Bariatric Times

NOV 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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18 Review Bariatric Times • November 2017 infection with antibiosis, or, in severe cases, correcting the underlying cause with revisional surgery. 9 The gold standard for treatment is antibiosis, but the choice of antibiotic regimen and duration of therapy remain controversial. Amoxicillin-clavulanate, ciprofloxacin, doxycycline, rifaximin, chlortetracycline, and metronidazole all have been used empirically in clinical practice, though studies directly comparing these regimens are sparse, especially in the setting of bariatric surgery. One randomized, controlled trial of 142 patients with SIBO found that rifaximin 1200mg/day for seven days was superior to metronidazole 750mg/day for seven days in reversing glucose breath test positivity at one month following randomization. 24 Suggested antibiotic regimens for treatment of SIBO are described in Table 1. 25–28 The role of the gut microbiome in weight regulation following RNYGB outside of clinically symptomatic SIBO is unclear. One study of 65 patients found that post-operative patients with positive glucose breath tests experienced less weight loss than those with normal glucose breath tests 29 . However, the authors did not observe increased rates of symptoms of SIBO (e.g., diarrhea, vitamin deficiency, and bloating) in patients with positive tests, again emphasizing the difficulty of accurately diagnosing SIBO in the presence of alterations in orocecal transit time following RNYGB. A similar study of 33 patients found no difference in weight loss related to hydrogen breath test status. 30 Nevertheless, using unbiased high- throughput sequencing technologies, 31 RNYGB has been shown to have major effects on the small intestinal microbiome. In a randomized controlled trial of 44 patients undergoing RNYGB. 32 Probiotic therapy has been shown to reduce rates of positive hydrogen breath testing, promote weight loss, and increase vitamin B12 availability. Thus, while debilitating side effects of SIBO such as BADAS are now rare due to the replacement of JIB with more modern surgeries, changes in the small intestinal microbiome might have subtle but important effects on patients undergoing malabsorptive bariatric procedures. CONCLUSION Bariatric surgery creates major alterations in the composition and activity of microorganisms inhabiting the gut, which can have effects ranging from minor changes in long- term weight loss to, in rare cases, serious malnutrition and abdominal discomfort. Timely diagnosis of SIBO in post-surgical patients with abnormal gastrointestinal symptoms could guide management toward appropriate antibiotic therapy and prevent potential morbidity from long-term vitamin deficiencies, gastrointestinal upset, total protein malnutrition, or suboptimal weight loss. Further research investigating the relationship between microbiology and bariatric surgery could further elucidate mechanisms by which changes in the gut microbiome affect nutrient absorption and weight loss in bariatric surgery patients. Additional research will also contribute to the discovery of new surgical innovations and medical management strategies that lead to optimal patient outcomes. REFERENCES 1. Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 366. 2012;1567–1576. 2. Inge TH, Courcoulas AP, Jenkins TM, et al. Weight loss and health status 3 years after bariatric surgery in adolescents. N Engl J Med. 2016;374:113–123. 3. Dukowicz AC, Lacy BE, Levine GM. Small intestinal bacterial overgrowth: a comprehensive review. Gastroenterol Hepatol. 2007;3:112–122. 4. Khoshini R, Dai SC, Lezcano S, Pimentel M. A systematic review of diagnostic tests for small intestinal bacterial overgrowth. Dig Dis Sci 2008;53:1443–1454. 5. Abidi WM, Chan WW, Thompson CC. Mo1285 breath testing for small intestinal bacterial overgrowth in Roux-en-Y gastric bypass patients: the importance of orocecal transit time. Gastroenterology. 2016;150:S688–S689. 6. Griffen, WO Jr, Bivins BA, Bell RM. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet. 1983;157:301–308. 7. McGouran RC, Rutter KP, Ang L, et al. Role of anaerobic bacteria in weight loss and reduced food intake after jejuno-ileal bypass in the rat. Int J Obes. 1982;6:197–204. 8. Corrodi P, Jejunoileal bypass: change in the flora of the small intestine and its clinical impact. Rev Infect Dis. 1980; 6 Suppl 1:S80–84. 9. Stein HB, Schlappner OL, Boyko W, et al. The intestinal bypass: arthritis-dermatitis syndrome. Arthritis Rheum 1981;24:684–690. 10. Ely PH. The bowel bypass syndrome: a response to bacterial peptidoglycans. J Am Acad Dermatol. 1980;2:473–487. 11. Jorizzo JL, Apisarnthanarax P, Subrt P, et al. Bowel-bypass syndrome without bowel bypass. Bowel-associated dermatosis- arthritis syndrome. Arch Intern Med. 1983;143:457–461. 12. Ginsberg J, Quismorio FP Jr, DeWind LT, Mongan ES. Musculoskeletal symptoms after jejunoileal shunt surgery for intractable obesity. Clinical and immunologic studies. Am J Med. 1979;67:443–448. 13. Drenick EJ, Ahmed AR, Greenway F, Olerud JE. Cutaneous lesions after intestinal bypass. Ann Intern Med 1980;93:557–559. 14. Slater GH, Kerlin P, Georghiou PR, Fielding GA. Bowel-associated dermatosis-arthritis syndrome after biliopancreatic diversion. Obes Surg. 2004;14:133–135. 15. Tu J, Chan JJ, Yu LL. Bowel bypass syndrome/bowel-associated dermatosis arthritis syndrome post laparoscopic gastric bypass surgery. Australasian Journal of Dermatology. 2011;52:e5–e7. 16. Dicken CH. Bowel-associated dermatosis-arthritis syndrome: bowel bypass syndrome without FIGURE 1. Anatomic features of jejunoileal bypass (JIB) and Roux-en-Y gastric bypass (RNYGB). Arrows indicate blind bowel loops in (A) JIB, which a re relatively long, and (B) RNYGB, which are relatively short, which can increase risk for development of SIBO. TABLE 1. Oral antibiotic therapy for small intestinal bacterial overgrowth SUGGESTED REGIMENS ALTERNATIVE REGIMENS Rifaximin 550mg three times per day for 7–14 days* Amoxicillin-clavulanate 500mg 3 times per day or 875mg twice per day for 7–14 days Neomycin 500mg twice daily plus rifaximin 550mg 3 times daily for 14 days** Metronidazole 500mg three times per day plus cephalexin 500mg 3 or 4 times per day for 7-14 days Metronidazole 500mg 3 times per day plus trimethoprim-sulfamethoxazole double-strength twice per day for 7–14 days *Recommended for hydrogen-predominant bacterial overgrowth **Recommended for methane-predominant bacterial overgrowth

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