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THE PREVALENCE OF DIARRHEA DUE TO SMALL INTESTINAL BACTERIAL OVERGROWTH (SIBO) AFTER DIETARY TREATMENT FOR CELIAC DISEASE IN ADULTS
K Sultan, J Gregor
Department of Medicine University of Western Ontario, London, ON
BACKGROUND: Although decreasing in prevalence, diarrhea remains the most common symptom of patients at first presentation before a diagnosis of celiac disease. However, even after the institution of appropriate dietary therapy, diarrhea does not resolve in all patients.
AIM: To estimate the prevalence of diarrhea in celiac disease and to determine its response to a gluten-free diet ( GFD ) and in refractory cases the response to empiric treatment for SIBO.
METHODS: A chart review was undertaken of patients presenting for the first time to gastroenterology clinic in whom a diagnosis of celiac disease was made. Data was gathered including symptoms prior to and after institution of a gluten free diet and response to other therapies including metronidazole for a presumptive diagnosis of SIBO.
RESULTS: The charts of 55 adult patients aged 20 to 84 years with a diagnosis of celiac disease were reviewed. Diarrhea was the predominant symptom in 30 out of 55 patients (55 %, F = 24 patients [80 %] M = 6 patients [20 %]). Of these, the diarrhea responded satisfactorily to the institution of GFD in 21/30 (70 %, F= 17 patients [ 81 % ] M = 4 patients [19 %]). The remaining 9 patients (30 % , F = 7 patients [ 88 % ] M = 2 patients [22%]) were given metronidazole 250 mg tid for 7 –14 days and the symptomatic response assessed. Diarrhea improved satisfactorily in 6 out of 9 patients (67 %, F = 5 patients [83 %] M = 1 patient [17 %]), although 4 of these patients required repeat future dosing (2 or more). No short or long-term side effects were noted.
CONCLUSION: Metronidazole is a simple, well-tolerated and effective therapy for diarrhea in celiac patients that is refractory to GFD. A substantial proportion of patients may require cyclic dosing. The mechanism of action is unclear but may be a result of treatment of unrecognized SIBO. In practice, empiric treatment with metronidazole appears to be more practical than formal testing for SIBO.