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What Tests Should You Use to Assess Small Intestinal Bacterial Overgrowth in Systemic Sclerosis? Y

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What Tests Should You Use to Assess Small Intestinal Bacterial Overgrowth in Systemic Sclerosis? Y What tests should you use to assess small intestinal bacterial overgrowth in systemic sclerosis? Y. Braun-Moscovici¹, M. Braun², D. Khanna3, A. Balbir-Gurman1, D.E. Furst4 ¹B. Shine Rheumatology Unit, Rambam ABSTRACT The pathogenesis of GIT involvement is Health Care Campus, Bruce Rappaport Objective. Small intestinal bacte- thought to include early vascular dam- Faculty of Medicine, Technion – Institute rial overgrowth (SIBO) plays a major age to the vasa nervorum of the nerves of Technology, Haifa, Israel; ²Liver Institute, Beilinson Hospital, role in the pathogenesis of malabsorp- innervating the GIT. This leads to neu- Petach-Tikwa, Sackler School of Medicine, tion in SSc patients and is a source of rological dysfunction, particularly in- Tel Aviv University, Israel; great morbidity and even mortality, in volving autonomic pathways (4-5). The ³Director of University of Michigan those patients. This manuscript reviews activation of the immune system may Scleroderma Program, University of which tests are valid and should be contribute to neurological dysfunc- Michigan, Ann Arbor, Michigan, USA; used in SSc when evaluating SIBO. tion by production of antibodies which 4Director of Therapeutic Research, David Geffen School of Medicine, University of Methods. We performed systematic lit- specifically inhibit M3-muscarinic California, Los Angeles, USA. erature searches in PubMed, Embase receptor-mediated enteric cholinergic Yolanda Braun-Moscovici, MD and the Cochrane library from 1966 up neurotransmission (6). With damage to Marius Braun, MD to November 2014 for English language, innervation, smooth muscle atrophies Dinesh Khanna, MD, MS published articles examining bacterial and is eventually replaced by fibrotic Alexandra Balbir-Gurman, MD overgrowth in SSc (e.g. malabsorption tissue which further leads to motility Daniel E. Furst, MD tests, breath tests, xylose test, etc). Ar- disorders of the GIT. At present, there Please address correspondence to: ticles obtained from these searches were is no single validated, objective, specif- Dr Daniel E. Furst, reviewed for additional references. The Geffen School of Medicine at ic test to assess the global involvement the University of California validity of the tests was evaluated ac- of the GI tract although the GIT2.0, a in Los Angeles, cording to the OMERACT principles of patient reported outcome measure has 1000 Veteran Ave, truth, discrimination and feasibility. been validated (7). Los Angeles, CA 90025, USA. Results. From a total of 65 titles, 22 Hypomotility of the small bowel may E-mail: [email protected] articles were reviewed and 20 were ul- cause intestinal pseudo-obstruction and Received on December 1, 2014; accepted timately extracted to examine the valid- small intestinal bacterial overgrowth in revised form on May 28, 2015. ity of tests for GI morphology, bacterial (SIBO). SIBO is one of the main patho- Clin Exp Rheumatol 2015; 33 (Suppl. 91): overgrowth and malabsorption in SSc. genetic factors of malabsorption which S117-S122. Only 1 test (hydrogen and methane is associated with 50% mortality over © Copyright CLINICAL AND breath tests) is fully validated. Four 8.5 years, in SSc patients (8). Diagno- EXPERIMENTAL RHEUMATOLOGY 2015. tests are partially validated, including sis of SIBO is problematic. Quantita- Key words: systematic literature jejunal cultures, xylose, lactulose tests, tive culture of small bowel contents is review, systemic sclerosis, and 72 hours fecal fat test. considered the gold standard, but the gastro-intestinal tract Conclusion. Only 1 of a total of 5 GI lack of standardisation of the normal tests of bacterial overgrowth (see above) bowel flora in the small intestine limits Competing interests: is fully validated in SSc. For clinical tri- its accuracy. A variety of indirect tests, D. Khanna has/had consulancy relationships als, fully validated tests are preferred, including breath tests and biochemical and/or has received research funding from although some investigators use par- tests based on bacterial metabolism of Bayer, Biogen Idec, Bristol Myers Squibb, Cytori, EMD Serono, Forward, Lycera, tially validated tests (4 tests). Further a variety of substrates, have been used Roche/Genentech, NIH/NIAID, NIH/NIAMS, validation of GI tests in SSc is needed. over the years in an attempt to facilitate PCORI, Scleroderma Foundation and the diagnosis of SIBO. Our aim is to Seattle Genetics. Introduction review the procedures used to evaluate D.E. Furst has received grant/research Involvement of the gastrointestinal tract SIBO in SSc patients and to assess their support from