utility of this test. Methods: Thirty-five adult subjects were investigated for bacterial overgrowth by culture of gastric and small intestinal aspirates and by a 1-g 14C-D-xylose breath test. Body weight, gastroduodenal pH and the in vitro capability of overgrowth flora to ferment D-xylose were assessed. Serial breath 14CO12 levels were also recorded before and after the resolution of malabsorption in a subject with celiac disease to determine the importance of postabsorptive metabolism of this substrate. Results: Gastric and small intestinal bacterial overgrowth were present in 19/35 (54.3%) and 21/35 (60.0%) subjects, respectively. The positivity rate of culture of aspirate exceeded that of the 1-g 14C-D-xylose breath test. Endogenous CO2 production independently influenced breath 14CO2 levels. After excluding this influence, sensitivity of the 1-g 14C-D-xyose breath test for gastric bacterial overgrowth or small intestinal bacterial overgrowth was poor, even when overgrowth with specific "marker organisms" was considered. Poor sensitivity could not be explained by unfavorable luminal pH. Overgrowth flora were proven capable of in vitro D-xylose fermentation in 81.8% of subjects. Systemic and/or colonic metabolism of 1-g 14C-D-xylose appear to be important factors influencing results of the 1-g 14C-D-xylose breath test, especially in partial gastrectomy subjects. Conclusions: The 1-g 14C-D-xylose breath test is not a suitable alternative to culture of aspirate for the investigation of subjects for bacterial overgrowth. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor in response to the article "Gut Flora and the Irritable Bowel Syndrome," that was previously published in the "American Journal of Gastroenterology."

Presents a letter to the editor about the use of lactulose breath hydrogen test to diagnose small intestine bacterial overgrowth.