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If your bowel problems persist after going GF, this study suggests it could
be due to bacterial overgrowth.  It's too bad the study didn't also check
for hypochlorhydria (low stomach acid) as a possible cause of the
overgrowth.  Also there was only a 1 month followup, meaning the overgrowth
could recur in these patients.

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American Journal of Gastroenterology Apr 2003, Vol 98, No 4, 839-843

High prevalence of small intestinal bacterial overgrowth in celiac patients
with persistence of gastrointestinal symptoms after gluten withdrawal

Antonio Tursi M.D., Giovanni Brandimarte M.D. and GianMarco Giorgetti M.D.
Received: 12/21/2001. Accepted: 4/12/2002.

Abstract

Objective
Celiac disease is a gluten-sensitive enteropathy with a broad spectrum of
clinical manifestation, and most celiac patients respond to a gluten-free
diet (GFD). However, in some rare cases celiacs continue to experience GI
symptoms after GFD, despite optimal adherence to diet. The aim of our study
was to evaluate the causes of persistence of GI symptoms in a series of
consecutive celiac patients fully compliant to GFD.

Methods
We studied 15 celiac patients (five men, 10 women, mean age 36.5 yr, range
24-59 yr) who continued to experience GI symptoms after at least 6-8 months
of GFD (even if of less severity). Antigliadin antibody (AGA) test,
antiendomysial antibody (EMA) test, and sorbitol H2-breath test (H2-BT), as
well as esophagogastroduodenoscopy (EGD) with histological evaluation, were
performed before starting GFD. Bioptic samples were obtained from the
second duodenal portion during EGD, and histopathology was expressed
according to the Marsh classification. To investigate the causes of
persistence of GI symptoms in these patients, we performed AGA and EMA
tests, stool examination, EGD with histological examination of small bowel
mucosa, and sorbitol-, lactose-, and lactulose H2-breath tests.

Results
Histology improved in all patients after 6-8 months of GFD; therefore,
refractory celiac disease could be excluded. One patient with Marsh II
lesions was fully compliant to his diet but had mistakenly taken an
antibiotic containing gluten. Two patients showed lactose malabsorption,
one patient showed Giardia lamblia and one patient Ascaris lumbricoides
infestation, and 10 patients showed small intestinal bacterial overgrowth
(SIBO) by lactulose H2-BT. We prescribed a diet without milk or fresh milk-
derived foods to the patient with lactose malabsorption; we treated the
patients with parasite infestation with mebendazole 500 mg/day for 3 days
for 2 consecutive wk; and we treated the patients with SIBO with rifaximin
800 mg/day for 1 wk. The patients were re-evaluated 1 month after the end
of drug treatment (or after starting lactose-free diet); at this visit all
patients were symptom-free.

Conclusions
This study showed that SIBO affects most celiacs with persistence of GI
symptoms after gluten withdrawal.

Affiliations:
Department of Emergency, "L. Bonomo" Hospital, Andria (BA), Italy.
Department of Internal Medicine, Digestive Endoscopy Unit, "Cristo Re"
Hospital, Rome, Italy. Department of Internal Medicine, Artificial
Nutrition Unit, "S. Eugenio" Hospital, Rome, Italy.

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