“Very low” quality evidence indicates very little confidence in the effect estimate, and that the true effect is likely to be substantially different than the estimate of effect. “Moderate” quality evidence is associated with moderate confidence in the effect estimate, although further research would be likely to have an impact on the confidence of the estimate, whereas “low” quality evidence indicates that further study would likely have an important impact on the confidence in the estimate of the effect and would likely change the estimate. “High” quality evidence indicates that further research is unlikely to change the authors' confidence in the estimate of effect, and that we are very confident that the true effect lies close to that of the estimate of the effect. The quality of the evidence is graded from high to low. “Conditional” is used when some uncertainty remains about the balance of benefits and potential harms. A “strong” recommendation is made when the benefits clearly outweigh the negatives and/or the result of no action. The GRADE system was used to evaluate the quality of supporting evidence ( 13).
Each recommendation statement has an associated assessment of the quality of evidence and strength of recommendation based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process. The guideline is structured in sections, each with recommendations, key concepts, and summaries of the evidence. In this guideline, we provide an evidence-based evaluation of the literature and assess the current unmet needs in SIBO research. Furthermore, treatment for SIBO has been largely empirical, has not undergone the scrutiny of sponsored clinical trials, and requires appraisal. As such, an effort has been underway to re-evaluate the criteria for the diagnosis of SIBO and define the optimal methods for diagnostic testing to identify this condition. Although these findings are important, a recent consensus document identified a number of strengths and weaknesses in the published work in this area ( 12).
#Small bacterial overgrowth series#
These include a series of articles linking SIBO to diseases such as irritable bowel syndrome (IBS) ( 3,4), inflammatory bowel disease (IBD) ( 5), systemic sclerosis ( 6), motility disorders ( 7,8), cirrhosis ( 9), fatty liver ( 10), postgastrectomy syndrome ( 11), and a variety of other conditions. Since the late 1990s, there has been a resurgence in SIBO research which has been further enhanced by the increasing knowledge of the gut microbiome and its roles in human health and disease ( 2). These bacteria are usually coliforms, which are typically found in the colon and include predominantly Gram-negative aerobic and anaerobic species that ferment carbohydrates producing gas ( 1).
SIBO is defined as the presence of excessive numbers of bacteria in the small bowel causing gastrointestinal (GI) symptoms. Although its definition has been debated, the principle concept is that the normal small bowel has lower levels of microbial colonization compared with the colon and this normal balance is significantly altered in SIBO. Small intestinal bacterial overgrowth (SIBO) has been recognized as a medical phenomenon for many decades.
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