SmallIntes+nalBacterialOvergrowth:UpdatesandClinicalImplica0ons

Chris&neStubbe,ND,FABNO

LahnorPowell,ND,MPHMedicalEduca0onSpecialist-Atlanta

Chris0neStubbe,ND,FABNO

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SmallIntes+nalBacterialOvergrowth:UpdatesandClinicalImplica0ons

Chris&neStubbe,ND

•  OverviewofSIBO•  Learnwhentoconsidertes&ngforSIBO•  Reviewthetestindetail•  Discusstreatmentrecommenda&ons•  Caseexamples•  GIandothertestconsidera&ons

LearningObjec0ves

•  “SmallIntes&nalBacterialOvergrowthisaheterogeneoussyndromecharacterizedbyanincreasednumberand/orabnormaltypeofbacteriainthesmallbowel.”

•  “SIBOisacondi&oninwhichthesmallboweliscolonizedbyexcessivenumbersofaerobicandanaerobicmicrobesthatarenormallyfoundinthelargeintes&ne.”

•  “Currentlyabacterialconcentra&onof>103c.f.u./mlisgenerallyconsideredsignificant.”

WhatisSmallIntes0nalBacterialOvergrowth?

SachdevAH,etal.Therapeu&cadvancesinchronicdisease.Sep2013;4(5):223-231.RezaieA,et.al.TheAmericanJournalofGastroenterology.2017;112:775-784.

BacterialConcentra0onsThroughouttheGITract

MowatA,etal.NatureReviewImmunology.2014;14(10):667-85.

•  Gastricacid•  Pancrea&candbiliarysecre&ons•  Peristalsisandthemigra&ngmotorcomplex(MMC)–stasispromotesbacterialgrowth

•  Ileocecalvalve–preventsrefluxofcolonicbacteriaintothesmallintes&ne

ThecompromiseofanyoftheseprocessescanleadtothedevelopmentofSIBO

WaystheBodyInnatelyPreventstheOvergrowthofBacteriaintheSmallIntes0ne

BuresJ,etal.WorldJournalofGastroenterology.2010;16(24):2978-90.HusebyeE.NeurogastroenterologyandMoAlity.1999;11(3):141-61.

MachadoWM,etal.ArquivosdeGastroenterologia.2008;45(3):212-18.PylerisE,etal.Diges&veDiseaseandScience.2012;57(5):1321-29.

WilliamsC.BestPracAceandResearch.ClinicalGastroenterology.2001;15(3):511-21.

WhentoConsiderSIBO?SignsandSymptomsAssociatedCondi&onsandRiskFactors

WhataretheCommonSignsandSymptomsofSIBO?

•  Abdominalbloa&ng•  Excessivegasorbelching•  Abdominalcramps•  Diarrhea•  Cons&pa&on•  Nausea•  Heartburn

•  Steatorrhea•  Nutrientdeficiencies

– VitaminB12–  Iron– Macronutrientmalabsorp&on–  Fat-solublevitamins– RBCfolate

Condi0onswithaHighPrevalenceofOvergrowth

•  Func&onalGIandmo&litydisorders(suchasIBS&gastroparesis)

•  NeuromuscularDiseases(suchasrestlesslegsyndrome)

•  InflammatoryBowelDisease(IBD) •  Pancrea&cdisease•  Celiacdisease

•  Hypothyroidism•  Liverdisease•  Diabetes •  Fibromyalgia•  Rosacea •  Parkinson’sdisease•  Obesity •  Plusmanyothercondi&ons

CostaMB,etal.ArquivosdeGastroenterologia.2012;49(4):279-83.Lauritano,et.al.JournalofClinicalEndocrinologyandMetabolism.2007;92(11):4180-84.

Mar&nsCP,etal.ArquivosdeGastroenterologia.2017;54(2):91-95.QueraPR,etal.RevistaMedicadeChile.2005;133(11):1361-70.

•  IBS–  78%ofpa&entsposi&ve–  48%ofpa&entstreatedsuccessfullyforSIBOnolongermetRomecriteria

•  FibromyalgiaandChronicFa&gueSyndrome–  42/42pa&entswithfibromyalgiahadanabnormallactulosebreathtestwithsignificantlygreaterhydrogenproduc&on;significantcorrela&onbetweendegreeofpainandpeakhydrogenlevel

–  77%ofCFSpa&entswerefoundtohaveSIBO

•  Hypothyroidism–  54%ofpa&entswithhypothyroidismhaveSIBOcomparedwith5%ofcontrols–  “Hypo-andhyperthyroidism,olenofautoimmuneorigin,arerespec&velyassociatedtosmallintes&nalbacterialovergrowthandtochangesinmicrobiotacomposi&on.”