AbbVie, Actelion, Amgen, BMS, Gilead, GSK, NIH, Novatis, Pfizer, (GIT) in SSc is extremely frequent; it validity. Roche/Genentech, and UCB; has received is a leading cause of morbidity and the consultancy fees from AbbVie, Actelion, third most common cause of mortality in Methods Amgen, BMS, Cytori, Janssen, Gilead, this disease. Oesophageal abnormalities We performed systematic literature GSK,NIH, Novatis, Pfizer, Roche/Genen- occur in up to 90% of patients, stomach searches in PubMed, Embase and the tech, and UCB; and is on the Speaker’s Bureau (CME only) of AbbVie, Actelion, involvement can be documented in 50% Cochrane library from 1966 through and UCB. or more of patients and small bowel, co- November 2014 for English language, The other co-authors have declared no lonic and anorectal involvement occur published articles examining bacterial competing interests. in 50–70% of SSc patients (1-3). overgrowth and malabsorption in SSc. S-117 Bacterial overgrowth assessment in scleroderma / Y. Braun-Moscovici et al. The keywords used were systemic scle- rosis and scleroderma and they were combined with text words such as small bowel, bacterial overgrowth, malab- sorption, breath tests, small bowel cul- tures, xylose test, lactulose tests, oro- cecal transit test, hydrogen, glucose, gut. Case reports, case series with less than 8 patients, reviews, articles with non-separable data for SSc patients, du- plicates and articles in languages other than English were excluded. The titles and abstracts obtained were screened for inclusion by both a rheumatologist and a gastroenterologist. Titles and ab- stracts which included at least one va- lidity criterion were selected and the data were extracted from the complete articles. Articles obtained from these searches were reviewed for additional references (Fig. 1). Reviews were not Fig. 1. Medline search of publications on the use of the diverse procedures for small intestinal bacte- rial overgrowth assessment in systemic sclerosis. included but their reference lists were examined for additional articles. Table I. Omeract principles. The validities of the tests were evalu- ated as to whether they conformed to Face validity apparent but untested statistical validity (whether a test measures what it OMERACT (Outcome Measures in was meant to measure, in the subjective opinion of the scientist); Rheumatologic Clinical Trials) princi- Content validity the items on the test represent the entire range of possible items the test should ples (truth, discrimination and feasibil- cover; ity). The principles used to assess the Construct validity the extent to which operationalisations of a construct (e.g. practical tests truth, discrimination and feasibility of developed from a theory) do actually measure what the theory says they do; measures, which are accepted world- Criterion validity the correlation between the test and a criterion variable (or variables) taken as wide, are described in Table I. representative of the construct. It compares the test with other measures or outcomes (the criteria) already held to be valid; Results Convergent validity the degree to which a measure is correlated with other measures that it is Validated or partially validated tests theoretically predicted to correlate with; (Table II) 1. Jejunal culture Reproducibility requires stability when a measure is done repeatedly; Jejunal cultures are only partially vali- Sensitivity to change requires that when an effective drug is used, the measurement changes by a dated in SSc. statistically or clinically important amount; Three out 4 articles met inclusion/ex- Feasibility requires that a measure should be easy to perform, requires little time and clusion criteria and were extracted. The requires minimal amount of equipment. gold standard for diagnosis of bacterial overgrowth has been quantitative cul- studies, the prevalence of small intes- trols, found significantbacterial counts: ture of an aspirate of luminal fluid from tinal bacterial overgrowth (SIBO) was >10(5) colony forming units per ml the jejunum. Growth of 10 million or 30–62.5% in SSc patients exhibiting (cfu/ml) of jejunal fluid in 8 patients more organisms/ml in either aerobic or gastrointestinal symptoms; in these (33%) compared to none in the con- anaerobic conditions is the criterion for series, SIBO was defined as microbial trols. Seven out of these 8 patients had a positive culture. Problems with use concentration (>105 CFU/ml) in the je- also a positive breath test (10). By im- of jejunal cultures as a test for bacte- junal aspirate culture (9-11). plication, although no statistics were rial overgrowth include lack of stand- Content validity: the procedure was done, this study meets convergent con- ardisation of the collection method, the used in SSc pts with limited and diffuse struct validity. requirement for intubation of the upper disease and various disease duration (9, Criterion validity:
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