Small intestinal malcolonization refers to an overgrowth of microbes in the small intestine of more than one hundred thousand germs per milliliter. The microbial overgrowth manifests itself in many nonspecific symptoms such as abdominal pain, flatulence, chronic diarrhea, and leads to damage of the intestinal villi. As it progresses, malassimilation and associated weight loss and deficiency symptoms occur.
What is small intestinal malabsorption?
Small intestinal malassimilation (DDFB) refers to microbial overgrowth in the small intestine. One hundred thousand germs per milliliter is considered the lower limit for DDFB. The Anglo-Saxon term small intestinal bowel (bacterial) overgrowth (SIBO) describes the situation even more precisely. The small intestine is directly connected to the stomach and is separated from the large intestine by the ileocecal valve, also known as the Bauhin valve. In simple terms, the enzymatic breakdown of the main nutrients takes place in the small intestine, and the absorption of the broken down substances as well as vitamins and part of the minerals takes place through the intestinal villi. The healthy small intestine is only weakly colonized by intestinal microbes compared to the large intestine. Normally, there are about one thousand to ten thousand germs per milliliter of intestinal mucus in the small intestine. In contrast, the large intestine is colonized with one hundred billion to one trillion germs per gram of intestinal mucus. Small intestinal miscolonization therefore corresponds simultaneously to microbial miscolonization and overcolonization.
Causes
The healthy small intestine has several protective mechanisms by which it protects itself from both miscolonization and overgrowth. Passive protection against colonization by colon bacteria is provided by the Bauhin valve (ileocecal valve), which is located at the transition from the small intestine to the large intestine. It also acts like a check valve to prevent reflux of the food pulp from the colon into the small intestine. Active protection consists of the antibiotic substances produced by the Paneth cells in the small intestine, which prevent the development of malabsorption. When the aforementioned protective mechanisms and others fail, DDFB can develop. The main causes for the occurrence of small bowel malcolonization are a defective ileocecal valve and the so-called short bowel syndrome. Short bowel syndrome can result from artificial, acquired or, in rare cases, congenital shortening of the small bowel. The starting point of DDFB is then usually an immobilized or inactive loop of intestine in which the passage of the intestinal contents is severely slowed. Slowed passage may also be the result of a disturbance in natural peristalsis. Other causative factors may be insufficient acid production by the stomach or a decreased supply of digestive enzymes from the pancreas and bile.
Symptoms, complaints, and signs
The main symptoms that occur can usually be attributed to an increased formation of digestive gases and to a decreased absorption capacity of the small intestine, so that malassimilation can lead to typical deficiency symptoms that trigger health symptoms and complaints. Increased gas formation leads to bloated abdomen and causes abdominal pain in alternate locations because the gas cannot be expelled naturally, but is mainly diffused into the blood and “exhaled” in the lungs. Often the leading symptoms are accompanied by chronic diarrhea and by intestinal inflammation leading to weight loss. In many cases, the symptoms resemble those of irritable bowel syndrome. In less frequent cases – mainly as a consequence of short bowel syndrome – bacterial breakdown of bile salts may occur, so that fat digestion is disturbed and so-called fatty stools are formed. The bacterial imbalance in the immobilized or inactive section of the intestine leads, among other things, to vitamin B12 deficiency, which is considered the main triggering factor for anemia.
Diagnosis and course
In principle, a sample of small intestinal mucus can provide information about bacterial colonization. However, the procedure requires a complex small bowel endoscopy, especially if samples are to be taken from sections of the intestine further downstream. A relatively elegant method is offered by a breath test, which detects hydrogen in the breath. Lactulose (not to be confused with lactose) has proven to be an effective and informative test substance.Lactulose is a disaccharide composed of the two monosaccharides galactose and fructose. Lactulose is not normally metabolized in the small intestine. If hydrogen does form in the small intestine, which can be detected by the breath test, this is considered an indication of DDFB. If left untreated, the course of the disease depends on the causative factors. If the causes are not recognized and treated, severe courses with poor prognosis may result. However, DDFB is generally well treatable.
Complications
Small intestinal malabsorption causes severe symptoms and complications in the intestines and stomach. In most cases, the symptoms resemble gastrointestinal disease. The patient suffers from severe pain in the abdomen and diarrhea. Also, flatulence, dizziness and vomiting may occur. Often, the affected person also loses appetite, which may be reflected in underweight. The constant diarrhea leads to dehydration. In the worst case, the intestines become inflamed. Due to the gastrointestinal complaints, it is often no longer possible for the affected person to perform physical activities, which restricts him in his everyday life. Even the intake of food is only possible to a limited extent. Treatment is usually by medication or surgery. In most cases, there are no further complaints or complications. In some cases, the affected person must avoid certain foods or ingredients due to the small intestinal malabsorption. The treatment does not prevent a recurrence of the small intestinal colonization, so that the patient may become ill again. Life expectancy is not limited or reduced by this disease.
When should you see a doctor?