PrevalenceofSIBOinCommonCondi0ons

LauritanoEC,et.al.JournalofClinicalEndocrinologyandMetabolism.2007;92(11):4180-84.PimentelM,et.al.AnnualsoftheRheumaAcDiseases.2004;63(4):450-52.

PimentelM,etal.AmericanJournalofGastroenterology.2000;95(12):3503-06.PimentelM,et.al.AmericanJournalofGastroenterology.2000;118(4):A414.

ViriliC,etal.Endocrine.2015;49(3):583-87.

•  MechanicalStasis–  Structural/Anatomic:Smallintes&nediver&cula,strictures,surgery–  Mo&lityDisorders:Gastroparesis,Medica&ons(i.e.opioidanalgesics)

•  IrritableBowelSyndrome•  Hypothyroidism•  MetabolicDisorders:Diabetes•  ElderlyAge•  OrganSystemDysfunc&on:Liver,kidney,pancrea&cdysfunc&on,Crohn’s,Celiac•  Immunodeficiencystates•  Hypochlorhydria•  Medica&ons:Recurrentan&bio&csandgastricacidsuppressors•  GIInfec&on

WhatareRiskFactorsfortheDevelopmentofSIBO?

DukowiczAC,etal.GastroenterologyandHepatology.2007;3(2):112-22.Mar&nsCP,etal.ArquivosdeGastroenterologia.2017;54(2):91-95.

•  Anovergrowthofbacteriainthesmallintes&necancause:–  Blun&ngofthevilli–  Thinningofthemucosaandcrypts–  Increasedintraepitheliallymphocytes– Microscopicinflammatorychanges

SIBOCanCauseHistopathologicChangeofSmallIntes0ne

HaboubiNY,LeeGS,MontgomeryRD.AgeAgeing.1991;20:29-32.BuresJ,et.al.WorldJournalofGastroenterology.2010;16(24):2978-2990.

Lappinga,P,et.al.ArchPatholLabMed.2010;134(2):264-70.

Tes0ngforSIBOGoldStandard:AspirateandCultureBreathTes&ng

Disadvantages•  Invasiveprocedureasthesmallintes&nemustbeintubatedsothataspiratescanbecollected

•  Culture-basedtechniquesdonotallowforgrowthofallorganisms,thusmayunderes&matethebacterialpopula&on

•  Poten&alforcontamina&onofinstrumenta&onandinaccuratesamplingduetotechnicalproblems

•  Endoscopycanonlyreachtheupperpor&onofthesmallintes&neandcolonoscopycanonlyreachthelower,thusthesubstan&almiddlesec&onofthesmallintes&neisnotaccessiblebythismethod

GoldStandard

DukowiczAC,etal.GastroenterologyandHepatology.2007;3(2):112-22.

Aspirate of small bowel fluid followed by culture and bacterial count

•  “Unlikebreathtes&ng,smallbowelaspira&onisinvasive,&me-consumingandcostly.”

•  “BreathTes&ngisauseful,inexpensive,simpleandsafediagnos&ctestintheevalua&onofcommongastroenterologyproblems.”

BreathTes0ngversusSmallBowelAspira0on

RezaieA,et.al.TheAmericanJournalofGastroenterology.2017;112:775-84.

BreathTes0ngforSIBO

•  Baselinebreathmeasurement•  Drinksubstrate(lactulose)•  Lactulosetransitsthroughsmallintes&ne-ifbacteriaarepresent,H2(hydrogen)orCH4(methane)gasisproduced

•  H2andCH4absorbedthroughintes&nesintobloodstream

•  Gasescarriedtolungsthroughbloodstreamandexpired

•  Breathcollectedat&medpoints

RanaSV,etal.WorldJournalofGastroenterology.2014;20(24):7587-601.

Tes0ngSubstancesforSIBOBreathTest

Lactulose •  Cannotbedigestedorabsorbedbyhumans,thuspassesthroughen&relengthofsmallintes&ne

•  Advantage:Candiagnosedistalovergrowthwhichisthoughttobemorecommon

•  Notassensi&veasglucose

Glucose•  Glucoseisabsorbedwithinfirstfewfeetofsmallintes&ne,thuscanonlydiagnoseproximalovergrowth

•  Disadvantage:Cannotdiagnosedistalovergrowth

•  Accuratediagnosisofproximalovergrowth

•  Veryimportanttoreviewtheinstruc&onswiththepa&entastheyaredetailedandspecific

•  Impropercollec&oncanleadtoambiguousresults•  Keyinstruc&ons:

–  4weeksprior:Noan&bio&cs,colonoscopyorbariumenema–  7daysprior:Nolaxa&ves,stoolsoleners,stoolbulkingagentsorantacids–  24hoursprior:Dietlimitedtoafewfoodsandnoprobio&cs–  12hoursprior(fas&ngwithonlywater):Nonon-essen&almedica&ons/supplements,toothpaste,gum,candiesormouthwash

–  1hourpriorandduringtes&ng(fas&ngwithonlywater):Nosmoking,sleeping,vigorousexerciseortoothpaste

Collec0onPackInstruc0ons

•  Collec&ontechniquewith&mingandbreathingintothetubemayneedtobereviewedwiththepa&ent–  Breathenormally,inhaleandhold5seconds–  Exhalenormallyintomouthpiece(donotblowhard)–  Inserttubeandremovealer2seconds–  Record&mesonlabelsandrequisi&onform

Collec0onPackInstruc0onsCon0nued…

Greatdemonstra&onvideoforpa&entstowatchcanbefoundontheSIBOpageonwww.gdx.net:

www.gdx.net/product/bacterial-overgrowth-of-the-small-intes&ne-sibo-test

TestInterpreta0on

2017NorthAmericanBreathTes0ngConsensusGuidelines•  Standardiza&onwaslackingregardingindica&onsfortes&ng,testmethodologyandinterpreta&onofresults

•  Whoformedtheconsensusgroup?•  Consensuswasreachedon26statementsintheareasofindica&ons,prepara&on,performance,interpreta&onofresultsandknowledgegaps

RezaieA,et.al.TheAmericanJournalofGastroenterology.2017;112:775-84.

BreathTests:3-Hourversus2-Hour

3-HourSIBOBreathTest 2-HourSIBOBreathTest

TestComponents

•  Graphofhydrogen(H2)andmethane(CH4)

•  Chartofbreathgasesatthe&medpoints

•  Carbondioxide(CO2)evalua&onforqualitycontrol

•  Actualcollec&on&mes•  Evalua&onforhydrogen•  Evalua&onformethane

•  AriseofH2of>20ppmoverbaselineinthefirst90minutesoftes&ngisposi&veforSIBO

•  Genova’sEvalua&onforhydrogenbasedonconsensuspaper;thiscutpointisseenwidelythroughouttheliterature

Evalua0onforHydrogen(H2)

•  SignificanceofelevatedbaselineH2levelsinpa&entsrepor&ngadherencetofas&nganddietaryguidelinesisnotknown–  Inasymptoma&cpa&ent,someclinicalgroupswithexper&seinSIBOmanagementmayconsideranelevatedhydrogenbaselineaposi&vetest

•  Approximately8to27%ofindividualsdonotproduceH2duetothepresenceofmethanogenicmicrobiotawhichconsumehydrogenmoleculestoproducemethanegas–  LowH2findingsthroughall&mepointsinasymptoma&cpa&entmayreflectafalsenega&veresult–  Clinicalaqen&onshouldbeshiledtoevalua&onofCH4

Evalua0onforHydrogen

•  Theconsensusgroupandotherpapersrefertoanabsolutevalueof10orgreateratanypointduringthetestasa“methaneposi&ve”result–  Results10+willbeoutlinedinredandflaggedwithan“H”

•  Peer-reviewedliteraturesuggestsanassocia&onwithcertainclinicalcondi&onsandmethanogenovergrowthatlevelsaslowas3ppm,CH4valuesbetween3and9mayindicatetheneedforclinicalinterven&oninthesymptoma&cpa&ent–  Results3-9willbeoutlinedinyellow

•  EmergingliteraturesuggeststhatunlikeH2,anelevatedCH4levelatbaselineiscommon

Evalua0onforMethane(CH4)

•  U&liza&onofbreathmethanelevelsforSIBOassessmentiscontroversiallargelyduetoalackofvalida&onrelatedtodiagnos&cspecificssuchas&mingandmagnitudeofincrease–  TheriseofCH4duringbreathtes&ngappearstonotbeassharpasH2

•  However,CH4measurementsareincreasinglyobtainedtoaddressotherclinicalques&onssuchas:–  Cons&pa&on