Dysbiosis in the intestine is increasing, but it is rarely diagnosed correctly. Dysbiosis in the small intestine can be detected by a hydrogen breath test. Self-tests can be found on the Internet that people can use to determine if small intestinal dysbiosis is present if digestive problems persist. The hydrogen breath test is usually described as the gold standard of diagnosis. A visit to a gastroenterologist is advised if intestinal symptoms persist. The reason: the breath test can produce a negative result in non-responders, even if small bowel malabsorption is present. Frequently, the self-diagnosis “irritable bowel syndrome” is fixed in the memory in the case of persistent fermentation complaints as a result of a bacterial malcolonization of the small intestine, although this is often incorrect. Also a food intolerance is not always present. If improper self-treatment is used, the underlying problem can worsen. If those affected react by avoiding supposedly intolerant foods, the result is an unbalanced diet. Instead of risking nutritional deficiency symptoms, a visit to a gastroenterologist would make more sense. Malabsorption of the small intestine can occur due to age. But it can also be the result of Crohn’s disease or short bowel syndrome. If the bacterial colonization in the intestine is in disarray, it should be quickly put back in order. After all, the functioning of the human immune system is related to the correctly working microbiome.
Treatment and therapy
Treatment is primarily aimed at eliminating the cause of DDFB. For example, causal therapy may consist of surgical intervention to restore the functionality of the Bauhin valve or to remove blind loops of the small intestine or narrowing (stenosis). If the supply of bile juices to the small intestine is disturbed, therapy aims to restore the functions of the pancreas and gallbladder. In parallel, in many cases, restorative preparations and vitamin replacement therapies are necessary. DDFB proper usually responds well to certain antibiotics, so treatment can then be given to help build a microbiome typical of the small intestine. Overall, the prognosis for DDFB can be considered favorable if the causes and the DDFB itself are treated appropriately.
Outlook and prognosis
Small bowel malabsorption can be treated well in most cases. In this regard, early diagnosis always has a positive effect on the further course of the disease. In some cases, patients are dependent on surgical intervention.Furthermore, the disease can also be well defeated by taking medication, whereby there are usually no particular complications. Should the small intestine malabsorption occur due to an allergy or an intolerance, the affected person must abstain from the triggering substance. Only in this way can the symptoms be permanently alleviated. Furthermore, stress can also aggravate the small intestine malabsorption, so that in many cases relaxation exercises can alleviate the disease. If the disease is not treated, it can lead to serious complications of the intestine. In the worst case, a rupture of the intestine occurs, which can lead to the death of the affected person. In this case, immediate surgical intervention is necessary. Similarly, the symptoms of small intestinal malabsorption often lead to psychological upsets or depression. With timely treatment, the patient’s life expectancy is not reduced by the disease.
Prevention
Preventive measures to avoid small intestinal malabsorption consist mainly of avoiding substances that favor the development of DDFB. This is especially true for foods to which individual sensitivity or intolerance has been demonstrated. In principle, a healthy lifestyle in which naturally left foods and exercise play a role, as well as periods of stress alternating with periods of relaxation, can be attributed a preventive effect.
Aftercare
Small intestinal malabsorption can occur in the context of food intolerance or irritable bowel syndrome. However, both can also be the cause of the same. Pancreatic insufficiency may also be related. Small bowel overgrowth often originates from slackening of the ileocecal valve. Overgrowth of harmful bacteria in the small intestine is often underestimated. Misdiagnoses are the order of the day. Only when there are persistent intestinal complaints are appropriate examinations carried out. Various procedures can be considered as therapy. These may include surgical procedures. These require postoperative follow-up and long-term observation of the patient. In other cases, antibiotics are prescribed as standard treatment for small intestinal colonization. If these do not work, the treating physicians speak of an antibiotic-responsive enteritis. Follow-up measures depend on the underlying disease. They also endeavor to compensate for the faulty colonization in the small intestine by appropriate measures. Pro- and prebiotics and foods high in resistant starch may be considered. Flora killers should be avoided. Unfortunately, the microbiome in the small intestine is rarely the focus of interest for family doctors. Not the cause of a disorder is treated, but the symptom. Therefore, especially in the case of small intestinal malabsorption, many unsuccessful self-treatment attempts are found. Follow-up with a gastroenterologist may also be deficient in this regard. Diagnosis is often not followed by therapy in cases of malabsorption.
Here’s what you can do yourself
Adjustment of behavior in everyday life and self-help measures can support a medical or surgical treatment of small intestinal malabsorption (DDFB) well. It is important that the causes of DDFB are correctly identified and specifically treated. For example, if the small bowel malabsorption is ascending via the defective Bauhin valve (ileocecal valve), it is urgently necessary to surgically replace the valve or make it functional again so that no new malabsorption can form. In other cases, the causes for the development of DDFB are a slowed passage of the food pulp through the small intestine due to short bowel syndrome as a result of an obstructed intestinal loop or due to reduced intestinal peristalsis. Similarly, insufficient acid production in the stomach or decreased influx of bile juices and digestive enzymes from the pancreas into the small intestine have similar effects. Self-help measures to accompany antibiotic therapy consist of a balanced diet rich in minerals, vitamins and enzymes. Fermented foods such as sauerkraut or yogurt have a particularly beneficial effect. The Paneth cells in the intestinal mucosa are thereby supported in the synthesis of their own antibiotic substances to regulate the bacterial colonization of the small intestine. If insufficient intestinal peristalsis is the cause of DDFB, there is the possibility of self-help through self-massage.In a relaxed supine position with legs slightly bent, gently massage the abdomen in a clockwise circular motion without applying pressure.