•  Methanegasitselfmayslowintes&naltransit,andpa&entswithCH4-predominantbacterialovergrowthhavebeenfoundtobefive&mesmorelikelytohavecons&pa&oncomparedtoindividualswithH2–predominantovergrowth

•  Theseverityofcons&pa&onhasbeenfoundtodirectlycorrelatewiththeCH4level–  IrritableBowelSyndrome(IBS)–  Obesity

Evalua0onforMethane

CarbonDioxide(CO2)

CarbonDioxide(CO2)ismeasuredineverysample.CO2levelsexceedingacceptablelimitsindicateroomaircontamina&onlikelyatthe&meofsamplecollec&on.IfCO2levelsexceedacceptablelimits,

sampleintegrityisques&onableandresultsaredesignatedasnon-reportable(NR).

ActualCollec0onTimes

Onthereport

Ontherequisi0onform

ActualTime•  Theactual&meofcollec&onofsamplesisprovidedtoenhanceclinicalinterpreta&on•  Theactual&mesreportedareu&lizedtodeterminetheactualintervalforcomparisontotherecommendedinterval

ActualInterval•  Theactualintervalcanbecomparedtotherecommendedcollec&oninterval.Iftherecommendedcollec&onintervalisnotfollowedcorrectly,interpreta&onshouldbemadewithinthecontextofthealteredcollec&onschedule.Generally,devia&onsofafewminuteswillnotsignificantlyaltertheinterpreta&on.

•  Ifthe90-minuteintervalismissed,evalua&onforhydrogenmaybeaffected,sincethecriteriafordiagnosisofhydrogen-producingbacterialovergrowthisby90-minutes

ActualCollec0onTimes

Trea0ngSIBOTreattheovergrowthProvidenutri&onalsupportCorrecttheunderlyingcause

•  Forthemajorityofpa&entsdiagnosedwithaposi&vebreathtest,SIBOwilllikelybeachronicandrelapsingcondi&on–  Forexample,onestudyfoundthat44%ofpa&entstreatedsuccessfullywithan&bio&csrelapsewithin9months

•  Goalsoftreatmentarethreefold:–  Treattheovergrowth–  Providenutri&onalsupport–  Correcttheunderlyingcause

Trea0ngSIBO

DukowiczAC,etal.GastroenterologyandHepatology.2007;3(2):112-22.LauritanoEC,etal.TheAmericanJournalofGastroenterology.2008;103(8):2031-35.

•  Rifaximin•  RifaximinplusNeomycin(orMetronidazole)•  Botanicals

–  Berberine–  Allicin(componentofgarlic)–  Oreganooil–  Neem–  Others

Trea0ngSIBO–TreattheOvergrowth

ChedidV,etal.GlobalAdvancesinHealthandMedicine:ImprovingHealthcareOutcomesWorldwide.2014;3(3):16-24.

Trea0ngSIBO–ProvideNutri0onalSupport

•  Nutri0onalconsequencesinclude:– Weightloss–  Fatsolublevitamindeficiency–  VitaminB12deficiency–  Irondeficiency–  Lowserumbileacids–  LowRBCfolatelevels

•  CommondietsprescribedforSIBO–  SpecificCarbohydrateDiet(SCD)–  LowFODMAPs–  ElementalDiet

•  Themigra&ngmotorcomplex(MMC)describesthewavesofelectromechanicalac&vitythatsweepthroughtheintes&nesinaregularcycle

•  TheMMCisresponsibleformovingbacteriafromthesmallintes&netothelargeintes&ne,aswellasforinhibi&ngmigra&onofcolonicbacteriaintotheterminalileum

•  Suppor&ngop&malfunc&onoftheMMCincludes:– Mealspacingevery4-5hourswithovernight12hourfast–  Useofprokine&cagents

•  Pharmaceu&calagentssuchaslow-doseerythromycin,Tegaserod,low-dosenaltrexone,andPrucalopride

•  Naturalagentssuchasginger,herbalbiqersandthebotanicalproductIberogast

Trea0ngSIBO–AddresstheCause

ChaixA,etal.CellularMetabolism.2014;20(6):991-1005.VantrappenG,etal.TheJournalofClinicalInvesAgaAon.1977;59(6):1158-1166.

•  Revisittheslideonriskfactorsandassociatedcondi&ons.Afewexamplesofaddressingthecausemayinclude:–  Discon&nua&onofmedica&ons:Tobediscussedbetweenpa&entandclinician(acid-blockingmedica&ons,medsthatslowtransit-opioidanalgesics,etc.)

–  TreatHypothyroidism•  TreatmentwithLevothyroxineassociatedwithgreaterincidenceofSIBO•  Whatiscausingthehypothyroidism?

–  Hypochlorhydria•  Biqers,BetaineHCl,etc.•  Whatiscausingthehypochlorhydria?

–  Somecausescannotbereversed(i.e.surgicalaltera&ons);ongoingmanagementmaybenecessary.

•  Considervisceralmanipula&onforadhesions

Trea0ngSIBO–AddresstheCause

BrechmannT,etal.WorldJournalofGastroenterology.2017;23(5):842-852.

www.siboinfo.comisaninforma0vewebsitemaintainedbyDr.AllisonSiebecker,ND,andincludestreatmentconsidera0ons

•  Inapa&enttreatedforSIBO,manyvariablesaffectthedecisionofwhentoretest—includingthepa&ent’sunderlyingcondi&onanditsseverity,lengthoftreatment,etc…

•  TheNAConsensusGrouprecommendsthatan&bio&csshouldbeavoidedfor4weekspriortotes&ng—thisrecommenda&onusuallyappliestoini&altes&ngforSIBO

•  However,thereareemergingclinicalrecommenda&onswhichsuggestretes&ngpa&entswithinafewdaysofan&microbialcoursecomple&ontoensureefficacyofthetreatment.TheNorthAmericanConsensusgroupaswellasotherssuggestthat‘breathtestsmaybeperformedshortlyalercessa&onofan&bio&ctherapytoconfirmeradica&on’

Retes0ng

RezaieA,et.al.TheAmericanJournalofGastroenterology.2017;112:775-84.

CaseExamplesCaseExample#1Hydrogenposi&ve,mildmethaneposi&veCaseExample#2Methaneposi&veAddi&onalScenario

•  34yofemalewithbloa&ngandalterna&ngdiarrheawithcons&pa&on

•  SymptomsongoingsinceshecaughtaGIbugwhiletravelinginCentralAmerica9monthsago;didnotexperiencethesesymptomspreviously

•  Certainfoodsareproblema&candshefindsherselfea&ngmorepaleototrytocontrolsymptoms

•  Pa&entisveryac&veandkeepsbusywithworkandtravel;theIBSsymptomshaveinterferedwithdailyliving

CaseExample#1

CaseExample#1

•  Hydrogenposi&veresults•  Methaneyellow–moderate•  Collec&onschedulefollowedcorrectly

•  Treatment:Sincethepa&entdidhaveamixedIBS-typepicturewithalterna&ngdiarrheaandcons&pa&on,theclinicianchosetotreatbothmethaneandhydrogen-producingbacteria–  BotanicalregimenincludingCandibac&nARandBRplusAllimed(formethane)x6weeks–  BeginlowFODMAPsdiet– Mealspacingevery4-5hours

•  Followup:Aler2months,thepa&entsymptomshadimproved,sotherewasnofollowuptes&ng.Thepa&entcon&nuedwiththemealspacingandmodifiedFODMAPs–  Thegoalisnotcon&nuousFODMAPs,sincefermentablecarbohydrateisimportanttothehealthofthecommensalbacteriaofthelargeintes&ne.Thegoalwouldbetointroducefermentablecarbohydrates/resistantstarchesover&me

CaseExample#1

•  66yomalewithbloa&ngandexcessivebelchingandflatulence•  Severecons&pa&onforaslongashecanremember•  Hasupto2bowelmovementsperweekthataredifficulttopass,heconsidersthispaqernnormalforhim

•  Obese,hypertension,hypothyroid,diabe&c•  Takesoxycodonedailyforabackinjury3yearsago•  EatsastandardAmericandiet

CaseExample#2

CaseExample#2

•  Methane-posi&vetest•  Hydrogennormal•  Collec&onschedulefollowedcorrectly

•  Treatment:–  Theclinicianchosetotreatmethane-producingorganismswithRifaximinplusNeomycinx14days

–  Aprokine&cwasprescribed–Mo&lPro(combina&onofgingerand5HTP)indefinitelyun&lchroniccons&pa&onresolves

– Magnesiumwasprescribeddailytoassistwithregularity–  LevothyroxineRxwasswitchedtoArmourThyroid–  Recommendedincreasingwaterintakefrom1cupdailytoatleast1-2Ldaily– Whilefiberisimportantforcons&pa&on,itwasavoidedini&allytoaddressSIBO–  Lowcarbohydratedietrecommended(fordiabetes,obesity,andSIBO)

CaseExample#2

•  Thelong-termfocuswiththispa&entwouldbetoworkonhisoverallhealthcondi&onsandhabitsthatmaypredisposetoSIBO(diabetes,hypothyroid,StandardAmericanDiet,oxycodoneuse)–  TherecurrenceofSIBOiscommonespeciallyifunderlyingcondi&onsarenotaddressed–  Thispa&ent’slifestyleandhealthcondi&onsareinflamma&on-promo&ng,sotransi&oningtoan&-inflammatorydiet/lifestylemaytake&me,inordertocomeoffoxycodone

•  AGIEffectsComprehensivestoolanalysiswasalsoorderedforthispa&ent–  IfthereareotherGIabnormali&es,forexamplepancrea&cinsufficiency,thenpancrea&cenzymescanbegiventohelpwithdiges&on(pancrea&cinsufficiencyiscommonwithdiabetes)

CaseExample#2

•  LowH2andCH4throughoutthetestcouldindicate:–  Itisanega&vetestforSIBO;considerothertes&ngtoassesse&ologyofpa&entsymptoms–  IfbothH2andCH4arelowall3hours,itmaysuggestthepresenceofH2S-producingbacteria

•  TheH2S-producingbacteriaconsumetheHthatwouldotherwisehavegonetothebacteriathatmakeH2orCH4

•  H2Ssmellslikeroqeneggs,soifthisiswhatthepa&entexperiences,thismaybethecase

–  Thepa&entmaynothavefollowedcollec&onpackinstruc&onscorrectly•  Thebreathdidn’tmakeitintothetube•  Theymayhavejustcompletedan&bio&cs

–  Instruc&onssaywait4weeksalerdiscon&nuingan&bio&cs–  Somecliniciansmayadvisetheirpa&enttocollectimmediatelyalerfinishingan&bio&cstoensureefficacyoftreatment

Addi0onalScenario:“FlatlineTest”

© Genova Diagnostics

BanikGD,etal.JournalofBreathResearch.2016;10(2):026010.RezaieA,etal.TheAmericanJournalofGastroenterology.2017;112(5):775-84.

GITestConsidera0onsSIBOOthertests

•  IBS•  GIsymptoms•  Bloa&ng•  IntolerancetocarbohydratesorFODMAPs•  Symptomsalerea&ng•  Unexplainedabdominalsymptoms•  Predisposingcondi&ons(seelist)

Itisimportanttodesignatesomeoneintheofficetogoovercollec+onpackageinstruc+onswitheachpa+enttoensureop+malresults

Review:WhentoOrderSIBOTes0ng

•  GIEffectsiscomprehensiveandcaniden&fy:–  Pancrea&cinsufficiency–  Inflamma&on–  Dysbiosis–  Yeastovergrowth–  Parasi&cinfec&on

•  FoodAn&bodypanel•  CeliacandGlutenSensi&vitypanel

OtherGITestConsidera0onsforSimilarSymptoms

GIEffectsprofilecannotdiagnoseSmallIntes0nalBacterialOvergrowth•  Therearemarkersonthisprofilethatcanbesugges&veofSIBOintherightpa&entpopula&on:–  Eleva&onsinProductsofProteinBreakdown–  Eleva&onsinFecalFats–  Unexpectedorextremeeleva&onsinTotalSCFAsandn-butyrate

GIEffects®ComprehensiveProfile

Nutri0onalInsufficiencies

•  Bvitamins•  Macronutrients•  Fat-solublevitamins

TheNutrEvalassessesurineorganicacidsincludingmalabsorp0on

anddysbiosisbiomarkers

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TheviewsandopinionsexpressedhereinaresolelythoseofthepresenteranddonotnecessarilyrepresentthoseofGenovaDiagnos&cs.Thus,GenovaDiagnos&csdoesnotacceptliabilityforconsequencesofanyac&onstakenonthebasisoftheinforma&onprovided.

TheviewsandopinionsexpressedhereinaresolelythoseofthepresenteranddonotnecessarilyrepresentthoseofGenovaDiagnos&cs.Thus,GenovaDiagnos&csdoesnotacceptliabilityforconsequencesofanyac&onstakenonthebasisoftheinforma&onprovided.

Chris&neStubbe,ND,FABNO

SmallIntes+nalBacterialOvergrowth:UpdatesandClinicalImplica0ons